Cytomegalovirus Infection in Adult Patients with Inflammatory Bowel Disease: A Literature Review

Human cytomegalovirus (HCMV) is classified within the Herpesvirales order and is prevalent in 50%‒80% of the general population. Most carriers experience this infection without noticeable clinical symptoms. HCMV causes a lifelong latent infection that can be reactivated due to immune disorders and inflammation. The reactivation of HCMV becomes particularly significant when it coincides with inflammatory bowel disease (IBD). While cytomegalovirus (CMV) colitis in IBD patients was identified years ago, the role of CMV in triggering flare-ups, acute severe colitis, treatment resistance, and other outcomes in IBD patients experiencing CMV reactivation remains a subject of ongoing debate. In this review, we aim to address an updated insight into aspects related to the CMV colitis in IBD patients including epidemiology, risk factors, clinical features, diagnostic tests, histology, place of immunosuppressants and indications for antiviral treatment. We suggest for personalized and thorough assessment based on the disease phase and colitis severity when prescribing drugs to these patients. Furthermore, we emphasize the importance of regular patient follow-up to monitor drug side effects, ensuring treatment success, and minimizing the risk of colectomy.

Antioxidative and Anti-inflammatory Effects of Plant-derived Hypoglycemic Medicines: An In vivo/In vitro Systematic Review

BACKGROUND

The activation of oxidative stress and inflammatory conditions has been associated with acceleration in diabetes (DM) onset and complications. Despite various anti-DM medications, there is a growing trend to discover inexpensive and effective treatments with low adverse effects from plants as one of the promising sources for drug development.

OBJECTIVE

This study aimed to systematically investigate the simultaneous anti-inflammatory and antioxidant effects of plant-derived hypoglycemic medicines in diabetic experimental models.

METHODS

The search terms consisted of "diabetes", "herbal medicine", "antioxidant", "Inflammatory biomarker", and their equivalents among PubMed, Scopus, Web of Science, and Cochrane Library databases up to 17 August 2021.

RESULTS

Throughout the search of databases, 201 eligible experimental studies were recorded. The results showed that the most commonly assessed inflammatory and oxidative stress biomarkers were tumor necrosis factor (TNF)-α, interleukin (IL) 6, IL-1β, IL-10, malondialdehyde (MDA), and nitric oxide (NO). The activity of antioxidant enzymes, including superoxide dismutase (SOD), glutathione (GSH), and catalase (CAT) were assessed in the present review. Among herbal treatments, Trigonella foenum-graecum L., Centella asiatica (L.) Urb., Vitis vinifera L., and Moringa oleifera Lam. were most commonly used for diabetic complications. Due to the dispersion of the treatments, meta-analysis was not applicable.

CONCLUSION

Our findings showed that the application of different plant-derived hypoglycemic treatments in animal models improved diabetes and its complications, as well as modulated concomitant inflammatory and oxidative stress biomarkers. These findings suggest that plant-based antidiabetic medicines and food supplements have the potential to manage diabetes and its complications.

Clinical Phenotype and Disease Course of Inflammatory Bowel Disease in Iran: Results of the Iranian Registry of Crohn's and Colitis (IRCC)

BACKGROUND

Data on the epidemiology of inflammatory bowel disease (IBD) in the Middle East are scarce. We aimed to describe the clinical phenotype, disease course, and medication usage of IBD cases from Iran in the Middle East.

METHODS

We conducted a cross-sectional study of registered IBD patients in the Iranian Registry of Crohn's and Colitis (IRCC) from 2017 until 2022. We collected information on demographic characteristics, past medical history, family history, disease extent and location, extra-intestinal manifestations, IBD medications, and activity using the IBD-control-8 questionnaire and the Manitoba IBD index, admissions history, history of colon cancer, and IBD-related surgeries.

RESULTS

In total, 9746 patients with ulcerative colitis (UC) (n=7793), and Crohn's disease (CD) (n=1953) were reported. The UC to CD ratio was 3.99. The median age at diagnosis was 29.2 (IQR: 22.6,37.6) and 27.6 (IQR: 20.6,37.6) for patients with UC and CD, respectively. The male-to-female ratio was 1.28 in CD patients. A positive family history was observed in 17.9% of UC patients. The majority of UC patients had pancolitis (47%). Ileocolonic involvement was the most common type of involvement in CD patients (43.7%), and the prevalence of stricturing behavior was 4.6%. A prevalence of 0.3% was observed for colorectal cancer among patients with UC. Moreover,15.2% of UC patients and 38.4% of CD patients had been treated with anti-tumor necrosis factor (anti-TNF).

CONCLUSION

In this national registry-based study, there are significant differences in some clinical phenotypes such as the prevalence of extra-intestinal manifestations and treatment strategies such as biological use in different geographical locations.

Comparison of Disease Phenotype and Course among Elderly- and Early-Onset Inflammatory Bowel Diseases in the Middle East

BACKGROUND

It is unknown if the clinical manifestations and phenotype of disease are comparable between early- and elderly-onset inflammatory bowel disease (IBD). We aimed to seek differences in disease phenotype, course, complications, and treatment between early- and elderly-onset IBD patients.

METHODS

This retrospective cohort study on registered IBD patients in the Iranian Registry of Crohn's and Colitis (IRCC) compared demographics, disease phenotype, disease activity, IBD-related surgery and medications between early- and elderly-onset IBD. A generalized linear regression model was used to investigate the relative risk of age at diagnosis adjusted for gender and disease duration for the outcomes.

RESULTS

From 10048 IBD patients, 749 with early-onset (7.5%), and 472 (4.7%) elderly-onset IBD were enrolled: 855 (63.1%) ulcerative colitis (UC) and 366 (26.9%) Crohn's disease (CD). Left-sided colitis was more frequent among elderly-onset UC patients (P<0.001). Ileum and ileocolonic locations were the most common types in elderly-onset and early-onset CD patients, respectively. In comparison with elderly-onset UC, early-onset cases more often used prednisolone (22.1% vs. 11.4%, P=0.001), immunomodulators (44.9% vs 25.2%, P<0.001) and anti-tumor necrosis factors (TNF) (20.1% vs 11.9%, P=0.002). Elderly-onset UC patients had 0.7 times lower risk of aggressive phenotype (95%CI:0.6‒0.9, P=0.005). Early-onset CD was associated with higher use of prednisolone (27.7% vs 8.1%, P<0.001), immunomodulators (58.7% vs 41.8%, P=0.005) and anti-TNF (49.6% vs 35.4%, P=0.006).

CONCLUSION

Early-onset IBD was associated with a more aggressive phenotype and higher prednisolone, immunomodulators, and anti-TNF use.

Association of indoor use of pesticides with CKD of unknown origin

INTRODUCTION

Chronic kidney disease (CKD) is a growing global health problem. Recently, an epidemic of CKD of unknown origin (CKDu), a form of CKD seen mostly in agricultural communities, has been emerged. One of the proposed causes of CKDu is pesticide use in farmers. On the other hand, the research on relation between indoor use of pesticides and CKDu is little. In this study, we aimed to investigate the association between indoor use of pesticide as well as the exposure time with CKDu. This study was done as part of the population-based cohort of Prospective Epidemiological Research Studies in Iran. We used the baseline data of the Zahedan Adult Cohort Study. All subjects with diabetes mellitus and/or hypertension, estimated glomerular filtration rate (eGFR) between 60-89 ml/min/1.73 m2, and unavailable creatinine measurement were excluded. Subjects with an eGFR of less than 60 ml/min/1.73 m2 were defined as having CKDu, and their data were compared with those with an eGFR of more than 90 ml/min/1.73 m2. Data regarding indoor pesticide use and duration of exposure were obtained through a questionnaire. After applying the exclusion criteria, 1079 subjects remained in the study. Female sex, single marital status, low physical activity, triglyceride (TG) levels of more than 150 mg/dl, body mass index (BMI) of more than 25 kg/m2, non-smokers, indoor pesticide use, and high pesticide exposure time were associated with CKDu. The effects of age, female sex, TG levels more than 150 mg/dl, pesticide use (OR 1.36; 95% CI 1.01-1.84), and high exposure time (third tertile of exposure time) compared to non-users (OR 1.64; 95% CI 1.07-2.51) remained significant in multivariable analysis.

CONCLUSION

We found a positive association between pesticide use, as well as longer exposure time to pesticides, and impaired kidney function in cases without diabetes mellitus and hypertension. Further longitudinal studies should be carried out to confirm these findings.

Modeling Epidemiology Data with Machine Learning Technique to Detect Risk Factors for Gastric Cancer

PURPOSE

Gastric cancer (GC) ranks as the 7th most common cancer worldwide and a leading cause of cancer mortality. In Iran, stomach malignancies are the most common fatal cancers with higher than world average incidence. In recent years, methods like machine learning that provide the opportunity of merging health issues with computational power and learning capacity have caught considerable attention for prediction and diagnosis of diseases. In this study, we aimed to model GC data to find risk factors and identify GC cases in Golestan Cohort Study (GCS), using gradient boosting as a machine learning technique.

METHODS

Since the GC class (280) was smaller than not-GC (49,467), "Synthetic Minority Oversampling Technique" was used to balance the dataset. Seventy percent of the data was used to train the gradient boosting algorithm and find effective factors on gastric cancer, and the remaining 30% was used for accuracy assessment.

RESULTS

Our results indicated that out of 19 factors, age, social economical status, tea temperature, body mass index, gender, and education were the top six effective factors with impact rates of 0.24, 0.16, 0.13, 0.13, and 0.07, respectively. The trained model classified 70 out of 72 GC patients in the test set, correctly.

CONCLUSION

The results indicate that this model can effectively detect gastric cancer (GC) by utilizing important risk factors, thus avoiding the need for invasive procedures. The model's performance is reliable when provided with an adequate amount of input data, and as the dataset expands, its accuracy and generalization improve significantly. Overall, the trained system's success stems from its ability to identify risk factors and identify cancer patients.

Investigating heavy-metal soil contamination state on the rate of stomach cancer using remote sensing spectral features

Heavy metal (HM) contamination in agricultural soils has been a serious environmental and health problem in the past decades. High concentration of HM threatens human health and can be a risk factor for many diseases such as stomach cancer. In order to investigate the relationship between HM content and stomach cancer, the under-study area should be adequately large so that the possible relationship between soil contamination and the patients' distribution can be studied. Examining soil content in a vast area with traditional techniques like field sampling is neither practical nor possible. However, integrating remote sensing imagery and spectrometry can provide an unexpensive and effective substitute for detecting HM in soil. To estimate the concentration of arsenic (As), chrome (Cr), lead (Pb), nickel (Ni), and iron (Fe) in agricultural soil in parts of Golestan province with Hyperion image and soil samples, spectral transformations were used to preprocess and highlight spectral features, and Spearman's correlation was calculated to select the best features for detecting each metal. The generalized regression neural network (GRNN) was trained with the chosen spectral features and metal containment, and the trained GRNN generated the pollution maps from the Hyperion image. Mean concentration of Cr, As, Fe, Ni, and Pb was estimated at 40.22, 11.8, 21,530.565, 39.86, and 0.5 mg/kg, respectively. Concentrations of As and Fe were near the standard limit and overlying the pollution maps, and patients' distribution showed high concentrations of these metals can be considered as stomach cancer risk factors.

Iranian Consensus Guideline for Pharmacotherapy with Biologics and Small Molecules Drugs in Adults with Inflammatory Bowel Diseases

Background: Pharmacotherapy with biologics and small molecules, as the more effective therapies for moderate to severe ulcerative colitis (UC) and Crohn's disease (CD), is complex. Choosing the best methods for their utilization in order to induce and maintain remission are critical for practicing gastroenterologists. We aimed to develop an Iranian consensus on the management of inflammatory bowel disease (IBD) patients with biologics and small molecules. Methods: A Delphi consensus was undertaken by experts who performed a literature summary and voting process. Quality of evidence was assessed using the Grading and Recommendations Assessment, Development, and Evaluation; and an additional risk of bias-protocol. Results: Following an extensive search of the literature, 219 studies were used to determine the quality of the evidence. After three rounds of voting, consensus (defined as≥80% agreement) was reached for 87 statements. Conclusion: We considered different aspects of pharmacotherapy in this consensus. This guideline, along with clinical judgment, can be used to optimize management of IBD patients.

Potential of Autologous Adipose-Derived Mesenchymal Stem Cells in Peritoneal Fibrosis: A Pilot Study

BACKGROUND

We aimed to determine the effects of systemic therapy with autologous adipose tissue derived mesenchymal stem cells (AD-MSCs) on different parameters of peritoneal function and inflammation in peritoneal dialysis (PD) patients.

METHODS

We enrolled nine PD patients with ultrafiltration failure (UFF). Patients received 1.2±0.1×106 cell/kg of AD-MSCs via cubital vein and were then followed for six months at time points of baseline, 3, 6, 12, 16 and 24 weeks after infusion. UNI-PET was performed for assessment of peritoneal characteristics at baseline and weeks 12 and 24. Systemic and peritoneal levels of tumor necrosis factor α (TNF-α), interleukin-6(IL-6), IL-2 and CA125 (by ELISA) and gene expression levels of transforming growth factor beta (TGF-β), smooth muscle actin (𝛼-SMA) and fibroblast-specific protein-1 (FSP-1) in PD effluent derived cells (by quantitative real-time PCR) were measured at baseline and weeks 3, 6, 12, 16 and 24.

RESULTS

Slight improvement was observed in the following UF capacity indices: free water transport (FWT, 32%), ultrafiltration - small pore (UFSP, 18%), ultrafiltration total (UFT, 25%), osmotic conductance to glucose (OCG, 25%), D/P creatinine (0.75 to 0.70), and Dt/D0 glucose (0.23 to 0.26). There was a slight increase in systemic and peritoneal levels of CA125 and a slight decrease in gene expression levels of TGF-β, α-SMA and FSP-1 that was more prominent at week 12 and vanished by the end of the study.

CONCLUSION

Our results for the first time showed the potential of MSCs for treatment of peritoneal damage in a clinical trial. Our results could be regarded as hypothesis suggestion and will need confirmation in future studies.

Antioxidative hypoglycemic herbal medicines with in vivo and in vitro activity against C-reactive protein; a systematic review

BACKGROUND

Inflammation is a double-edged sword in the pathophysiology of chronic diseases, such as type 2 diabetes mellitus (T2DM). The global rise in the prevalence of T2DM in one hand, and poor disease control with currently-available treatments on the other hand, along with an increased tendency towards the use of natural products make scientists seek herbal medicines for the management of diabetes and its complications by reducing C-reactive protein (CRP) as an inflammatory marker.

PURPOSE

To systematically review the literature to identify the efficacy of various medicinal plants with antioxidative and anti-inflammatory properties considering their effect on CRP in animal models of T2DM.

STUDY DESIGN

systematic review.

METHODS

Electronic databases including PubMed, Scopus, Web of Science and Cochran Library were searched using the search terms "herbal medicine", "diabetes", "c-reactive protein", "antioxidants" till August 2021. The quality of evidence was assessed using the Systematic Review Centre for Laboratory animal Experimentation (SYRCLE's) tool. The study protocol was registered in PROSPERO with an ID number CRD42020207190. A manual search to detect any articles not found in the databases was also made. The identified studies were then critically reviewed and relevant data were extracted and summarized.

RESULTS

Among total of 9904 primarily-retrieved articles, twenty-three experimental studies were finally included. Our data indicated that numerous herbal medicines, compared to placebo or hypoglycemic medications, are effective in treatment of diabetes and its complications through decreasing CRP concentrations and oxidative stresses levels. Medicinal plants including Psidium guajava L., Punica granatum L., Ginkgo biloba L., Punica granatum L., Dianthus superbusn L.. Moreover, Eichhornia crassipes (Mart.) Solms, Curcuma longa L., Azadirachta indica A. Juss., Morus alba L., and Ficus racemosa L. demonstrated potential neuroprotective effects in animal models of diabetes.

CONCLUSION

Hypoglycemic medicinal plants discussed in this review seem to be promising regulators of CRP, and oxidative stress. Thus, these plants are suitable candidates for management of diabetes' complications. Nevertheless, further high-quality in vivo studies and clinical trials are required to confirm these effects.

Scientometric assessment of scientific documents published in 2020 on herbal medicines used for COVID-19

Objective

Many studies have suggested herbal medicines as alternatives or adjuvants to modern drugs for COVID-19. Their scientometric analyses can provide a scientific overview of this topic.

Materials and methods

Web of Science (WOS) and Scopus were searched for articles on the use of herbal medicines in COVID-19 published until 26 October 2020. Collected data were analyzed for document type, subject area, top journal, citation number, and authors’ collaboration network using VOSviewer 1.6.15, ScientoPy 2.0.3, Gephi 0.9.2, and SPSS 15 statistical tools.

Results

After screening the 3185 retrieved records, 378 and 849 records, respectively from WOS and Scopus, remained for quantity analysis. Original and review articles were the two main types of papers in both databases. Top subject areas were drug and medicine, respectively in the WOS and Scopus databases. The top three productive countries in the field were China, the US, and India. The most cited article was a practice guideline in both databases. “Journal of Biomolecular Structure Dynamics” in WOS and “Chinese Traditional and Herbal Drugs” in Scopus were the top journals. Top keywords included “COVID-19″ and “Traditional Chinese Medicine”. US authors had the highest collaboration with other authors.

Conclusions

The current study provides a snapshot of the quantity and characteristics of published scholarly documents in recent months in the intersection of herbal medicines and COVID-19. Our findings help scientists to find the existing gaps, identify the active authors and scientific institutes to collaborate with and use their experience to produce new knowledge in the future.

Clinical Phenotype and Disease Course of Inflammatory Bowel Disease: A Comparison Between Sporadic and Familial Cases

BACKGROUND

The role of genetic and environmental factors in inflammatory bowel disease's (IBD) clinical course is not fully clear. We aimed to assess the clinical phenotype, disease course, and prognosis of familial IBD in comparison with sporadic cases.

METHODS

We conducted a prospective national matched case-control study of registered IBD patients in the Iranian Registry of Crohn's and Colitis (IRCC) recruited from 2017 until 2020. Sporadic and familial IBD patients were matched based on age, sex, and disease duration. Data on demographics, past medical disease, family history of IBD, disease type, clinical phenotype, extraintestinal manifestations, IBD medications, IBD activity using the IBD-control-8 questionnaire and the Manitoba IBD index, emergency visits in the past 12 months, admissions in the past 3 months, history of colon cancer, IBD-related surgeries, and aggressive phenotype were gathered. Variable distributions were compared between sporadic and familial cases.

RESULTS

Overall, 5231 patients with ulcerative colitis (UC, 18.3% familial) and 1438 patients with Crohn's disease (CD, 16.7% familial) were registered in the IRCC. Age at diagnosis was similar between familial and sporadic cases. After matching, 3523 UC patients and 908 CD patients were enrolled in the study. Extraintestinal manifestations, UC extent, CD location and behavior, anti-TNF use, disease activity, colon cancer, IBD-related surgeries and the aggressive phenotype were similar between these sporadic and familial cases.

CONCLUSIONS

The prevalence of familial UC and CD cases in Iran was more similar to western countries, and family history did not show a predictive value for disease phenotype, course, and outcomes in our study.

COVID-19 epidemic effects on sleep quality among health sector workers: A follow up study

Health care workers (HCWs) were vulnerable to sleep disturbances in normal circumstances. Poor sleep quality (PSQ) is common during the coronavirus disease 2019 (COVID-19) epidemic. The aim of this study is evaluation of sleep quality among healthcare workers during COVID-19 epidemic in a cohort study. In a follow-up study, we assessed sleep quality in 453 Iranian HCW participants in late-April 2021, after approximately 8 weeks of the epidemic of COVID-19. In order to compare the sleep quality in the two time intervals, during and before COVID-19, we used the recorded data of the same group of participants who were enrolled in a study named SHAHWAR (SHAhroud Health care Workers Associated Research) cohort that is focused on the health of HCWs who work at the Shahroud university of medical sciences. Data collection process in the SHAHWAR study started on October 2, 2019 and continued until February 19, 2020. Our results showed sleep quality worsened among shift-workers during COVID-19 outbreak; however, it was improved among non-shift staff. Sleep quality was more likely to be worsening if HCWs had shift-working roles [OR: 1.84(1.11-3.06), and if they experienced death in their families [OR: 5.06(1.60-12.80)]; however, having a paramedical role was a protective effect [OR: 0.52(0.27-092)], for poor quality sleep. Sleep quality worsened during the epidemic among HCWs. A greater impact, in terms of higher PSQI index, in this group of workers was seen in shift working staff.

Susceptibility of Patients with Inflammatory Bowel Disease to COVID-19 Compared with Their Households

BACKGROUND: Immunosuppressive agents used in the treatment of inflammatory bowel diseases (IBDs) could potentially increase the risk of coronavirus disease 2019 (COVID-19). We aimed to compare COVID-19 frequency in patients with IBD with their households and identify the related risk factors. METHODS: Firstly, a multi-centered, observational study on 2110 patients with IBD and 2110 age-matched household members was conducted to compare COVID-19 frequency. Secondly, the data of patients with IBD and COVID-19 who had called the COVID-19 hotline were added. Multivariable logistic regression was used to evaluate the effect of age, type and severity of IBD, the number of comorbidities, and medications on the frequency of COVID-19 among the patients with IBD. RESULTS: The prevalence of COVID-19 in patients with IBD and household groups was similar (34 [1.61%] versus 35 [1.65%]; P = 0.995). The prevalence of COVID-19 increased from 2.1% to 7.1% in those with three or more comorbidities (P = 0.015) and it was significantly higher in those with severe IBD (P = 0.026). The multivariable analysis only showed a significant association with anti-TNF monotherapy (OR: 2.5, CI: 0.97-6.71, P = 0.05), and other medications were not associated with COVID-19. CONCLUSION: The prevalence of COVID-19 in patients with IBD was similar to the household members. Only patients with IBD receiving anti-TNF monotherapy had a higher risk of COVID-19 susceptibility. This finding could be attributed to the higher exposure to the virus during administration in health care facilities.

Outcomes of COVID-19 in Patients with Inflammatory Bowel Disease: Comparison with Household Members and the Role of IBD Medications

BACKGROUND

Most data on the effect of inflammatory bowel disease (IBD) and its treatments on coronavirus disease 2019 (COVID-19) outcomes have not had non-IBD comparators. Hence, we aimed to describe COVID-19 outcomes in IBD compared to non-IBD patients.

METHODS

We conducted a prospective cohort study of registered IBD patients with confirmed COVID-19 from six provinces in Iran from February to April 2020. Proven COVID-19 patients were followed up at four weeks and the frequency of outcomes was assessed. Multivariable logistic regression was used to assess associations between demographics, clinical characteristics and COVID-19 outcomes.

RESULTS

Overall, 2159 IBD patients and 4721 household members were enrolled, with 84 (3.9%) and 49 (1.1%) participants having confirmed COVID-19, respectively. Household spread of COVID-19 was not common in this cohort (1.2%). While hospitalization was significantly more frequent in IBD patients compared with non-IBD household members (27.1% vs. 6.0%, P=0.002), there was no significant difference in the frequency of severe cases. Age and presence of IBD were positively associated with hospitalization in IBD compared with non-IBD household members (OR: 1.06, 95% CI: 1.03-1.10; OR: 5.7, 95% CI: 2.02- 16.07, respectively). Age, presence of new gastrointestinal symptoms, and 5-aminosalicylic acid (5-ASA) use were associated with higher hospitalization rate in IBD patients (OR: 1.13, 95% CI: 1.05-1.23; OR: 6.49, 95% CI: 1.87-22.54; OR: 6.22, 95% CI: 1.90-20.36, respectively). Anti-tumor necrosis factor (TNF) was not associated with more severe outcomes.

CONCLUSION

Age, presence of new gastrointestinal symptoms and use of 5-ASA were associated with increased hospitalization rate among IBD patients, while anti-TNF therapy had no statistical association.

A case of COVID 19 with concomitant infection with hepatitis A

Symptoms of COVID-19 range from mild to severe with pulmonary manifestations being predominate, however, liver injury is not rare. There might be a reciprocal influence between COVID-19 and hepatic disease. While high levels of liver enzyme is associated with an increased prevalence of severe complications, search for other etiologies of hepatic disease should be not be ignored. We report a case of COVID-19 presented with acute fulminant hepatitis A (HAV) without previous history.

Prevalence of impaired renal function and determinants in the southwest of Iran

BACKGROUND

Chronic kidney disease (CKD) is a growing global health problem with faster progression in developing countries such as Iran. Here we aimed to evaluate the prevalence and determinants of CKD stage III+.

METHODS

This research is part of the Khuzestan Comprehensive Health Study (KCHS), a large observational population-based cross-sectional study in which 30,041 participants aged 20 to 65 were enrolled. CKD was determined with estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73m2, based on two equations of Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI). The multivariate logistic regression was used to evaluate the CKD stage III+ determinants.

RESULTS

Prevalence of CKD stage III+ is estimated to be 7.1, 5.5, and 5.4% based on MDRD, CKD-EPI, and combination of both equations, respectively. More than 89% of CKD subjects aged higher than 40 years. In regression analysis, age more than 40 years had the strongest association with CKD stage III+ probability (OR: 8.23, 95% CI: 6.91-9.18). Higher wealth score, hypertension, High-Density Lipoprotein levels less than 40 mg/dl, and higher waist to hip ratio were all associated with CKD stage III+ while Arab ethnicity showed a protective effect (OR: 0.69, 95% CI: 0.57-0.78).

CONCLUSION

Our findings provide detailed information on the CKD stage III+ and its determinants in the southwest region of Iran. Due to strong association between age and CKD stage III+, within a few decades we might expect a huge rise in the CKD prevalence.

Characterization of a xenograft model for anti-CD19 CAR T cell studies

PURPOSE

Chimeric antigen receptor (CAR) T cell development for B cell malignancies treatment has triggered a paradigm shift in oncology. The development of anti-CD19 CAR T cells relies primarily on a panel of cell line-derived xenograft models, including Raji cells; however, the behavior of this model is under debate. We attempted to characterize this lymphoma model and propose outcome measures for CAR T cell studies METHODS: Raji cell line was inoculated into NOG mice via intra-venous (IV), intra-peritoneal (IP), and subcutaneous (SC) routes with different inoculum sizes, and consequent clinical and histopathological outcomes were assessed.

RESULTS

Inoculum sizes of 10⁵-10⁶ resulted in a complete take rate. The mice with IV and SC-inoculated Raji cells presented the shortest and longest survival among lymphoma-bearing mice, respectively (P < 0.01). The IP group had the highest number of both infiltrated organs (P < 0.05; compared to SC) and involvement of lymphatic sites (P < 0.05; compared to IV). The number of lymphoma lesions on the liver was higher in the IV compared to IP (P < 0.001) and SC (P < 0.05).

CONCLUSION

We demonstrate that the Raji cell line inoculation route could determine the xenograft model system behavior in terms of survival, tumor burden, and dissemination pattern and gives the model the specific features suitable for testing the specific hypothesis in CAR T cell therapy. We also conclude outcome measures for CAR T cell studies that do not require imaging techniques.

Efficacy and Safety of Tofacitinib for Treatment of Moderate to Severe Active Ulcerative Colitis: First Report from Iran

BACKGROUND

Tofacitinib, a selective inhibitor of JAK/STAT pathway, has recently become available in our region. Here, we examined the safety and efficacy of tofacitinib in active ulcerative colitis (UC).

METHODS

In a prospective, non-randomized, placebo-free, 52-week clinical trial defined in two phases of induction and maintenance, adult patients with active UC and no response or loss of response to previous conventional treatments, or anti-TNF were recruited (IRCT20181217042020N2). Patients received 10 mg/BID of tofacitinib for 8 weeks. Clinically responding patients were entered into the maintenance phase and received tofacitinib 5 mg/BID for 44 weeks. Clinical evaluation, biochemical tests and endoscopy at time points of baseline, 8, 24 and 52 weeks were performed. The primary outcome was clinical remission at 8 and 52 weeks.

RESULTS

Fifty out of 53 enrolled patients completed the induction phase. Clinical response and clinical remission at 8 weeks occurred in 84% and 9.5%, respectively. Forty-two patients who had clinical response entered the maintenance phase. Clinical remission based on the total Mayo score and the partial Mayo score occurred in 38.9% and 55.3% at 24 weeks and in 61.1% and 72.2% at 52 weeks, respectively. There was significant correlation between the total and partial Mayo score with regard to clinical remission in both 24 and 52 weeks. No serious adverse events, no case of herpes zoster, but two cases of deep vein thrombosis were seen.

CONCLUSIONS

Our study showed acceptable efficacy and safety for tofacitinib and suggested a correlation between the total Mayo score with partial Mayo score with regard to clinical remission.

The relationship between bone mineral indices and survival in patients on peritoneal dialysis

Introduction: Disorders of minerals metabolism are common metabolic problems in patients undergoing peritoneal dialysis (PD) which causes increase in mortality and morbidity in these patients. Objectives: In this study, the relationship between bone metabolic indices and mortality rate in patients on PD was assessed. Patients and Methods: Data were collected from Iranian peritoneal dialysis registry database, covering the period 2009–2015 and comprised 2000 adult patients. Patients with less than three months follow-up and incomplete data were excluded. Demographic and some laboratory data (including age, gender, body mass index, serum albumin, dialysis vintage and comorbidities) of patients recorded. Additionally, the unadjusted and adjusted, hazard ratios (HRs) of serum phosphorus (P), calcium (Ca) and parathyroid hormone (PTH) levels, to find their association with mortality were calculated, using the Cox proportional-hazards model. Results: In total, 1197 out of 2000 patients had the inclusion criteria and were included in the study. We found that serum iPTH (intact parathyroid hormone) over 600 pg/mL significantly increased the mortality rate by 2.7 times compared to iPTH levels between 200 to 600 pg/ mL (HR: 2.7, P=0.002). Additionally, the serum phosphorus level less than 4 mg/dL was significantly (P=0.0001) related to higher mortality rate (HR: 1.6). There was no significant association of serum calcium and alkaline phosphatase (ALP) levels with mortality (P > 0.05). Conclusion: Although high serum iPTH and low-serum phosphorus levels could determine the mortality risk in PD patients, Ca and ALP levels were not risk factors for mortality.

Efficacy of Anti-TNF Therapy for the Treatment of Patients with Moderate-to-Severe Inflammatory Bowel Disease; a First Iranian Report

BACKGROUND The anti-TNF drugs are shown to be highly effective in treatment of patients with moderate-tosevere inflammatory bowel disease (IBD). Here, we aimed to assess the efficacy and safety of antiTNF therapy at the national level. METHODS IBD patients aged 15 > years who received Infliximab and/or CinnoRA® between 2013 to July 2018 were identified. The data extracted from medical dossier and telephonic interview. The efficacy of therapy was defined as time to drug discontinuation or need for IBD-related surgery. The safety was assessed based on patient's reported adverse events. RESULTS We included 315 patients. The mean age of patients was 37.2 years and 62.2% of them developed the disease before age 30 years. Involvement of masculoskeletal system was reported in 7.3% of patients. Partial and complete response to Anti-TNF therapy was seen in 67% of patients. About 16% of patients did not respond to induction therapy and 16.9% of patients lost their response to Anti-TNF during one year. No serious adverse events, serious opportunistic infection, tuberculosis and malignancies reported by patients. Two patients reported pneumonia. CONCLUSION This study for the first time in our country, provides the evidences for efficacy of anti-TNF therapy in moderate to severe IBD patients.

Strategies for Prevention and Treatment of Peritoneal Fibrosis: A Scientometric Study

Background:

Interest in using peritoneal dialysis (PD) shows global and national increase. However, it remains a challenge to prevent the progression of PD-associated fibrosis in clinical practice. Here, we assessed the status of scientific publications in prevention and management of PD-associated fibrosis in a scientometric study.

Methods:

We retrieved the bibliometric data by search terms “encapsulating peritoneal fibrosis,” “treatment or prevention,” and their synonyms in the Scopus databases until December 2, 2017. Data were analyzed using Scopus analysis tools, SPSS version 15 and Visualizing Scientific Landscapes viewer version 1.6.5.

Results:

Number of publications showed a steady significant increase (P < 0.001) reaching to 390 documents. Japan had the highest share (21.3%) followed by United Kingdom. Coauthorship network assessment assigned “Ikeda M.” from Japan as the top author. The top source of documents was “Peritoneal Dialysis International.” Most of documents were original articles focusing on prevention and management of malignant fibrosis of peritoneum (72.6%). The documents were cited totally 5636 times with average citations per article of 14.45, and relatively high H-index of 38.

Conclusions:

Despite the global increasing trend in scientific output in this field, contribution of our country is very small. Perhaps more national and international collaboration is required to encourage our researchers for producing more scientific products.

Iranian Registry of Crohn's and Colitis: study profile of first nation-wide inflammatory bowel disease registry in Middle East

Background/Aims

A recent study revealed increasing incidence and prevalence of inflammatory bowel disease (IBD) in Iran. The Iranian Registry of Crohn’s and Colitis (IRCC) was designed recently to answer the needs. We reported the design, methods of data collection, and aims of IRCC in this paper.

Methods

IRCC is a multicenter prospective registry, which is established with collaboration of more than 100 gastroenterologists from different provinces of Iran. Minimum data set for IRCC was defined according to an international consensus on standard set of outcomes for IBD. A pilot feasibility study was performed on 553 IBD patients with a web-based questionnaire. The reliability of questionnaire evaluated by Cronbach’s α.

Results

All sections of questionnaire had Cronbach’s α of more than 0.6. In pilot study, 312 of participants (56.4%) were male and mean age was 38 years (standard deviation=12.8) and 378 patients (68.35%) had ulcerative colitis, 303 subjects (54,7%) had college education and 358 patients (64.74%) were of Fars ethnicity. We found that 68 (12.3%), 44 (7.9%), and 13 (2.3%) of participants were smokers, hookah and opium users, respectively. History of appendectomy was reported in 58 of patients (10.48%). The most common medication was 5-aminosalicylate (94.39%).

Conclusions

To the best of our knowledge, IRCC is the first national IBD registry in the Middle East and could become a reliable infrastructure for national and international research on IBD. IRCC will improve the quality of care of IBD patients and provide national information for policy makers to better plan for controlling IBD in Iran.

Systemic Infusion of Autologous Adipose Tissue-Derived Mesenchymal Stem Cells in Peritoneal Dialysis Patients: Feasibility and Safety

Objective

Using mesenchymal stem cells (MSCs) is regarded as a new therapeutic approach for improving fibrotic diseases. the aim of this study to evaluate the feasibility and safety of systemic infusion of autologous adipose tissue-derived MSCs (AD-MSCs) in peritoneal dialysis (PD) patients with expected peritoneal fibrosis.

Materials and Methods

This study was a prospective, open-label, non-randomized, placebo-free, phase I clinical trial. Case group consisted of nine eligible renal failure patients with more than two years of history of being on PD. Autologous AD-MSCs were obtained through lipoaspiration and expanded under good manufacturing practice conditions. Patients received 1.2 ± 0.1×10⁶ cell/kg of AD-MSCs via cubital vein and then were followed for six months at time points of baseline, and then 3 weeks, 6 weeks, 12 weeks, 16 weeks and 24 weeks after infusion. Clinical, biochemical and peritoneal equilibration test (PET) were performed to assess the safety and probable change in peritoneal solute transport parameters.

Results

No serious adverse events and no catheter-related complications were found in the participants. 14 minor reported adverse events were self-limited or subsided after supportive treatment. One patient developed an episode of peritonitis and another patient experienced exit site infection, which did not appear to be related to the procedure. A significant decrease in the rate of solute transport across peritoneal membrane was detected by PET (D/P cr=0.77 vs. 0.73, P=0.02).

Conclusion

This study, for the first time, showed the feasibility and safety of AD-MSCs in PD patients and the potentials for positive changes in solute transport. Further studies with larger samples, longer follow-up, and randomized blind control groups to elucidate the most effective route, frequency and dose of MSCs administration, are necessary (Registration Number: IRCT2015052415841N2).

Comparison of icodextrin and glucose solutions for long-dwell exchange in continuous ambulatory peritoneal dialysis patients; a preliminary study

Introduction: Icodextrin is widely used in peritoneal dialysis (PD) and several clinical observations suggest the superiority of icodextrin compared with 4.25% dextrose in optimizing peritoneal ultrafiltration (UF). However this solution has been introduced to our PD centers over the last two years. Objectives: In this study we aimed to evaluate the effects of employment of this solution in our PD patients. Patients and Methods: The study was carried out in two Iranian PD centers (Shafa and Shariati centers). We included 29 established patients (12 male and 17 female, mean age 58.9 ±11.1 years) who used icodextrin for the long-dwell exchange for last 6 months. Clinical data were collected at baseline and 6 months after icodextrin administration. Results: When the data between baseline and after 6 months of icodextrin administration was evaluated, we found no significant change in evaluated parameters including 24 hours UF, 24 hours urine volume, membrane transport type, Kt/V and creatinine clearance was observed. Conclusion: Icodextrin for the long-dwell exchange did not improve the creatinine clearance despite producing, a non-significant increase in 24-hour UF, after 6 months. Due to low proportion of patients and high inter-patients variability we cannot reach a robust conclusion. Studies with bigger sample size involving several PD centers are necessary to further address this subject.

A systematic review of preclinical studies on therapeutic potential of stem cells or stem cells products in peritoneal fibrosis

INTRODUCTION

Peritoneal fibrosis remains a serious complication of long-term peritoneal dialysis. Stem cell therapy is an innovative field of scientific investigation with potential for clinical application. Here, we systematically reviewed the studies to determine whether stem cell based therapy could improve the peritoneal fibrosis in experimental models of peritoneal fibrosis.

EVIDENCE ACQUISITION

Our systematic search of PubMed, Scopus, Web of Science, and Cochrane Library yield 5219 article. After screening for eligibility, in vivo, experimental, interventional studies using stem cells in animal models of peritoneal fibrosis; 11 articles were included. The studies underwent comprehensive review, quality assessment, and data extraction.

EVIDENCE SYNTHESIS

Mesenchymal stem cells were the most used type (90.9%) originated either from bone marrow (70%), adipose tissue (20%), or umbilical cord (10%). In 90.9% of studies, stem cells were injected after peritoneal insult and 63.6% of studies used the intraperitoneal injection route. Eight studies met the ≥50% of criteria indicated by ARRIVE recommendation. Information regarding the nature of ethical review permissions, species, strain and gender, dose, route and duration of treatment, was stated by all studies; 81.8% of the studies reported the number of animals in each group. Adverse events were reported in one study. Improvement in histological parameters including attenuation of submesothelial thickness (100%), inflammation (62.5%), angiogenesis (60%), and fibrosis (85.7%) was reported after stem cell therapy. Peritoneal permeability function by assessing the ultrafiltration, glucose transport and solute permeability was improved in all studies. Stem cell treatment resulted in mesothelial recovery in 100% of studies.

CONCLUSIONS

In preclinical studies, the use of stem cells is associated with improved peritoneal fibrosis. This may provide an important foundation to support future translational clinical research using stem cell therapy to repair the injured peritoneum and modulate immune responses in PD patients.

Mechanisms involved in altered bone metabolism in diabetes: a narrative review

Many studies have shown that change in metabolism caused by diabetes can influence the bone metabolism in a way that quality and strength of bone is decreased. A 6 times and 2 times increased risk of fracture is reported in patients with type 1 and type 2 diabetes, respectively. There are several mechanisms by which diabetes can affect the bone. The fact that some of these mechanisms are acting in opposite ways opens the door for debate on pathways by which diabetes affects the bones. On the other hand, bone is not a simple organ that only get influence from other organs, but it is an endocrine organ that by secreting the agents such as osteocalcin, adiponectin and visfatin which can affect the insulin sensitivity and metabolism. In this paper we tried to briefly assess the latest finding in this matter.

Risk factors of severe peritoneal sclerosis in chronic peritoneal dialysis patients

Peritoneal dialysis (PD) offers the healthiest way for starting renal replacement therapy (RRT) in End Stage Renal Disease patients, however exposes long-term PD patients to a dangerous complication named encapsulating peritoneal sclerosis (EPS). In this study, we searched for possible risk factors of EPS. Data were collected from two PD centers covering period 1995-2012 and comprised 464 patients. Control group defined as PD patients stayed on PD >42 month (n = 122), and case group was 12 confirmed EPS patients. Associations were analyzed using linear regression analysis. Prevalence and incidence of EPS were 2.59% and 8.9% with an incidence of 0.7% patient-years, respectively. The age at start of PD in EPS patients (32.75 ± 10.8 year) was significantly lower compared with control group (49.61 ± 16.18 year, p = .0001). The mean duration of PD in EPS and control group were 2494.4 ± 940.9 and 1890.2 ± 598.8 days (p = .002). Control group had 145 episodes of peritonitis during total duration of 7686 patient months (peritonitis rate of 1/53). This was 1/26 with a total 38 episodes of peritonitis during the total duration of 997 patient months (p = .01) for EPS group. In regression analysis, PD duration, age at PD start and duration of Ultrafiltration failure (UFF) were associated with EPS. Longer time being on PD, younger age, and higher UFF duration were the risk factors for EPS development.

Relationship between insulin resistance and subclinical atherosclerosis in individuals with and without type 2 diabetes mellitus

Background

Insulin resistance is of utmost importance as an underlying mechanism for increased risk of cardiovascular disease (CVD). We assessed the association between Homeostatic Model Assessment (HOMA-IR) and two surrogate subclinical atherosclerosis markers (SCA) among individuals with and without type 2 diabetes (DM), those who did not have any clinical presentation of the CVD.

Methods

In a cross-sectional study, 208 participants (105 diabetics and 103 non-diabetics) were enrolled from referred patients with diabetes to an academic outpatient clinic and their non-diabetic relatives in-law. Fasting serum levels of insulin, blood glucose and lipid profile, were measured. Anthropometric and blood pressure were measuremented standardly. Body Mass Index (BMI) and Homeostatic Model Assessment-Insulin Resistance (HOMA-IR) index were calculated. Coronary Artery Calcium Score(CACS) was measured using a Multi-Detctor CT scanner. Flow mediated dilation (FMD) was measured using bimode ultrasonography (with linear transducer 13,000 MHZ). Univariate and multivariate logistic regression models were used to evaluate the association between these SCA markers and HOMA index in adjusting models.

Results

CACS and HOMA-IR were higher and FMD was lower in diabetic participants than non-diabetic ones (P < 0.01) In a stepwise logistic regression model, CACS and FMD were associated with HOMA-IR (odds ratio = 1.778; 95 % confidence interval (CI): 1.211–2.726 and odds ratio = 1.557; 95 % CI: 1.601–2.275, respectively) in non-diabetics but not among diabetic participants.

Conclusions

CACS and FMD are related to insulin resistance among non-diabetic individuals, but we could not find this relationship among diabetic patients.

National Profiles of Urinary Calculi: a Comparison Between Developing and Developed Worlds

INTRODUCTION

The incidence of urolithiasis has increased in both the developed and the developing countries during the past decades. Economically, the increase of urolithiasis contributes to the rise of the healthcare burden everywhere. Moreover, this increase has been associated with a change in the epidemiology of urolithiasis in terms of age and sex distribution, and also the location and type of calculi.

MATERIALS AND METHODS

We searched the MEDLINE for relevant literature dating back to 1980. This review compared the trends in epidemiological factors affecting urolithiasis in the developed and the developing countries during the past decades.

RESULTS

People in the developing countries are more likely to contract kidney calculi at a younger age than in the developed countries. Although calculus disease is still more prevalent in men than in women, the latter are increasingly affected in both worlds. Uric acid calculi are more prevalent in the developing than in industrialized countries. There is a progressive increase in the frequency of calcium oxalate and calcium phosphate calculi in the developing countries where these used to be less frequent.

CONCLUSIONS

The incidence and prevalence of urinary calculi is increasing globally. Many factors including aging of the population, changes in diet, global warming, and employment of more accurate diagnostic tools seem to be involved in this increase. An increasing affluence and adaptation of Western diet habits in many developing countries seem likely to contribute to the changes.

Association of Brain-dead Donor's Urine Neutrophil Gelatinase-associated Lipocalin Levels With Kidney Allograft Function

INTRODUCTION

Development of delayed graft function is more prevalent in patients receiving a kidney allograft from brain-dead than living donors. This study aimed to evaluate the association between urine neutrophil gelatinase-associated lipocalin (NGAL) levels in brain-dead donors and subsequent allograft function.

MATERIALS AND METHODS

Urine NGAL concentration was measured in urine samples obtained from 24 brain-dead kidney allograft donors before organ retrieval. The 24 kidney recipients were followed for 6 months. The immunosuppressive therapy was similar for all of the recipients. Following transplantation, plasma creatinine was recorded daily during the recipient's stay in the hospital and then at 1, 3, and 6 months after transplantation. Delayed graft function was defined as the need for dialysis in the first 7 days after transplantation.

RESULTS

The mean age of the donors was 28.7 ± 11.2 years and 70.8% were men. Their median urine NGAL level was 7.4 ng/ml (range, 2 ng/mL to 45 ng/mL). Urine NGAL levels were only associated with the need for cardiopulmonary resuscitation (P = .007). On the 1st day after transplantation, 16.7% of the recipients developed delayed graft function, which was declined to 12.5% on the 2nd day and to 8.3% during the 3rd day and the following days. No significant association was observed between the donor's urine NGAL levels and graft function (P = .86).

CONCLUSIONS

Our results did not show any association between urine NGAL levels and outcome of allograft function obtained from brain-dead donors. Larger studies are required to confirm this finding.

Role of steroid hormone receptors in formation and progression of bladder carcinoma: a case-control study

PURPOSE

To compare the expression rate of sex steroid hormone receptors of estrogen (ER), progesterone (PR) and androgen (AR) in normal urothelium and urothelial bladder cancer (UBC) and to evaluate the possible associations of these receptors expression with cancer progression and patient's survival.

MATERIALS AND METHODS

We evaluated the clinical data and tumor specimens of 120 patients with pathologically confirmed primary UBC with 132 normal healthy controls. Both patients and controls selected from list of subjects who have been referred to Sina Urology clinic, and had a minimum of one year follow-up duration. Data collected from medical cords. For evaluation of expression, immunohistochemistry was performed on paraffin-embedded tissue sections using a monoclonal antibody for androgen, estrogen and progesterone receptors. Presence of at least 10% positive cells defined as positive expression.

RESULTS

None of the control subjects showed AR expression, while 22% of the patients were AR-positive. ER/PR expressions were observed in 4.2%/ and 2.5% of the cases and in 2.3% and 1.5% of the controls, respectively. A statistically significant correlation was found between AR expression and tumor stage and grade (P &lt; .001). AR-positive patients showed a significantly poorer prognosis than AR-negative cases (log-rank test, P = .02, hazard ratio = 2.12; 95% confidence interval: 1.36-4.65).

CONCLUSION

AR expression was significantly associated with higher grade and poorly differentiated tumors with unfavorable outcome. AR expression test might be useful as a diagnostic tool for determining the malignancy and outcome of UBC patients.&nbsp;

The effect of treatment with N-acetylcysteine on the serum levels of C-reactive protein and interleukin-6 in patients on hemodialysis

Patients with end-stage renal disease (ESRD) are at an increased risk of cardiovascular disease due to many factors including inflammation and oxidative stress. N-acetylcysteine (NAC) is a thiol-containing anti-oxidant with anti-inflammatory properties. We aimed to assess the effect of three months treatment with oral NAC on the plasma levels of inflammatory mediators like interleukin-6 (IL-6) and C-reactive protein (hs-CRP) in patients on hemodialysis (HD). Twenty-four patients (nine males and 15 females) on maintenance HD were recruited in the study. Their mean age was 55.3 years. All the patients received oral NAC (600 mg twice a day) for a period of three months. The serum levels of biomedical parameters and IL-6 and hs-CRP were measured at baseline and three months after initiation of treatment. A significant decrease in serum levels of hs-CRP (22.4 vs. 5.2), IL-6 (8.1 vs. 3.6), parathyroid hormone (iPTH) (257.2 vs. 158.8), ferritin (632.0 vs. 515.1) and erythrocyte sedimentation rate (ESR) (54.2 vs. 38.3) was observed following NAC treatment. Female subjects presented with a significantly higher change in serum levels of hs-CRP compared with males (23 vs. 5.4). In three subjects who were less than 40 years old, the hs-CRP and IL-6 levels showed an increase following NAC treatment. Our study found that short-term oral NAC treatment might result in the reduction of IL-6 and hs-CRP in patients who are on regular HD. This suggests that patients with ESRD may benefit from the anti-inflammatory effects of NAC.

Effect of low dose ω-3 poly unsaturated fatty acids on cognitive status among older people: a double-blind randomized placebo-controlled study

Background

Cognitive impairment is a prevalent health problem in older people and its global prevalence tends to increase parallel to the extended life expectancy in world. The beneficial effect of ω-3 PUFAs on cognitive impairment has been demonstrated in some experimental and cohort studies. In this study we aimed to assess the effect of low dose docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) supplementation on cognitive status in the elderly.

Methods

In a double-blind, randomized placebo-controlled study, 199 individuals aged ≥65 years with normal or mild to moderate cognition impairment were assigned to receive either 180 mg of DHA plus 120 mg of EPA or placebo for 180 days. Cognitive status was assessed using Mini-Mental State Examination (MMSE) and Abbreviated Mental Test (AMT) score.

Results

MMSE and AMT scores were not different at the time of allocation [18.84 (5.37), 18.55 (5.12), (P = 0.70) and 4.81 (2.79) and 4.64 (2.77), (P = 0.67) respectively] and over 6 months between the ω-3 PUFA- and placebo- treated groups [18.57 (5.21), 18.39 (5.10), (P = 0.80) and 4.64 (2.77) and 4.48 (2.69) and (P = 0.67)]. The participants were categorized based on MMSE score into normal cognition, mild and moderate cognitive impairment. After multivariate adjustment, there was no significant difference among categorized groups regarding the ω-3 PUFA effect except in normal cognition group, that amount of decline in AMT in ω-3 poly unsaturated fatty acids (PUFAs) was less than placebo group.

Conclusions

It seems that prescription of low dose ω-3 PUFAs for 6 months had no significant beneficial effects on improvement of cognition or prevention of cognitive decline in older people.

Impact of hypertension on various markers of subclinical atherosclerosis in early type 2 diabetes

Background

Presence of Diabetes Mellitus increases the risk of subclinical atherosclerosis. In this study was aimed to determine the influence of hypertension (HTN) on surrogate markers of atherosclerosis in a population of patients with early type 2 diabetes.

Methods

125 diabetic subjects drawn from Dr. Shariati outpatient’s clinic list and 153 non- diabetic subjects who were the relatives in law of diabetic participants were recruited. Participants with type 2 diabetes were free of clinical evidence of cardiovascular disease and renal involvement. Two groups of diabetic and control were further divided into two subgroups of hypertensive (known case of HTN or blood pressure ≥140/90 mmHg) and normotensive, and anthropometric characteristics, metabolic biomarkers as well as markers of subclinical atherosclerosis including Carotid intima media thickness (CIMT), flow mediated dilation (FMD) and Ankle Brachial Index (ABI) were measured.

Results

Diabetic group with a mean age of 49.9 ± 7.5 years had significantly higher CIMT (0.64 ± 0.14 vs 0.76 ± 0.19, p = 0.001) and lower FMD (16.5 ± 8.1 vs 13.3 ± 7.1, p = 0.003) and ABI (1.2 ± 0.1 vs 1.1 ± 0.1, p = 0.01) than control with mean age of 52.9 ± 10.1 years. 34% of control and 59.2% of diabetic were hypertensive. Fasting blood sugar, insulin levels and calculated insulin resistance index of HOMA IR. of hypertensive subjects were higher than normotensive subjects in both groups of diabetic and non-diabetic. Similar pattern was presented for measured inflammatory mediators of hs-CRP and IL-6. Among subclinical atherosclerosis markers, only CIMT was significantly different between hypertensive and normotensive subjects in both groups. In adjusted linear regression analysis, a constant significant association existed between age and CIMT, ABI and FMD in non-diabetic, while in diabetic, age only correlated with CIMT and not the other two markers. In multiple regression model, HTN was recognized as a risk factor for increasing CIMT (OR = 2.93, 95% CI = 1.03-8.33, p = 0.04) but not attenuating FMD or ABI.

Conclusions

Since FMD and CIMT may measure a different stage of subclinical atherosclerosis in diabetic patients, influence of HTN on these markers might be different.

Association of cardiac autonomic neuropathy with arterial stiffness in type 2 diabetes mellitus patients

Background

Diabetic patients are at the risk of cardiac autonomic neuropathy (CAN) and arterial stiffness. This study aimed to investigate the association of heart rate variability (HRV) as an index for CAN and pulse wave velocity (PWV) as an index for arterial stiffness.

Methods

Uncomplicated diabetes type-2 patients who had no apparent history of cardiovascular condition underwent HRV and PWV measurements and the results were compared with the control group consisting of non-diabetic peers. Also, the findings were adjusted for the cardiovascular risk factors and other confounding factors.

Results

A total of 64 diabetic patients (age= 52.08±8.50 years; males=33 [51.6%]) were compared with 57 controls (age= 48.74±6.18 years; males=25 [43.9%]) in this study. Hypertension, dyslipidemia, and thereby systolic blood pressure and statin use were significantly more frequent in the diabetic group, while the serum levels of cholesterol, HDL-C and LDL-C were significantly higher in the controls. Pulse wave was significantly increased in the diabetic patients (p<0.001). Main HRV parameters were significantly lower in diabetics than in controls. After adjustment for the confounders, PWV and HRV remained significantly different between the groups (p=0.01 and p=0.004, respectively). Multiple logistic regression of the association between pulse wave velocity and HRV index was independently significant both in diabetics and controls.

Conclusions

There exists a significant relationship between heart rate variability and arterial stiffness as a measure for atherosclerosis in diabetic patients, although the role of the confounding factors is noteworthy.

Conversion to sirolimus in kidney transplant recipients: a single-center study

INTRODUCTION

As an immunosuppressive treatment, cyclosporine carries a significant risk of nephrotoxicity. In this study, we assessed the safety and efficacy of sirolimus conversion in our kidney transplant recipients.

MATERIALS AND METHODS

Sirolimus conversion in 99 kidney transplant recipients was evaluated. Serum level of creatinine, glomerular filtration rate (GFR), and the occurrence of adverse effects of sirolimus were evaluated at conversion time and 1, 6, 12, 24, and 36 months after conversion.

RESULTS

The major causes of conversion were chronic allograft nephropathy and cyclosporine nephrotoxicity. The median time to conversion and follow-up were 54.7 months and 24 months, respectively. Three patients died during the study period. The acute rejection rate was 4%. In 16.6% of the patients, sirolimus was discontinued because of refractory adverse effects. No significant changes in estimated GFR and incidence of adverse effects were observed between patients with baseline estimated GFR lower or higher than 40 mL/min. Patients with early sirolimus conversion (less than 6 months after transplant) had improvement of their GFR (59.9 +/- 22.3 mL/min to 68.0 +/- 15.5 mL/min, P = .02), while kidney recipients with late conversion did not show such an improvement. The difference between GFRs in these two groups reached significant level at 12 months and stayed significant until the end of the follow-up.

CONCLUSIONS

This study emphasizes that conversion of cyclosporine to sirolimus could be associated with stable kidney allograft function. However, cyclosporine discontinuation should be considered early when it is indicated.

Seventeen years' experience of peritoneal dialysis in Iran: first official report of the Iranian peritoneal dialysis registry

BACKGROUND

To facilitate planning, national renal registries provide reliable and up-to-date information on numbers of patients with end-stage renal disease (ESRD), developing trends, treatment modalities, and outcomes. To that end, the present publication represents the first official report from Iranian Peritoneal Dialysis Registry.

METHODS

The prevalence, demographics, and clinical characteristics of patients on peritoneal dialysis (PD) were collected from all PD centers throughout the country.

RESULTS

By the end of 2009, the prevalence of ESRD was 507 per million population in Iran. The most common renal replacement modality was hemodialysis (51.2%), followed by kidney transplantation (44.7%), and then PD (4.1%). The mean age of PD patients was 46 years, and the most common causes of ESRD were diabetes (33.5%), hypertension (24.4%), and glomerulonephritis (8.2%). Overall patient mortality was 25%, with cardiac events (46%), cerebral stroke (10%), and infection (8%) being the main causes of death. The 1-, 3-, and 5-year survivals were 89%, 64%, and 49% respectively. The most common cause of dropout was peritonitis (17.6%). Staphylococcus (coagulase-negative and S. aureus) was the most prevalent causative organism in peritonitis episodes; however, in more than 50% of episodes, a sterile culture was reported. Mean baseline serum hemoglobin and albumin were 10.7 g/dL and 3.6 g/dL respectively.

CONCLUSIONS

Our registry results, representing the second largest report of PD in the Middle East, is almost comparable to available regional data. We hope that, in future, we can improve our shortcomings and lessen the gap with developed countries.

Association of overtime urine volume and ultrafiltration changes with patient survival in continuous ambulatory peritoneal dialysis patients

BACKGROUND

Associations between patient survival and baseline urine volume (UV), ultrafiltration (UF) volume, and combined UV and UF were evaluated in Iranian continuous ambulatory peritoneal dialysis (CAPD) patients.

METHODS

From 1995 to 2006, data on 1472 CAPD patients from 26 centers were collected. Demographic, clinical, and laboratory characteristics were analyzed using STATA software. Baseline UV was considered as an indicator of residual renal function and patients with an annual decrease of more than 250 cc/day were placed in decreasing UV group. The role of a new variable, net positive fluid removal, which defines as the combination of baseline UV and UF, was also evaluated.

RESULTS

Patients with higher baseline UV were significantly more married and educated and candidate for CAPD based on positive selection criteria. In dichotomous categorization, mean of serum creatinine was lower and albumin was higher in patients with UV ≥ 1000 cc/day compared with UV < 250 cc/day. A significant correlation was found between baseline UV <250 cc/day and ≥1000 cc/day and patient survival. Patients with stable UV had better survival compared with patients with decreasing UV (p = 0.04). There was no correlation between UF and patient survival. Remarkable association with patient and technique survival and net positive fluid removal ≥2000 cc/day and <500 cc/day was observed. Multiple Cox regression analysis revealed significant correlation between net positive fluid removal ≥2000 cc/day and higher patient survival [p = 0.01, hazard ratio (HR) = 13.2], higher first albumin (albumin ≥ 3.5 mg/dL, p = 0.01, HR = 0.02), and lower negative selection (p = 0.0001, HR = 11.8).

CONCLUSION

Loss of UV over time and lower net positive fluid removal increase mortality of PD patients.

The association of carotid intima media thickness with retinol binding protein-4 and total and high molecular weight adiponectin in type 2 diabetic patients

BACKGROUND

The aim of this study was to investigate whether carotid intima media thickness (CIMT) is associated with serum level of retinol- binding protein-4 (RBP4) and total and high molecular weight (HMW) adiponectin in type 2 diabetes (T2DM) without clinical symptom of atherosclerotic disease.

METHOD

101 type 2 diabetic patients (mean age, 53.63 ± 8.42 years) and 42 body mass index (BMI) matched control (mean age 50.1 ± 8.4) were recruited. The CIMT was assessed by using B-mode ultrasonography, while serum levels of RBP4 and total and HMW adiponectin were measured by using enzyme linked immunosorbant assay (ELISA). Linear regression analysis was performed with CIMT as dependent variable and adipokines and cardio metabolic risk factors as independent variables.

RESULT

The CIMT was higher in diabetic group compared to control group (p <0.05). The mean concentration of RBP4 and total and HMW adiponectin did not differ between two groups.Age (B = 0.44 P <0.05), blood pressure (B = 0.37 P = <0.05), waist circumference (B = -0.21 P <0.05) and TG (B = 0.1 P <0.05) were identified as independent predictors for CIMT in diabetic group, while RBP4 and adiponectin were not associated with CIMT neither in diabetic group nor in control group.

CONCLUSION

In conclusion, the present study showed that serum levels of RBP4 or total and HMW adiponectin were not potential predictors of CIMT in type 2 diabetic patients who exposed to this risk factor at least for nine years.

Prevalence of chronic kidney disease and its associated risk factors: the first report from Iran using both microalbuminuria and urine sediment

BACKGROUND

The incidence of major risk factors of chronic kidney disease (CKD) in the world is on the rise, and it is expected that this incidence and prevalence, particularly in developing countries, will continue to increase. Using data on urinary sediment and microalbuminuria, we aimed to estimate the prevalence of CKD in northeast Iran.

METHODS

In a cross-sectional study, the prevalence of CKD in a sample of 1557 regionally representative people, aged ≥ 18 years, was analyzed. CKD was determined based on glomerular filtration rate (GFR) and microalbuminuria. Life style data, urine and blood samples were collected. Urine samples without any proteinuria in the initial dipstick test were checked for qualitative microalbuminuria. If the latter was positive, quantitative microalbuminuria was evaluated.

RESULTS

1557 subjects with a mean age of 56.76 ± 12.04 years were enrolled in this study. Based on the modification of diet in renal disease (MDRD) equation, 137 subjects (8.89%) were categorized as CKD stages III-V. Based on urine abnormalities, the prevalence of combined CKD stages I and II was 10.63%, and based on macro- and microalbuminuria it was 14.53%. The prevalence of CKD was significantly associated with sex, age, marital status, education, diabetes mellitus (DM), hypertension (HTN), ischemic heart disease (IHD), waist to hip ratio, myocardial infarction (MI), and cerebrovascular accident (CVA).

CONCLUSION

CKD and its main risk factors are common and represent a definite health threat in this region of Iran. Using and standardizing less expensive screening tests in low resource countries could be a good alternative that may improve the outcome through early detection of CKD.

Carotid intima media thickness, brachial flow mediated dilation and previous history of gestational diabetes mellitus

AIM

Gestational diabetes mellitus (GDM) is a common pregnancy condition with long-term complications. We examined the association between inflammatory mediators and early atherosclerosis process by measuring the flow mediated dilatation (FMD) of brachial artery and carotid intima media thickness (CIMT) in women with previous GDM (pGDM).

MATERIAL AND METHODS

Women with and without pGDM with an average of 4 years following the indexed pregnancy, participated in this study. Serum levels of IL-6, hs-CRP, adiponectin, homocystein and other biomedical parameters were measured. The existence of early atherogenesis process was evaluated by measuring CIMT and FMD.

RESULTS

HOMA-IR and insulin were significantly higher in women with pGDM. Women with pGDM had slightly higher CIMT and significantly lower percent of brachial FMD. FMD and CIMT, adjusted for age and blood pressure, showed the same pattern. FMD showed no correlation with biochemical or inflammatory markers.

CONCLUSION

Follow-up of this group of women, who are at increased risk of cardiovascular disease, with FMD should be considered.

Differences in cardiovascular disease risk factors associated with maximum and mean carotid intima-media thickness among hemodialysis patients

INTRODUCTION

Carotid intima-media thickness (CIMT) could be used as a surrogate marker of atherosclerosis in hemodialysis patients. Since different mechanisms are involved in the atheroma formation and arterial wall thickness, we assessed the relationship between the maximum and the mean CIMT with different cardiovascular risk factors in dialysis patients.

MATERIALS AND METHODS

The mean and the maximum CIMT were measured using a B-mode ultrasonography in 75 hemodialysis patients, and the correlation between CIMT and cardiovascular risk factors were assessed.

RESULTS

The mean and maximum CIMT measurements were 0.5 mm (range, 0.2 mm to 1 mm) and 3.4 mm (1.4 mm to 5.6 mm), respectively. Among all the studied variables, age (P = .04, r = 0.238), HS-CRP (P = .01, r = 0.284), mean arterial blood pressure (P = .003, r = 0.343), and DM (P = .02) had significant correlations with the mean CIMT, while only age (P = .02, r = 0.473) and serum creatinine levels (P = .02, r = -0.493) were significantly associated with the maximum CIMT. A positive nonsignificant correlation was observed between the mean and maximum CIMT values (P = .08, R2 linear = 0.214).

CONCLUSIONS

These findings suggest that in dialysis patients, effects of cardiovascular risk factors on the mean and maximum CIMT might be different. Further studies are recommended to evaluate the prediction impact of each risk factor in end-stage renal disease patients compared with otherwise healthy individuals.

Cytokine profile, Foxp3 and nuclear factor-kB ligand levels in multiple sclerosis subtypes

AIM

Patients with multiple sclerosis (MS) present with heterogeneous clinical courses. To elucidate whether different immunopathological mechanisms are involved in MS subgroups, we compared serum levels of TNF-α, IL-1β, hs-CRP, receptor activator of nuclear factor kappa-B ligand (RANKL) and peripheral blood foxp3 expression in clinical subtypes of MS (relapsing remitting: RR-MS; secondary progressive: SP-MS; primary progressive: PP-MS) and healthy subjects.

METHODS

In a case-control study, 72 healthy individuals and 72 age- and sex-matched multiple sclerotic patients (57% RR-MS, 18% SP- MS and 25% PP-MS) were evaluated. The age, gender distribution, and BMI of MS patients in these three sup-types were similar. The serum levels of TNF-α, IL-1β, and RANKL were measured by ELISA. hs-CRP was measured by imunoturbidimetric method. Peripheral blood mononuclear cells expression of Foxp3 was measured by real time PCR.

RESULTS

A significant elevation of TNF-α, hs-CRP, IL-1β and RANKL and diminution of Foxp3 expression in MS patients compared to control was found (P<0.001). PP-MS had highest levels of TNF-α, IL-1β, CRP and RANKL, and lowest levels of foxp3, with difference in TNF-α reached significant level (P<0.01). RANKL and TNF-α showed a reverse (P<0.01) significant correlation with Foxp3 relative expression levels. Patients with early age onset (onset before 30 years) had significantly higher levels of hs-CRP compared to late age onset patients.

CONCLUSION

These data demonstrate the presence of immunopathogenesis differences between relapsing and non-relapsing form and is also the first to stress a role for cytokine RANKL in MS patients.

Inflammatory profile, age of onset, and the MTHFR polymorphism in patients with multiple sclerosis

Both genetic and inflammatory factors are suspected in the etiology of multiple sclerosis (MS). Of genetic factors, the methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism has been associated with increased levels of plasma homocysteine, a neuronal excitotoxic amino acid. Sclerotic patients also have elevated levels of plasma and CSF homocysteine. In this study, the association between C677T polymorphism and MS was tested by recruiting 230 healthy and 194 multiple sclerotic age- and gender-matched patients. The MTHFR C677T polymorphism and the serum levels of inflammatory mediators IL-1β, TNFα, and CRP were measured. TNFα, CRP, and IL-1β levels were significantly higher in sclerotic patients. T allele was 1.7 times more present in this group. In patient's group, the levels of all inflammatory mediators were higher in T/T compared to two other genotypes. Evaluation of the age of onset of disease revealed that subjects with T allele developed the MS disease, almost 4 years sooner than other genotype. We concluded that having T allele of C677T in MS might be accompanied with higher levels of serum inflammatory mediators and a vulnerability to earlier age of onset of disease. Further studies are needed to elucidate the underlying mechanisms.

Serial combination therapy: is immune modulation in multiple sclerosis enhanced by initial immune suppression?

Background

Although the concept that an initial course of immune-suppression facilitates subsequent immune-modulation (such as Th1 to Th2 deviation) is attractive for several autoimmune diseases, such a mechanism for serial-combination therapy has never been formally demonstrated. Recently, brief mitoxantrone induction-chemotherapy followed by immune-modulation with glatiramer acetate (GA) was significantly more effective at reducing multiple sclerosis disease activity than with GA alone.

Objective

To examine whether the benefit of initial immune suppression with mitoxantrone before GA treatment is associated with more efficient immune modulation.

Methods

IgG1/IgG4 GA-reactive antibody profiles, previously established as markers of GA-induced Th2 immune-deviation, were prospectively measured in vivo in patients treated with GA alone or with mitoxantrone induction therapy followed by GA.

Results

Significant and sustained increase in IgG4 antibodies (and the anticipated reversal of the IgG1/IgG4 ratio) was seen in patients treated with GA alone. Combination therapy resulted in lesser IgG4 induction (and no reversal of IgG1/IgG4 ratio). Thus, the enhanced efficacy of mitoxantrone–GA combination regimen was associated with decreased, rather than increased, efficiency of shifting the GA-reactive IgG1/IgG4 antibody profile.

Conclusion

These results provide important insights into mechanisms of combination therapy and therapeutic strategies for autoimmune diseases.

Natalizumab effects on immune cell responses in multiple sclerosis

OBJECTIVE

Our objective was to study in vivo biological effects of natalizumab on immune cell phenotype and function in multiple sclerosis (MS) patients.

METHODS

Blood was obtained before and after serial monthly natalizumab infusions to track functional expression of VLA-4 and migratory capacity of immune cells. The impact of infusion on activation thresholds of immune cells was evaluated.

RESULTS

Preinfusion VLA-4 expression differed across immune cell subsets. Natalizumab significantly, albeit partially, diminished VLA-4 expression on circulating immune cells. Cell subsets were differentially affected. Treatment significantly decreased migratory capacity of immune cells, correlating well with changes in VLA-4 expression. Effects of a single dose were not saturating and did not persist through the monthly dose interval. Infusion effect varied across patients but was remarkably stable in individual patients, over multiple infusions. Treatment significantly modulated proliferative responses of immune cells.

INTERPRETATION

To our knowledge, we provide first proof of concept that natalizumab diminishes migratory capacity of immune cells. Our prospective study further shows that effects of therapy likely (1) differ for distinct immune cell subsets, (2) are not sustained over current dose interval, (3) have unique profiles in individual patients, and (4) include modulation of activation threshold of immune cells. Monitoring these parameters could be relevant to ongoing safety and efficacy considerations.