Renal insufficiency in IBD--prevalence and possible pathogenetic aspects

BACKGROUND AND AIMS

Extraintestinal manifestations of parenchymatous organs like kidney are rarely noticed in Inflammatory Bowel Disease (IBD). The aim of this study was to investigate the prevalence of renal insufficiency (RI) in IBD and look for potential causative factors and pathogenetic aspects.

METHODS

The study consists of two parts; the first determined the prevalence of RI in IBD and the second possible causative factors. For the first part all patients with IBD who had been investigated at our institution in the period from March 2006 to December 2007 were included. For the second part 25 IBD patients with RI were matched with 50 IBD patients without RI. To determine causative factors several gastroenterologic and renal parameters were compared between these two groups.

RESULTS

Eleven out of 775 patients with IBD had RI, all of them suffering from Crohn's disease (CD). This led to a prevalence of 1.99% for patients with CD and of 0% for patients with ulcerative colitis (UC). Concerning IBD risk factors only duration of disease (p=0.002) and length of resected small bowel (p=0.004) had a significant impact. Two nephrologic parameters, recurrent urolithiasis and the number of interventions due to kidney stones, were risk factors for the development of RI (p=0.03).

CONCLUSIONS

RI is a rare (2%) but relevant complication in CD, not found in UC. Extensive small bowel resection and recurrent urolithiasis seem to be the major causative factors.

Increased responsiveness to thrombin through protease-activated receptors (PAR)-1 and -4 in active Crohn's disease

BACKGROUND AND AIMS

Platelets are essential in hemostasis and inflammation, thereby linking coagulation with inflammation. Abundant thrombin generation in association with inflammation is considered a major reason for the increased risk for thromboembolic events. We therefore investigated platelet responsiveness to thrombin.

METHODS

In this case-control study 85 patients with Crohn's disease (active CD 42, remission 43) and 30 sex- and age-matched controls were enrolled. Clinical disease activity (Harvey-Bradshaw-Index) was assessed and CD-related data were determined by chart review. Platelets' response to protease activated receptor-1 and -4 (PAR-1, -4) was assessed by whole blood platelet aggregometry (MEA), levels of platelets adhering to monocytes (PMA), and platelet surface P-selectin.

RESULTS

Platelets' aggregation after activation with the specific PAR-1 agonist (SFLLRN) and PAR-4 agonist (AYPGKF) was higher in patients with active CD compared to patients in remission and controls (p=0.0068 and p=0.0023 for SFLLRN, p=0.0019 and 0.0003 for AYPGKF). Likewise, levels of PMA after activation with PAR-1 and PAR-4 receptor agonists were higher in patients with active CD compared to patients in remission and controls (p=0.0001 and p<0.0001 for SFLLRN, p=0.0329 and p=0.0125 for AYPGKF). However, P-selectin expression on human platelets showed heterogeneous results. Only PAR-1 activation of platelets resulted in significant differences between CD patients and controls (p=0.0001 and p=0.0022 for active and inactive CD versus controls, respectively).

CONCLUSIONS

Our data suggest a new mechanism of platelet activation which has the potential to increase risk for thromboembolism in patients with active CD which might be due to platelets poised for thrombin-inducible activation.

Die Umkipp-Plastik nach Silfverskjöld bei Achillessehnenruptur: Eine Alternative für Sportler?

AIM

The most recent meta-analysis of randomized trials recommended open repair for competitive athletes suffering from Achilles tendon rupture due to low re-rupture rates and recommended for all other patients percutaneous repair. The report did not include patients with open augmented repair. The aim of this study was to analyse our results with open augmented repair after Silfverskjöld and to discuss whether this method is an alternative form of treatment, especially for athletes.

METHODS

This retrospective study included all patients who received open augmented repair in the Silfverskjöld technique between the years 1996 and 2002. A total of 104 patients were clinically evaluated, involving ultrasound as well, and were scored according to the Thermann scale. The average age was 43 years. The operation took place on average within 5.7 days. Twenty athletes were identified and were compared with non-athletes using the Thermann scale and the two randomsample t-tests. The follow-up period averaged 3.7 years.

RESULTS

Overall, the results were rated as good, with an average of 88.1 points. The re-rupture rate was 1.9% (2 out of 104) with a deep infection incidence of 2.8% (3 out of 104). Athletes averaged 88.7 and non-athletes 88.0 points. No significant difference was recorded (t=0.98). Nineteen out of 20 (95%) athletes and 48 out of 84 (57%) non-athletes were able to return to their original level of sport activity.

CONCLUSIONS

Open augmented repair after Silfverskjöld is found to be a real alternative to simple open reconstruction of Achilles tendon ruptures. Clinical outcome in both athletes and nonathletes was recorded as good to very good. Especially athletes were able to regain their original activity level with an overall low re-rupture and infection rate.

Are inherited thrombotic risk factors associated with fibrostenosis in Crohn's disease?

BACKGROUND

Fibrostenotic lesions are common complications in Crohn's disease (CD) often requiring surgery. Inherited thrombotic risk factors are associated with fibrosis in other chronic inflammatory diseases. The aim of the study was to assess whether inherited thrombotic risk factors are associated with fibrostenosis in CD.

METHODS

Clinical data on 529 CD patients were collected retrospectively. Subjects were tested for and grouped according to the presence of factor V Leiden (FVL), the prothrombin G20210A, and the methylenetetrahydrofolate reductase C677T mutation (MTHFR). Patients who underwent CD-related intestinal surgery were assessed for the presence of fibrostenosis, which was the primary endpoint. The diagnosis of fibrostenosis was based on surgical, pathological, and histopathological reports. A Cox proportional hazards model was used for statistical analysis.

RESULTS

Thirty-two (6.1%, heterozygous 30, homozygous 2) patients were carriers of FVL, 19 (3.6%, all heterozygous) carried the prothrombin variant, and 318 (60.1%) the MTHFR variant (243 heterozygous, 75 homozygous). In all, 303 (57.3%) patients underwent intestinal surgery. Fibrostenosis was identified in 219 (72.3%) surgical specimens. The rate of first intestinal surgeries with fibrostenosis tended to be more frequent in patients with the homozygous 677TT MTHFR mutation (hazard ratio, HR 1.39; 95% confidence interval [CI]: 0.98-1.97; P = 0.067). After adjustment for potential confounders homozygous 677TT MTHFR mutation did not remain a risk factor for intestinal surgery with fibrostenosis (HR 1.23; 95% CI: 0.77-1.98; P = 0.387). FVL and the prothrombin variant had no influence on the primary endpoint.

CONCLUSIONS

The MTHFR 677TT mutation, factor V Leiden, and the prothrombin G20210A mutation are not associated with fibrostenosis in CD.

[No influence of physiotherapy on outcome after open repair of achilles tendon ruptures?]

AIM

Many studies have been performed to analyse the influence of surgical techniques and the postoperative aftercare after Achilles tendon ruptures on the outcome. However, there is no study investigating the influence of physiotherapy on outcome after surgical repair and standardised early functional rehabilitation of Achilles tendon rupture, so that this was the objective of the present study.

PATIENTS AND METHODS

In this retrospective study, 104 patients with Achilles tendon ruptures, all treated by open repair followed by a standardised early rehabilitation, were evaluated by the Thermann score. The average age was 42 years. We could identify 3 patient groups. Group I (n=23) did not receive any physiotherapy. Group II (n=41) received physiotherapy for 3-6 weeks, and group III (n=40) received more than 6 weeks of physiotherapy. Physiotherapy consisted of 3 units per week. Each unit lasted for 30 min. All groups were compared statistically via variance analysis.

RESULTS

Group I scored on average 88.8 points, group II 88.6 and group III 87.0 points. There were no statistically significant differences between the three groups (p=0.50). The age of patients had also no relevant influence on the outcome (p=0.48).

CONCLUSIONS

Physiotherapy and age of the patients involved were not found to influence the outcome after open augmented repair of Achilles tendon ruptures followed by a standardised early rehabilitation. These results should be confirmed by a prospective randomised trial. Also elderly patients participating in demanding sport activities should receive a surgical repair.

[Open augmented repair according to Silfverskjöld for Achilles tendon rupture: an alternative for athletes?]

AIM

The most recent meta-analysis of randomized trials recommended open repair for competitive athletes suffering from Achilles tendon rupture due to low re-rupture rates and recommended for all other patients percutaneous repair. The report did not include patients with open augmented repair. The aim of this study was to analyse our results with open augmented repair after Silfverskjöld and to discuss whether this method is an alternative form of treatment,especially for athletes.

METHOD

This retrospective study included all patients who received open augmented repair in the Silfverskjöld technique between the years 1996 and 2002. A total of 104 patients were clinically evaluated, involving ultrasound as well,and were scored according to the Thermann scale. The average age was 43 years. The operation took place on average within 5.7 days. Twenty athletes were identified and were compared with all non-athletes using the Thermann scale and the two random sample t-tests. The follow-up period averaged 3.7 years.

RESULTS

Overall, the results were rated as good,with an average of 88.1 points. The re-rupture rate was 1.9% (2 out of 104) with a deep infection incidence of 2.8% (3 out of 104). Athletes averaged 88.7 and non-athletes 88.0 points. No significant difference was recorded (t = 0.98). Nineteen out of 20 (95%) athletes and 48 out of 84(57%) non-athletes were able to return to their original level of sport activity.

CONCLUSIONS

Open augmented repair after Silfverskjöld is found to be a real alternative to simple open reconstruction of Achilles tendon ruptures. Clinical outcome in both athletes and non athletes was recorded as good to very good. Especially athletes were able to regain their original activity level with an overall low re-rupture and infection rate.