Altered proteomics profile in the amnion of patients with oligohydramnios

In pregnancy, idiopathic oligohydramnios is an obstetrical complication that compromises maternal health with poor perinatal outcome. Effective therapeutic treatment of this condition has been hampered by the unknown etiology and lack of understanding of cellular and molecular mechanisms that underlie idiopathic oligohydramnios. Amniotic fluid volume (AFV) is determined by intramembranous (IM) transport of amniotic fluid across the amnion and this pathway is regulated to maintain AFV within the normal range. To gain understanding of the causes of idiopathic oligohydramnios, we performed proteomics analysis of the human amnion to investigate the changes in protein expression profiles of cellular transport pathways and regulators in patients with oligohydramnios. Placental amnions from five patients with normal pregnancies and five patients with oligohydramnios were subjected to proteomics experiments followed by bioinformatics analysis. Using Ingenuity Pathway Analysis (IPA) software, five categories of biological functions and multiple canonical pathways within each category were revealed. The top differentially expressed proteins that participate in mediating these pathways were identified. The functional pathways activated include: (a) cellular assembly and organization, (b) cell signaling and energy metabolism, and (c) immunological, infectious, and inflammatory functions. Furthermore, the analysis identified the category of pathways that facilitate molecular endocytosis and vesicular uptake. Under oligohydramniotic conditions, the mediators of clathrin vesicle-mediated uptake and transport as well as intracellular trafficking mediators were up-regulated. These findings suggest that idiopathic oligohydramnios may be associated with alternations in cellular organization and immunological functions as well as increases in activity of vesicular transport pathways across the amnion.

Multiomics analyses of vesicular transport pathway-specific transcripts and proteins in ovine amnion: responses to altered intramembranous transport

Amniotic fluid volume (AFV) is determined by the rate of intramembranous (IM) transport of amniotic fluid (AF) across the amnion. This transport is regulated by fetal urine-derived stimulators and AF inhibitors. Our objective was to utilize a multiomics approach to determine the IM transport pathways and identify the regulators. Four groups of fetal sheep with experimentally induced alterations in IM transport rate were studied: control, urine drainage (UD), urine drainage with fluid replacement (UDR), and intra-amniotic fluid infusion (IA). Amnion, AF, and fetal urine were subjected to transcriptomics (RNA-Seq) and proteomics studies followed by Ingenuity Pathway Analysis. The analysis uncovered nine transport-associated pathways and four groups of differentially expressed transcripts and proteins. These can be categorized into mediators of vesicular uptake and endocytosis, intracellular trafficking, pathway activation and signaling, and energy metabolism. UD decreased IM transport rate and AFV in conjunction with enhanced expression of vesicular endocytosis regulators but reduced expression of intracellular trafficking mediators. With UDR, IM transport rate decreased and AFV increased. Energy metabolism activators increased while trafficking mediators decreased in expression. IA increased IM transport rate and AFV together with enhanced expressions of vesicular endocytosis and trafficking mediators. We conclude that IM transport across the amnion is regulated by multiple vesicular transcytotic and signaling pathways and that the mediators of intracellular trafficking most likely play an important role in determining the rate of IM transport. Furthermore, the motor protein cytoplasmic dynein light chain-1, which coexpressed in AF and fetal urine, may function as a urine-derived IM transport stimulator.

Effects of maternal western-style diet on amniotic fluid volume and amnion VEGF profiles in a nonhuman primate model

During pregnancy, high fat diet (HFD) induces maternal obesity, insulin resistance, and placental inflammatory responses that compromise placental and fetal development. Whether maternal HFD would adversely affect amniotic fluid volume (AFV) has not been explored. Vascular endothelial growth factor (VEGF) is expressed in the amnion and has been proposed as a regulator of AFV. Our aim was to investigate the effects of HFD on AFV and the associated changes in VEGF and soluble VEGF receptor 1 (sFlt-1) expression profiles in three amnion regions of a nonhuman primate model. Further, we examined the relationships between VEGF expression and HFD-induced changes in maternal metabolic status. Japanese macaques were maintained on control or HFD and amniotic fluid index (AFI) was measured as an ultrasonic estimate of AFV. Amniotic fluid VEGF concentrations were determined by ELISA and amnion VEGF and sFlt-1 mRNA levels by real-time RT-qPCR. HFD increased maternal plasma triglyceride while glucose levels were unchanged. Maternal weight gain was found in diet-sensitive animals whereas amniotic fluid VEGF concentration was reduced in diet-resistant animals. HFD did not alter AFI and there was no correlation between AFI and maternal weight or amniotic fluid VEGF concentrations. VEGF mRNA levels were lowest in secondary placental amnion while sFlt-1 mRNA were lowest in the primary placental amnion. HFD did not affect amnion VEGF or sFlt-1 mRNA expression. These findings suggest that although maternal HFD increased maternal weight in diet-sensitive and reduced amniotic fluid VEGF concentrations in diet-resistant phenotype, AFV as indicated by the AFI, was not significantly affected.

Regulation of amniotic fluid volume: insights derived from amniotic fluid volume function curves

Recent advances in understanding the regulation of amniotic fluid volume (AFV) include that AFV is determined primarily by the rate of intramembranous absorption (IMA) of amniotic fluid across the amnion and into fetal blood. In turn, IMA rate is dependent on the concentrations of yet-to-be identified stimulator(s) and inhibitor(s) that are present in amniotic fluid. To put these concepts in perspective, this review 1) discusses the evolution of discoveries that form the current basis for understanding the regulation of AFV, 2) reviews the contribution of IMA to this regulation, and 3) interprets experimentally induced shifts in AFV function curves and amnioinfusion function curves in terms of the activity of the amniotic fluid stimulator and inhibitor of IMA. In the early 1980s, it was not known whether AFV was regulated. However, by the late 1980s, IMA was discovered to be a "missing link" in understanding the regulation of AFV. Over the next 25 years the concept of IMA evolved from being a passive process to being an active, unidirectional transport of amniotic fluid water and solutes by vesicles within the amnion. In the 2010s, it was demonstrated that a renally derived stimulator and a fetal membrane-derived inhibitor are present in amniotic fluid that regulate IMA rate and hence are the primary determinants of AFV. Furthermore, AFV function curves and amnioinfusion function curves provide new insights into the relative efficacy of the stimulator and inhibitor of IMA.

High-fat diet effects on amniotic fluid volume and amnion aquaporin expression in non-human primates

Western style, high-fat diet (HFD) and associated high lipid levels have deleterious effects on fetal and placental development independent of maternal obesity and/or diabetes. Our objectives were to determine whether HFD without development of obesity would alter amniotic fluid volume (AFV) and amnion aquaporin (AQP) expression in a non-human primate model. Japanese macaques were fed either a control diet or HFD before and during pregnancy. The four quadrant amniotic fluid index (AFI) was used as an ultrasonic estimate of AFV at 120 days gestation. Amnion samples were collected at 130 days gestation by cesarean section and AQP mRNA levels were determined by quantitative RT-PCR. Similar to that in human, AQP1, AQP3, AQP8, AQP9, and AQP11 were expressed in the macaque amnion with significant differences in levels among AQPs. In macaque, neither individual AQPs nor expression profiles of the five AQPs differed between control and non-obese HFD animals. There were regional differences in AQP expression in that, AQP1 mRNA levels were highest and AQP8 lowest in reflected amnion while AQP3, AQP9, and AQP11 were not different among amnion regions. When subdivided into control and HFD groups, AQP1 mRNA levels remain highest in the reflected amnion of both groups. The HFD did not significantly affect the AFI, but AFI was positively correlated with AQP11 mRNA levels independent of diet. Collectively, these data suggest that HFD in pregnant non-obese individuals may have at most modest effects on AFV as the AFI and amnion AQP expression are not substantially altered.

Transport-associated pathway responses in ovine fetal membranes to changes in amniotic fluid dynamics

Current evidence suggests that amniotic fluid volume (AFV) is actively regulated by vesicular transport of amniotic fluid outward across the amnion and into the underlying fetal vasculature in the placenta. Our objective was to determine whether gene expression profiles of potential stimulators, inhibitors, and mediators of vesicular transport are altered in response to changes in intramembranous absorption (IMA) rate. Samples of ovine amnion and chorion were obtained from fetal sheep with normal, experimentally reduced or increased AFVs and IMA rates. Amnion and chorion levels of target mRNAs were determined by RT‐qPCR. In the amnion, caveolin‐1 and flotillin‐1 mRNA levels were unchanged during alterations in IMA rate. However, levels of both were significantly higher in amnion than in chorion. Tubulin‐α mRNA levels in the amnion but not in chorion were reduced when IMA rate decreased, and amnion levels correlated positively with IMA rate (P < 0.05). Dynamin‐2 mRNA levels were not altered by experimental conditions. Vascular endothelial growth factor (VEGF₁₆₄ and VEGF₁₆₄b) mRNA levels increased during both increases and decreases in IMA rate, whereas soluble Flt‐1 levels did not change. Neither HIF‐1α nor PBEF mRNA levels in the amnion were correlated with VEGF₁₆₄ expression levels and were not related to IMA rate. Collectively, our findings suggest that changes in amnion microtubule expression may be important in the regulation of transcellular vesicular transport of amniotic fluid and thus modulate IMA rate. Further, our results are consistent with the concept that the amnion is the rate‐limiting layer for amniotic fluid transport.

Retinoic Acid Pathway Regulation of Vascular Endothelial Growth Factor in Ovine Amnion

Vascular endothelial growth factor (VEGF) has been proposed as an important regulator of amniotic fluid absorption across the amnion into the fetal vasculature on the surface of the placenta. However, the activators of VEGF expression and action in the amnion have not been identified. Using the pregnant sheep model, we aimed to investigate the presence of the retinoic acid (RA) pathway in ovine amnion and to determine its effect on VEGF expression. Further, we explored relationships between RA receptors and VEGF and tested the hypothesis that RA modulates intramembranous absorption (IMA) through induction of amnion VEGF in sheep fetuses subjected to altered IMA rates. Our study showed that RA receptor isoforms were expressed in sheep amnion, and RA response elements (RAREs) were identified in ovine RARβ and VEGF gene promoters. In ovine amnion cells, RA treatment upregulated RARβ messenger RNA (mRNA) and increased VEGF transcript levels. In sheep fetuses, increases in IMA rate was associated with elevated VEGF mRNA levels in the amnion but not in the chorion. Further, RARβ mRNA was positively correlated with VEGF mRNA levels in the amnion and not chorion. We conclude that an RA pathway is present in ovine fetal membranes and that RA is capable of inducing VEGF. The finding of a positive relationship between amnion VEGF and RARβ during altered IMA rate suggests that the retinoid pathway may play a role through VEGF in regulating intramembranous transport across the amnion.

Hypereosinophilic Syndrome Presented as Acute Ischaemic Stroke and Raised Cardiac Enzymes

The hypereosinophilic syndromes (HES) are a group of disorders marked by the sustained overproduction of eosinophils, resulting in multiple organ damage. We report a 55-year-old lady presented with sudden onset of left-sided limb weakness and hypereosinophilia. Cerebral computerised tomography scan showed multiple small infarctions in bilateral corona radiata and right thalamus. A transesophageal echocardiogram revealed endomyocardial damage with mural thrombus suggesting Loeffler endocarditis. The multiple cerebral infarctions were probably due to cardiac thromboembolism. Treatment with prednisolone led to significant clinical improvement. This case illustrates hypereosinophilia should be considered in patients with multiple cerebral infarctions.

Vesicular uptake of macromolecules by human placental amniotic epithelial cells

INTRODUCTION

Studies in animal models have shown that unidirectional vesicular transport of amniotic fluid across the amnion plays a primary role in regulating amniotic fluid volume. Our objective was to explore vesicle type, vesicular uptake and intracellular distribution of vesicles in human amnion cells using high- and super-resolution fluorescence microscopy.

METHODS

Placental amnion was obtained at cesarean section and amnion cells were prepared and cultured. At 20%-50% confluence, the cells were incubated with fluorophore conjugated macromolecules for 1-30 min at 22 °C or 37 °C. Fluorophore labeled macromolecules were selected as markers of receptor-mediated caveolar and clathrin-coated vesicular uptake as well as non-specific endocytosis. After fluorophore treatment, the cells were fixed, imaged and vesicles counted using Imaris^® software.

RESULTS

Vesicular uptake displayed first order saturation kinetics with half saturation times averaging 1.3 min at 37 °C compared to 4.9 min at 22 °C, with non-specific endocytotic uptake being more rapid at both temperatures. There was extensive cell-to-cell variability in uptake rate. Under super-resolution microscopy, the pattern of intracellular spatial distribution was distinct for each macromolecule. Co-localization of fluorescently labeled macromolecules was very low at vesicular dimensions.

CONCLUSIONS

In human placental amnion cells, 1) vesicular uptake of macromolecules is rapid, consistent with the concept that vesicular transcytosis across the amnion plays a role in the regulation of amniotic fluid volume; 2) uptake is temperature dependent and variable among individual cells; 3) the unique intracellular distributions suggest distinct functions for each vesicle type; 4) non-receptor mediated vesicular uptake may be a primary vesicular uptake mechanism.

Factors affecting the deceased organ donation rate in the Chinese community: an audit of hospital medical records in Hong Kong

INTRODUCTION

The number of actual donors per million population is the most commonly used metric to measure organ donation rates worldwide. It is deemed inadequate, however, because it does not take into account the potential donor pool. The aim of this study was to determine the true potential for solid organ donation from deceased brain-dead donors and the reasons for non-donation from potential donors in the Chinese community.

METHODS

Medical records of all hospital deaths between 1 January and 31 December 2014 at a large regional hospital in Hong Kong were reviewed. Those who were on mechanical ventilation with documented brain injury and aged ≤75 years were classified as possible organ donors. The reasons why some potential organ donors did not become utilised organ donors were recorded and evaluated.

RESULTS

Among 3659 patient deaths, 121 were classified as possible organ donors. The mean age of the possible organ donors was 59.4 years and 72.7% of them were male. The majority (88%) were from non-intensive care units. Of the 121 possible organ donors, 108 were classified as potential organ donors after excluding 13 unlikely to fulfil brain death criteria. Finally 11 patients became actual organ donors with an overall conversion rate of 10%. Reasons for non-donation included medical contra-indication (46%), failure to identify and inform organ donation coordinators (14%), failure of donor maintenance (11%), brain death diagnosis not established (18%), and refusal by relatives (11%).

CONCLUSIONS

It is possible to increase the organ donation rate considerably by action at different stages of the donation process. Ongoing accurate audit of current practice is necessary.

Aquaporins in ovine amnion: responses to altered amniotic fluid volumes and intramembranous absorption rates

Aquaporins (AQPs) are transmembrane channel proteins that facilitate rapid water movement across cell membranes. In amniotic membrane, the AQP‐facilitated transfer of water across amnion cells has been proposed as a mechanism for amniotic fluid volume (AFV) regulation. To investigate whether AQPs modulate AFV by altering intramembranous absorption (IMA) rate, we tested the hypothesis that AQP gene expression in the amnion is positively correlated with IMA rate during experimental conditions when IMA rate and AFV are modified over a wide range. The relative abundances of AQP1, AQP3, AQP8, AQP9, and AQP11 mRNA and protein were determined in the amnion of 16 late‐gestation ovine fetuses subjected to 2 days of control conditions, urine drainage, urine replacement, or intraamniotic fluid infusion. AQP mRNA levels were determined by RT‐qPCR and proteins by western immunoblot. Under control conditions, mRNA levels among the five AQPs differed more than 20‐fold. During experimental treatments, mean IMA rate in the experimental groups ranged from 100 ± 120 mL/day to 1370 ± 270 mL/day. The mRNA levels of the five AQPs did not change from control and were not correlated with IMA rates. The protein levels of AQP1 were positively correlated with IMA rates (r² = 38%, P = 0.01) while the remaining four AQPs were not. These findings demonstrate that five AQPs are differentially expressed in ovine amnion. Our study supports the hypothesis that AQP1 may play a positive role in regulating the rate of fluid transfer across the amnion, thereby participating in the dynamic regulation of AFV.

Vascular Endothelial Growth Factor Activation of Intramembranous Absorption: A Critical Pathway for Amniotic Fluid Volume Regulation

OBJECTIVE

The purpose of this review is to propose a critical role for vascular endothelial growth factor (VEGF) in mediating the transfer of amniotic fluid from the amniotic compartment through the fetal membranes and fetal surface of the placenta into fetal blood.

METHODS

Experimental findings in humans and animal models on the action of VEGF in mediating fluid transfer are reviewed and interpreted in order to postulate a proposed mechanism for VEGF regulation of amniotic fluid absorption through the fetal membranes and placenta.

RESULTS

Recent scientific advances suggest that up-regulation of VEGF gene expression in the amnion and chorion is associated with increased transfer of amniotic fluid into fetal blood. The possible mechanisms of action for VEGF appear to involve regulation of intramembranous blood vessel proliferation and membrane transport via passive permeation as well as nonpassive transcytotic vesicular movement of fluid.

CONCLUSION

Currently evolving concepts suggest that amniotic fluid volume is regulated through modulation of the rate of intramembranous absorption of amniotic fluid by both passive and nonpassive mechanisms. The permeability factor VEGF appears to be a critical regulator of amniotic fluid transport in the fetal membranes.

Pre-delivery Changes in Amniotic Fluid Volume and Composition in Sheep

OBJECTIVE

To determine the changes in amniotic fluid (AF) volume and solute concentrations during the last 3 weeks of gestation in fetal sheep with a ligated urachus.

METHODS

AF volume as well as solute concentrations of AF, fetal urine, fetal blood, and maternal blood were measured serially over the last 24 days of gestation in chronically catheterized fetal sheep. Statistical analyses included regression analysis and analysis of variance (ANOVA).

RESULTS

Delivery occurred at 145.5 +/- 1.1 (SE) days (n = 11 animals). AF volume averaged 913 +/- 46 mL (n = 119 determinations total from 11 animals) and was unchanged with time when analyzed against either gestational age (P = .9) or time prior to delivery (P = .81). Amniotic osmolality, sodium, chloride, glucose, and calcium concentrations decreased as gestation progressed, while potassium and lactate concentrations increased. Only amniotic lactate underwent a pre-delivery increase in concentration. From multivariate regression, AF solute concentrations correlated positively with fetal blood and urine concentrations and negatively with gestational age.

CONCLUSIONS

In fetal sheep with a ligated urachus, AF volume does not decrease prior to labor and delivery. This differs from the sharp pre-delivery decrease in AF volume that occurs in rats, mice, and pigs and is similar to the relatively constant AF volume in humans, baboons, and monkeys. Further, pre-delivery changes in AF lactate concentration may reflect the consequences of a low AF volume. Regression analysis suggests that fetal blood and urine independently contribute to AF solute concentrations and that gestational age-specific changes in intramembranous transport also may contribute.

Clozapine-induced acute interstitial nephritis

Acute interstitial nephritis is a common cause of acute kidney injury. Acute interstitial nephritis is most commonly induced by drug although the cause may also be infective, autoimmune, or idiopathic. Although eosinophilia and eosinophiluria may help identify this disease entity, the gold standard for diagnosis remains renal biopsy. Prompt diagnosis is important because discontinuation of the culprit drugs can reduce further kidney injury. We present a patient with an underlying psychiatric disorder who was subsequently diagnosed with clozapine-induced acute interstitial nephritis. Monitoring of renal function during clozapine therapy is recommended for early recognition of this rare side-effect.

Intrarenal abscess caused by community-associated methicillin-resistant Staphylococcus aureus in a transplanted kidney

Emergence of multidrug-resistant bacteria is important in solid organ transplant recipients, because it can jeopardize patient and graft survival. Methicillin-resistant Staphylococcus aureus (MRSA) infections are not rare in kidney transplant recipients. On the other hand, infections related to community-associated MRSA (CA-MRSA) strains are seldom reported in the literature. Herein, we report the first patient, to our knowledge, with CA-MRSA renal graft abscess who was successfully treated with drainage and parenteral antibiotics.

Differential expression and regional distribution of aquaporins in amnion of normal and gestational diabetic pregnancies

The region of the amnion overlying the placenta plays an active role in fluid exchange between amniotic fluid and fetal blood perfusing the surface of the placenta, whereas little transfer occurs across the reflected amnion that contacts the membranous chorion. Because aquaporins (AQPs) facilitate rapid movement of water across cells, we hypothesized that AQP gene expression in placental amnion is higher than in reflected amnion. Furthermore, because gestational diabetes mellitus (GDM) is often associated with polyhydramnios, we hypothesized that amnion AQP gene expression is reduced when amniotic fluid volume is elevated. Human placental and reflected amnion were obtained at cesarean delivery and subjected to relative quantitation of AQP mRNA by real-time RT-qPCR and proteins by western immunoblot. Amnion mRNA levels of five AQPs differed by up to 400-fold (P < 0.001), with AQP1 and AQP3 most abundant, AQP8 least and AQP9 and AQP11 intermediately expressed. Aquaporin proteins showed a similar profile. Aquaporin mRNA abundance was higher (P < 0.001) in placental than reflected amnion, whereas protein levels were lower (P < 0.01). In GDM pregnancies, neither AQP mRNA nor protein levels were different from normal. There was no correlation between AQP mRNA or protein levels with the amniotic fluid index in normal or GDM subjects. We conclude that there is a strong differential expression profile among individual AQPs and between regions of the amnion. These findings suggest differences in contribution of individual AQPs to water transport in the two regions of the amnion. Furthermore, AQP expression in the amnion is not altered in patients with GDM.

Regulation of amniotic fluid volume: mathematical model based on intramembranous transport mechanisms

Experimentation in late-gestation fetal sheep has suggested that regulation of amniotic fluid (AF) volume occurs primarily by modulating the rate of intramembranous transport of water and solutes across the amnion into underlying fetal blood vessels. In order to gain insight into intramembranous transport mechanisms, we developed a computer model that allows simulation of experimentally measured changes in AF volume and composition over time. The model included fetal urine excretion and lung liquid secretion as inflows into the amniotic compartment plus fetal swallowing and intramembranous absorption as outflows. By using experimental flows and solute concentrations for urine, lung liquid, and swallowed fluid in combination with the passive and active transport mechanisms of the intramembranous pathway, we simulated AF responses to basal conditions, intra-amniotic fluid infusions, fetal intravascular infusions, urine replacement, and tracheoesophageal occlusion. The experimental data are consistent with four intramembranous transport mechanisms acting in concert: 1) an active unidirectional bulk transport of AF with all dissolved solutes out of AF into fetal blood presumably by vesicles; 2) passive bidirectional diffusion of solutes, such as sodium and chloride, between fetal blood and AF; 3) passive bidirectional water movement between AF and fetal blood; and 4) unidirectional transport of lactate into the AF. Further, only unidirectional bulk transport is dynamically regulated. The simulations also identified areas for future study: 1) identifying intramembranous stimulators and inhibitors, 2) determining the semipermeability characteristics of the intramembranous pathway, and 3) characterizing the vesicles that are the primary mediators of intramembranous transport.

Prostaglandin E2 regulation of amnion cell vascular endothelial growth factor expression: relationship with intramembranous absorption rate in fetal sheep

We hypothesized that prostaglandin E2 (PGE2) stimulates amniotic fluid transport across the amnion by upregulating vascular endothelial growth factor (VEGF) expression in amnion cells and that amniotic PGE2 concentration correlates positively with intramembranous (IM) absorption rate in fetal sheep. The effects of PGE2 at a range of concentrations on VEGF 164 and caveolin-1 gene expressions were analyzed in cultured ovine amnion cells. IM absorption rate, amniotic fluid (AF) volume, and PGE2 concentration in AF were determined in late-gestation fetal sheep during control conditions, isovolumic fetal urine replacement (low IM absorption rate), or intra-amniotic fluid infusion (high IM absorption rate). In ovine amnion cells, PGE2 induced dose- and time-dependent increases in VEGF 164 mRNA levels and reduced caveolin-1 mRNA and protein levels. VEGF receptor blockade abolished the caveolin-1 response, while minimally affecting the VEGF response to PGE2. In sheep fetuses, urine replacement reduced amniotic PGE2 concentration by 58%, decreased IM absorption rate by half, and doubled AF volume (P < 0.01). Intra-amniotic fluid infusion increased IM absorption rate and AF volume (P < 0.01), while amniotic PGE2 concentration was unchanged. Neither IM absorption rate nor AF volume correlated with amniotic PGE2 concentration under each experimental condition. Although PGE2 at micromolar concentrations induced dose-dependent responses in VEGF and caveolin-1 gene expression in cultured amnion cells consistent with a role of PGE2 in activating VEGF to mediate AF transport across the amnion, amniotic PGE2 at physiological nanomolar concentrations does not appear to regulate IM absorption rate or AF volume.

Ovine fetal swallowing responses to polyhydramnios

Swallowing of amniotic fluid by late gestation fetuses increases when amniotic fluid volume (AFV) is elevated. Our objectives were to quantitatively characterize fetal swallowing when AFV is elevated above normal to polyhydramniotic levels and to explore the mechanisms that mediate these changes. Late gestation fetal sheep were studied under basal conditions and during intra‐amniotic infusion of lactated Ringer's solution. Control AFV averaged 631 ± 214 mL (SE, n = 6), swallowed volume was 299 ± 94 mL/day, and there were 5.7 ± 1.8 bouts/day of rapid swallowing. During intra‐amniotic infusion, AFV (3065 ± 894 mL) and daily swallowed volume (699 ± 148 mL/day) increased (P < 0.05) and the number of bouts reached a maximum of 13.7 ± 2.0 bouts/day when AFV exceeded 1500 mL. Unexpectedly, the volume swallowed per bout (57.3 ± 5.8 mL, n = 102) did not vary with AFV (r = 0.023, P = 0.81). Neither the number of swallows/day nor the volume/swallow changed consistently with elevated AFV. Daily swallowed volume increases and reaches a maximum of twice normal as AFV approaches polyhydramniotic levels. Mechanistically, the increase in swallowing was achieved primarily by an increase in the number of bouts of swallowing per day rather than the expected passive increase in volume per bout. This implies changes in fetal behavior as AFV was elevated. Furthermore, swallowed volume was four times more sensitive to increases in AFV than reported previously.

Daily swallowed volume in the ovine fetus varies sharply with changes in amniotic fluid volume around normal and reaches a maximum as amniotic fluid volume exceeds 2000 mL. These changes are mediated by altering the number of bouts of swallowing per day rather than the volume swallowed per bout. Retrograde esophageal flow was normally low but became large as daily swallowed volume increased above 900 mL/day.

Inhibitor of intramembranous absorption in ovine amniotic fluid

Intramembranous absorption increases during intra-amniotic infusion of physiological saline solutions. The increase may be due partly to the concomitant elevation in fetal urine production as fetal urine contains a stimulator of intramembranous absorption. In this study, we hypothesized that the increase in intramembranous absorption during intra-amniotic infusion is due, in part, to dilution of a nonrenal inhibitor of intramembranous absorption that is present in amniotic fluid. In late-gestation fetal sheep, amniotic fluid volume and the four primary amniotic inflows and outflows were determined over 2-day intervals under three conditions: 1) control conditions when fetal urine entered the amniotic sac, 2) during intra-amniotic infusion of 2 l/day of lactated Ringer solution when urine entered the amniotic sac, and 3) during the same intra-amniotic infusion when fetal urine was continuously replaced with lactated Ringer solution. Amniotic fluid volume, fetal urine production, swallowed volume, and intramembranous absorption rate increased during the infusions independent of fetal urine entry into the amniotic sac or its replacement. Lung liquid secretion rate was unchanged during infusion. Because fetal membrane stretch has been shown not to be involved and because urine replacement did not alter the response, we conclude that the increase in intramembranous absorption that occurs during intra-amniotic infusions is due primarily to dilution of a nonrenal inhibitor of intramembranous absorption that is normally present in amniotic fluid. This result combined with our previous study suggests that a nonrenal inhibitor(s) together with a renal stimulator(s) interact to regulate intramembranous absorption rate and, hence, amniotic fluid volume.

Abstract P1-01-21: Is it safe to skip intra-operative frozen section examination of sentinel lymph node for core biopsy-diagnosed DCIS?

Background

Our initial experience on sentinel lymph node (SLN) biopsy with on-table frozen section examination has shown to be an accurate alternative to axillary dissection in the staging of invasive breast cancer. Patients with a preoperative diagnosis of ductal carcinoma in-situ (DCIS) by core biopsy follow a similar treatment pathway because the risk of axillary metastasis and histological upstaging in the final excisional specimen is not negligible. Intra-operative frozen section reporting facilitates axillary clearance in a single operation when necessary. However, with the declining role of completion axillary dissection for those with minimal SLN involvement, its significance in DCIS is questioned.

Methods

A retrospective analysis was performed for patients with core biopsy-diagnosed DCIS undergoing SLN biopsy at the time of definitive surgery. Those with evidence of microinvasion in the core biopsy specimen were excluded. SLN were identified by blue dye, radioactive isotope, or combined mapping technique, and examined by intra-operative frozen section. Full axillary dissection was performed if frozen section was positive for metastasis, whereas patients with failed SLN localization were spared from the procedure. All lymph nodes harvested would undergo further paraffin section with immuno-histochemical staining. The results of SLN biopsy in relation to the final pathology of the primary tumour and the axillary disease status were analysed.

Results

From March 2002 to March 2013, 297 patients who had a core biopsy diagnosis of DCIS underwent simultaneous SLN biopsy with their definitive excisional operation. SLN localization was successful in 283 patients (95.3%). Metastases in SLN were found in 19 (6.4%) of them. Axillary dissection, either in the same or second operative setting, was completed in 12 (4%) patients. Only four (1.3%) showed additional positive lymph nodes in the rest of axilla. All of these four patients had invasive disease revealed in their primary lesions upon final pathological assessment. Overall, 83 patients (27.9%) had histological upstaging from DCIS to microinvasive or invasive carcinoma. It was more commonly associated with the presence of a palpable (48.5% versus 21.6%, p = 0.0067) or radiological (46.3% versus 19.7%, p = 0.0047) mass lesion. Out of the 214 patients who remained in the category of “pure DCIS”, six (2.8%) had SLN metastases. Three proceeded to axillary dissection and their SLN were confirmed to be the only positive ones in the axilla.

Conclusion

Although SLN metastases were rare in patients with “pure DCIS”, underestimation of invasive disease was frequent on core biopsy. Performing SLN biopsy during definitive surgery for DCIS allowed correct nodal staging in a single operation. Nevertheless, in contrast to invasive carcinoma, frozen section examination could safely be foregone since the additional yield of completion axillary dissection was shown to be slim in “pure DCIS” even if SLN shows positive results. However, management of SLN in DCIS with high risk features should follow that of invasive breast cancer in view of the considerable chance of histological upstaging.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-21.

Regulation of intramembranous absorption and amniotic fluid volume by constituents in fetal sheep urine

Our objective was to test the hypothesis that fetal urine contains a substance(s) that regulates amniotic fluid volume by altering the rate of intramembranous absorption of amniotic fluid. In late gestation ovine fetuses, amniotic fluid volumes, urine, and lung liquid production rates, swallowed volumes and intramembranous volume and solute absorption rates were measured over 2-day periods under control conditions and when urine was removed and continuously replaced at an equal rate with exogenous fluid. Intramembranous volume absorption rate decreased by 40% when urine was replaced with lactated Ringer solution or lactated Ringer solution diluted 50% with water. Amniotic fluid volume doubled under both conditions. Analysis of the intramembranous sodium and chloride fluxes suggests that the active but not passive component of intramembranous volume absorption was altered by urine replacement, whereas both active and passive components of solute fluxes were altered. We conclude that fetal urine contains an unidentified substance(s) that stimulates active intramembranous transport of amniotic fluid across the amnion into the underlying fetal vasculature and thereby functions as a regulator of amniotic fluid volume.

Role of cyclooxygenase-2 in H5N1 viral pathogenesis and the potential use of its inhibitors

1. Cyclooxygenase-2 (COX-2), along with TNF-α and other proinflammatory cytokines, was hyperinduced in H5N1- infected macrophages in vitro and in epithelial cells of autopsied lung tissues of infected patients. 2. The COX-2 mediated amplification of the proinflammatory response is rapid, and the effects elicited by the H5N1-triggered proinflammatory cascade are broader than those arising from direct viral infection. 3. Selective COX-2 inhibitors suppress the H5N1- hyperinduced cytokines in the proinflammatory cascade.

Aspirin desensitisation for Chinese patients with coronary artery disease

OBJECTIVE. To assess the efficacy and safety of aspirin desensitisation in Chinese patients with coronary artery disease. DESIGN. Case series. SETTING. A regional hospital in Hong Kong. PATIENTS. Chinese patients with coronary artery disease and a history of a hypersensitivity reaction to aspirin or non-steroidal anti-inflammatory drug, who underwent aspirin desensitisation between February 2008 and July 2012. RESULTS. There were 24 Chinese patients with coronary artery disease who were admitted to our unit for aspirin desensitisation during this period. The majority (79%) were clinical admissions for desensitisation; eight (33%) of them developed a hypersensitivity reaction during desensitisation. Half of the latter had only limited cutaneous reactions and were able to complete the desensitisation protocol and developed aspirin tolerance. Overall, 20 (83%) of the patients were successfully desensitised at the initial attempt. No serious adverse reactions occurred in the cohort. Twelve of the patients had significant coronary artery disease revealed by coronary angiography and received a percutaneous coronary intervention, nine of whom received drug-eluting stents while three received bare metal stents due to financial constraints. All 11 successfully desensitised patients received aspirin and clopidogrel as double antiplatelet therapy after percutaneous coronary intervention. The remaining patient had a bare metal stent implant due to failed aspirin desensitisation. CONCLUSION. Given the potentially different genetic basis of aspirin hypersensitivity in different ethnicities, recourse to desensitisation in the Chinese population has not previously been addressed. This study demonstrated that aspirin desensitisation using a rapid protocol can be performed effectively and safely in Chinese patients. Our results were comparable to those in other reported studies involving other ethnicities. Successful aspirin desensitisation permits patients to pursue long-term double antiplatelet therapy that includes aspirin after percutaneous coronary intervention, and thus allows the use of drug-eluting stents as a feasible option.

Malignancies after kidney transplantation: Hong Kong renal registry

Manystudies have shown that kidney transplant recipients have a higher incidence of cancers when compared with general population. However, most data on the posttransplant malignancies (PTM) are derived from Western literature and large population-based studies are rare. There is also lack of information about the posttransplant cancer-specific mortality rate. We conducted a population-based study of 4895 kidney transplants between 1972 and 2011, with data from the Hong Kong Renal Registry. Patterns of cancer incidence and mortality in our kidney transplant recipients were compared with those of the general population using standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) respectively. With 40 246 person-years of follow-up, 299 PTM was diagnosed. The SIR of all cancers was 2.94 (female 3.58 and male 2.58). Non-Hodgkin lymphoma (NHL), kidney, and bladder cancers had the highest SIRs. The overall SMR was 2.3 (female 3.4 and male 1.7) and the highest SMR was NHL. The patterns of PTM differ among countries. Increases in cancer incidence can now translate into similar increases in cancer mortality. NHL is important in our kidney transplant recipients. Strategies in cancer screening in selected patient groups are needed to improve transplant outcomes.

Fetal swallowing as a protective mechanism against oligohydramnios and polyhydramnios in late gestation sheep

Our objectives were to (1) quantify the relationship between daily swallowed volume and amniotic fluid volume (AF volume) in late gestation ovine fetuses and (2) use the resulting regression equation to explore the role of swallowing in regulating AF volume. Daily swallowed volume ranged from 36 to 1963 mL/d while experimental AF volume ranged from 160 to 6150 mL (n = 115). Swallowed volume was near zero when AF volume was far below normal, a maximum of 635 ± 41 (standard error) mL/d when AF volume was 1682 ± 31 mL and did not increase further with higher AF volumes. Computer simulations predicted that fetal swallowing would (1) return AF volume to normal in 5 to 6 days following an acute volume change in the absence of changes in other amniotic inflows or outflows and (2) stabilize AF volume in 4 to 8 days following sustained alterations in amniotic inflows or outflows other than swallowing.

CONCLUSIONS

The volume of AF swallowed each day by the fetus is a strong function of AF volume and reaches a maximum when mild polyhydramnios develops. With deviations in AF volume from normal, changes in fetal swallowing protect against oligohydramnios and polyhydramnios because the changes in swallowing over time reduce the extent of the AF volume change. However, with experimental changes in AF volume stabilizing in 1 to 2 days, it appears that swallowing is not the major regulator of AF volume.

Reperfusion strategy for ST-segment elevation myocardial infarction: trend over a 10-year period

OBJECTIVES. To review the 10-year trend of reperfusion strategies in patients with ST-segment elevation myocardial infarction, and the adoption rate of percutaneous coronary interventions as opposed to thrombolytic therapy. Also to explore why some patients did not receive reperfusion therapy, and document changes in reperfusion strategies after the introduction of primary percutaneous coronary intervention programmes. DESIGN. Case series. SETTING. A regional hospital, Hong Kong. PATIENTS. All patients with ST-segment elevation myocardial infarction from January 2000 to December 2009. RESULTS. There were 1835 patients with ST-segment elevation myocardial infarction in that period, of which 1179 (64.3%) received reperfusion therapy (thrombolytic therapy, 46.0%; primary percutaneous coronary intervention, 17.5%; emergency coronary artery bypass graft, 0.7%). After introduction of the primary percutaneous coronary intervention programme, significantly more ST-segment elevation myocardial infarction cases underwent that particular intervention (1.6% in 2000 increasing to 30.6% in 2009), while the proportion receiving thrombolytic therapy declined (57.4% in 2000 decreasing to 35.0% in 2009). Seven reasons for no reperfusion therapy were identified. The commonest ones were delayed presentation (45.1%), succumbed before reperfusion (16.0%), multiple medical co-morbidities (15.2%), and contra-indication to thrombolytic therapy (14.8%). The proportion without reperfusion therapy due to a contra-indication to thrombolytic therapy declined (22.7% in 2000 decreasing to 4.9% to 2009), whilst an increasing proportion received primary percutaneous coronary interventions. CONCLUSIONS. Primary percutaneous coronary intervention is increasingly used as the reperfusion therapy in ST-segment elevation myocardial infarction and is replacing thrombolytic therapy, though the latter still remains a mainstay of therapy. A significant proportion of ST-segment elevation myocardial infarction cases received no reperfusion due to various reasons.

Automatic glaucoma diagnosis from fundus image

Glaucoma is currently diagnosed by glaucoma specialists using specialized imaging devices like HRT and OCT. Fundus imaging is a modality widely used in primary healthcare. An automatic glaucoma diagnosis system based on fundus image can be deployed to primary healthcare clinics and has potential for early disease diagnosis. A mass glaucoma screening program can also be facilitated using such a system. We present an automatic fundus image based cup-to-disc ratio measurement system; and demonstrate its potential for automatic objective glaucoma diagnosis and screening. It provides strong support to use fundus image as the modality for automatic glaucoma diagnosis.

SARS CoV subunit vaccine: antibody-mediated neutralisation and enhancement

1. A SARS vaccine was produced based on recombinant native full-length Spike-protein trimers (triSpike) and efficient establishment of a vaccination procedure in rodents. 2. Antibody-mediated enhancement of SARS-CoV infection with anti-SARS-CoV Spike immune-serum was observed in vitro. 3. Antibody-mediated infection of SARS-CoV triggers entry into human haematopoietic cells via an FcγR-dependent and ACE2-, pH-, cysteine-protease-independent pathways. 4. The antibody-mediated enhancement phenomenon is not a mandatory component of the humoral immune response elicited by SARS vaccines, as pure neutralising antibody only could be obtained. 5. Occurrence of immune-mediated enhancement of SARS-CoV infection raises safety concerns regarding the use of SARS-CoV vaccine in humans and enables new ways to investigate SARS pathogenesis (tropism and immune response deregulation).

Amniotic fluid volume and composition after fetal membrane resection in late-gestation sheep

The chronically catheterized fetal sheep is a widely used model for fetal physiologic and pathophysiologic investigations. Catheterization involves opening the amniochorion to gain access to the fetus. In the current study, we explored the role of the amnion and amniochorion in maintaining normal amniotic fluid volume (AFV) and composition and fetal blood-gas status after surgery. Fetal sheep were catheterized at 119.6 ± 0.3 (mean ± SE, n = 25) d gestation (term, approximately 147 d). An opening equal to approximately 5% of total membrane surface area was created by resecting a portion of the amnion or amniochorion during surgery. The uterine wall was closed in all animals. Compared with control sheep (AFV = 992 ± 153 mL, n = 11), resection of the amnion had no significant effect on AFV (745 ± 156 mL, n = 7) measured 5 d after surgery, whereas resection of the amniochorion resulted in extensive loss of amniotic fluid (AFV = 131 ± 38 mL, n = 7). This loss resulted from extensive entry of amniotic fluid into the space between the chorion and uterine wall. Amniotic fluid, fetal plasma, and urinary solute concentrations; arterial pH; oxygen tension; and carbon dioxide tension were unchanged. A small opening in the amnion has minimal effects on ovine AFV, whereas a small opening in the amniochorion results in oligohydramnios. In addition, the amnion appears to be the primary site that limits the rate of amniotic fluid absorption by the chorionic vasculature.

Retinal vascular tortuosity in persons with diabetes and diabetic retinopathy

AIM/HYPOTHESIS

The aim of this hypothesis was to examine the association of retinal vessel tortuosity with diabetes and diabetic retinopathy (DR).

METHODS

A clinic-based study of 327 participants (224 with diabetes and 103 non-diabetic controls) aged ≥ 18 years. DR was graded from fundus photographs according to the modified Airlie House Classification system and categorised into mild non-proliferative DR (NPDR), moderate NPDR and vision-threatening DR (VTDR). Retinal vessel tortuosity was measured from disc-centred retinal photographs. Measurements were taken, using a semi-automated computer program by a single grader, of arterioles and venules within 0.5 to 2 disc diameters away from the optic disc.

RESULTS

There were 114 (44%) participants with DR. In the multivariate analysis, retinal arteriolar and venular tortuosity were increased in participants with diabetes without DR (mean difference 12.4 × 10(-5) and 13.3 × 10(-5), respectively; both p < 0.05) and in those with DR (mean difference 15.4 × 10(-5) and 15.0 × 10(-5), respectively; both p < 0.01) compared with non-diabetic participants. Among participants with diabetes, increased arteriolar tortuosity was significantly associated with mild NPDR (OR 1.53, 95% CI 1.03-2.05, per SD increase in arteriolar tortuosity) and moderate NPDR (OR 1.67, 95% CI 1.10-2.55) but not VTDR (OR 0.91, 95% CI 0.54-1.54). No association with DR was found for venular tortuosity.

CONCLUSIONS/INTERPRETATION

Persons with diabetes had more tortuous retinal vasculature than persons without diabetes. In persons with diabetes, increased arteriolar tortuosity was associated with mild and moderate stages of DR. This suggests that retinal vascular tortuosity might be an early indicator of microvascular damage in diabetes; thus, further investigation is indicated.

A case of young-onset dementia

Dementia is a major worldwide public health concern in view of the global ageing phenomenon. Dementia usually occurs in old age. However, if the symptoms occur in young patients, the diagnosis can be challenging. Posterior cortical atrophy is a variant of the Alzheimer's disease, which is described as a presenile disease affecting relatively late-middle-aged patients. A combination of clinical, neuropsychological, and neuroimaging techniques may facilitate making a diagnosis of this particular patient group, as demonstrated in this report. Although there is no effective disease-modifying agent for treating these patients to date, there may be considerable pressure to arrive at a quick and accurate diagnosis from the perspective of employment and insurance.

The preparedness of Hong Kong medical students towards advance directives and end-of-life issues

OBJECTIVES

To explore the preparedness of medical students towards advance directives and related end-of-life issues, and to examine background factors such as knowledge, attitudes, and experience concerning advance directives and related end-of-life issues.

METHODS

In 2007, 448 medical students in years 3 to 5 were surveyed at the Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong. Their knowledge, attitudes, and experiences of advance directives and related end-of-life issues, and their self-perceived preparedness to discuss these matters with patients were evaluated.

RESULTS

A total of 220 (49%) of the eligible students responded, of whom 79% supported the use of advance directives. Only 65 (30%) students were certain of what advance directives meant and 198 (90%) students felt that their knowledge of advance directives was inadequate. Also, 197 (90%) students felt unprepared about advance directives and end-of-life issues. Factors associated with positive attitude towards advance directives included religion and knowledge. No factors were found to be associated with self-perceived preparedness towards advance directives or end-of-life issues.

CONCLUSIONS

Most of the medical students surveyed demonstrated a positive attitude towards advance directives and recognised the importance of advance directives. However, they felt that they were unprepared and lacking in knowledge and experience of advance directives and end-of-life issues. Wider range and more depth of education is needed to better equip medical students for future practice.

Unidirectional transport across cultured ovine amniotic epithelial cell monolayer

OBJECTIVE

To determine whether ovine amniotic cells in monolayer culture exhibit unidirectional transport.

METHODS

Permeability of (14)C-inulin was measured in two directions across ovine amniotic cells grown to confluence on cell culture inserts.

RESULTS

Permeability was 0.69 + 0.17 (SE) microl/min/cm(2) from the top of the insert where the cells were attached to the bottom and 0.11 + 0.02 microl/min/cm(2) in the reverse direction (P < 0.001). Permeability was similar in the two directions for chorionic cells and umbilical vein endothelial cells. Addition of vascular endothelial growth factor did not alter permeability.

CONCLUSIONS

Transcellular transport in ovine amniotic monolayers is directionally specific. The transport ratio of 6.2:1 for (14)C-inulin is comparable to the in vivo ratio of 4.7:1 for the ovine intramembranous pathway and is consistent with passive diffusion in both directions and vesicular transport in one direction across the monolayer at 5.2 times the rate of passive diffusion.

Impact of delayed graft function on renal function and graft survival in deceased kidney transplantation

OBJECTIVES

To define the risk factors for delayed graft function and study the impact of such delays on renal function and long-term allograft survival in renal transplant recipients.

DESIGN

Single-centre retrospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Records of 118 Chinese renal transplant recipients from 1 July 1997 to 31 July 2005 were reviewed, and categorised into delayed and immediate graft function groups.

RESULTS

Delayed graft function was observed in about 19% of patients, for which cold ischaemic time was an important independent predictor. For each additional hour of cold ischaemic time, the odds ratio increased for delayed function by 0.002 (95% confidence interval, 0.001-0.003; P=0.03). Multivariate analysis revealed that neither cold ischaemic time nor delayed graft function was associated with acute rejection. On the other hand, at 1 year both delayed graft function (odds ratio=18.5; 95% confidence interval, 2.6-130.5; P=0.003) and donor age (1.2; 1.1-1.3; P=0.003) were related to a glomerular filtration rate of less than 30 mL/min. When renal function between patients with and without delayed graft function during the first 3 years was compared, it was significantly better in those without delayed graft function. However, there was no significant difference in death-censored graft survival between delayed graft function and immediate graft function groups.

CONCLUSIONS

Delayed graft function has a significant adverse effect on graft function at 1 year. Limiting cold ischaemic time is important as it is an independent predictor of delayed graft function.

Primary percutaneous coronary intervention for ST elevation myocardial infarction: performance with focus on timeliness of treatment

OBJECTIVE

To review primary percutaneous coronary interventions performed for patients with ST elevation myocardial infarction with a focus on door-to-treatment time, especially after introduction of a new management programme in November 2003.

DESIGN

Retrospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

All patients with ST elevation myocardial infarction who underwent primary percutaneous coronary intervention in our hospital from January 2002 to December 2007.

RESULTS

In all, 209 patients with ST elevation myocardial infarction had primary percutaneous coronary interventions between January 2002 and December 2007; 140 of them were admitted within office hours, 125 of whom came directly from Accident and Emergency Department. The mean door-to-balloon time of these patients was 115 minutes, and in 41% the time was less than 90 minutes (as recommended by the American College of Cardiology/American Heart Association guidelines). Since introduction of the new programme, the mean door-to-balloon time has diminished significantly, from 146 to 116 minutes (P=0.047). Delay in diagnosis (28%) and Cardiac Catheterization Laboratory being occupied (20%) were the two most common reasons for prolonged door-to-balloon times.

CONCLUSION

We achieved satisfactory performance in our primary percutaneous coronary intervention programme, providing timely reperfusion therapy for patients with ST elevation myocardial infarction. A well-organised and systematic clinical pathway is a prerequisite for a centre that provides a timely and effective primary percutaneous coronary intervention service for patients with ST elevation myocardial infarction. Better public education and greater awareness on the part of medical service providers are needed, so as to facilitate urgent revascularisation and improve outcomes in patients with ST elevation myocardial infarction.

Regulation of caveolin-1 expression and phosphorylation by VEGF in ovine amnion cells

Vascular endothelial growth factor (VEGF) has been implicated in the regulation of vesicular transport of amniotic fluid via caveolae across the amnion. This study tested the hypothesis that VEGF regulates caveolar function by stimulating caveolin-1 expression and phosphorylation in ovine amniotic epithelial cells (oAECs). Using primary cultures of oAECs, caveolin-1 was identified by immunofluorescent staining. Caveolin-1 messenger RNA (mRNA) abundance was determined by Reverse Transcription-Polymerase Chain Reaction (RT-PCR) and protein by Western blotting. The effects of VEGF( 165) on caveolin-1 expression and phosphorylation were determined. Caveolin-1 immunoreactivity was detected in oAECs. In response to 10 ng/mL VEGF( 165), caveolin-1 mRNA levels increased whereas the protein levels were unaffected. Furthermore, VEGF stimulated caveolin-1 phosphorylation, an effect abrogated by the inhibition of c-Src protein kinase. These data suggest that VEGF upregulates caveolin-1 activity through c-Src signaling pathways. Our observations support the hypothesis that VEGF regulates amniotic fluid transport across the amnion by stimulating caveolin-1 activity to mediate caveolar function in amnion cells.

A rare cause of nephrotic syndrome: lipoprotein glomerulopathy

Lipoprotein glomerulopathy is a rare kidney disease in which lipoprotein thrombi are seen in the glomerular capillaries. Most of these patients are found in Japan and East Asian countries. The presenting symptoms include proteinuria, an abnormal plasma lipoprotein profile that resembles type III hyperlipoproteinaemia, and a marked increase in serum apolipoprotein E concentration. Previous studies have suggested that lipoprotein glomerulopathy might be related to APOE gene mutation. No effective therapeutic regimen has been established for lipoprotein glomerulopathy. We report the first case of biopsy-proven lipoprotein glomerulopathy in Hong Kong in a patient who presented with nephrotic syndrome and dyslipidaemia. DNA analysis revealed apolipoprotein E Kyoto together with a novel apolipoprotein E mutation, apolipoprotein E (Asp230Tyr) Hong Kong. There was significant improvement in the clinical parameters and resolution of symptoms after the introduction of statins. Further studies will be needed to clarify the role of apolipoprotein E Hong Kong and its interaction with apolipoprotein E Kyoto in the pathogenesis of lipoprotein glomerulopathy.

Prevalence of metabolic syndrome in Chinese renal transplant recipients

OBJECTIVE

To investigate the prevalence of metabolic syndrome in Chinese renal transplant recipients, using two different sets of diagnostic criteria.

DESIGN

Cross-sectional study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

All Chinese patients who received solitary living-related or cadaveric kidney transplantation from 1 July 1997 to 31 December 2005 in our hospital with follow-up of more than 6 months were recruited. The diagnosis of metabolic syndrome was made according to the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATPIII) criteria and the International Diabetes Federation criteria.

RESULTS

Using the modified (Asian) NCEP-ATPIII criteria, a total of 39 (32%) of 121 patients had metabolic syndrome, which included 20/69 (29%) of the males and 19/52 (37%) of the females. Using the International Diabetes Federation criteria, metabolic syndrome was diagnosed in 26% of the patients, 22% in males and 31% in females. In our patients, the most common component of metabolic syndrome was hypertension and the least common was low high-density-lipoprotein-cholesterol level. Low high-density-lipoprotein-cholesterol levels were significantly more common in female patients.

CONCLUSION

This study shows that there is a high prevalence of metabolic syndrome in our Chinese renal transplant recipients.