Boronate Affinity Chromatography Accurately Measures HbA1c also in Patients with End-Stage Renal Disease - Performance Evaluation of the A1c HPLC Analyzer

BACKGROUND

Boronate affinity chromatography is widely used, and the method has lately been improved and designed for HbA1c measurements. We report performance evaluation of the affinity chromatography HbA1c HPLC analyzer.

METHODS

Within- and between-run imprecision was assessed based on the results of a series of measurements in three different EDTA blood samples and in control materials. HbA1c levels were measured and compared in 349 EDTA blood samples and 50 samples from patients with end-stage renal disease (ESRD) using the Premier Hb9210 analyzer (affinity chromatography) and the D-10 Hemoglobin Testing System (ion-exchange chromatography).

RESULTS

The within- and between-run imprecision CVs ranged from 0.72% to 2.01%. Median HbA1c level measured by the Premier Hb9210 was significantly lower (6.4% [46 mmol/mol] vs. 6.6% [49 mmol/mol], p < 0.001). The Passing-Bablok agreement test yielded a slope of 1.0 (95% CI: 1.0 to 1.0) and intercept of -0.1 (95% CI: -0.1 to -0.1). Correlation coefficient and the mean difference amounted to 0.992 and -0.13% (95% CI: -0.11 to -0.15), respectively. Similar results were obtained for HbA1c levels < 7% [< 53 mmol/mol] and ≥ 7% [≥ 53 mmol/mol]. In ESRD patients, median HbA1c level measured by the Premier Hb9210 was also significantly lower (6.0% [42 mmol/mol] vs. 6.5 [48 mmol/mol], p < 0.001) with the mean difference equal to -0.52% (95% CI: -0.59 to -0.46).

CONCLUSIONS

Although the Premier Hb9210 gave lower HbA1c levels, good results agreement with the D-10 Hemoglobin Testing System was found. Analytical performance found for HbA1c measurements in ESRD patients was similar. The Premier Hb9210 analyzer is suitable for routine HbA1c testing in clinical practice.

Angiopoietin-2 Is an Early Indicator of Acute Pancreatic-Renal Syndrome in Patients with Acute Pancreatitis

Within the first week of the disease, acute kidney injury (AKI) is among the most common causes of mortality in acute pancreatitis (AP). Recently, serum angiopoietin-2 (Ang-2) has been associated with hyperdynamic state of the systemic circulation. The aim of this study was to examine the associations between Ang-2 and the clinical AP severity during the first 72 hours of the disease, and organ disfunction, including AKI. Methods. Study included patients admitted to the surgery ward, diagnosed with AP. AKI was diagnosed according to KDIGO guidelines and renal failure according to modified Marshall scoring system. Ang-2 was determined in serum with ELISA. Results. AP was classified as mild (MAP) in 71% of patients, moderately severe (MSAP) in 22%, and severe (SAP) in 8%. During the first 72 hours of AP, 11 patients developed AKI and 6 developed renal failure. Ang-2 at 24, 48, and 72 hours following the onset of AP symptoms significantly predicted SAP and MSAP, as well as AKI and renal failure. Also, Ang-2 significantly correlated with acute phase proteins as well as with the indicators of renal disfunction. Conclusions. Serum Ang-2 may be a relevant predictor of AP severity, in particular of the development of AP-renal syndrome.

Renal interstitial mast cell counts differ across classes of proliferative lupus nephritis

Systemic lupus erythematosus frequently involves the kidneys leading to significant morbidity and mortality. It is classified according to glomerular involvement pattern but tubulointerstitial lesions are also important for progression and prognosis, as seen in other kidney glomerular diseases. One of the cell types which participate in this process are mast cells. The aim of the study was to analyze the counts of tryptase-positive and chymase-positive mast cells in lupus nephritis classes II, III and IV. Material consisted of 42 renal biopsies from patients with lupus nephritis; 11 class II, 9 class III and 22 class IV. Chymase- and tryptase-containing cells were stained by immunohistochemistry and counted microscopically. Mean count of chymase-positive mast cells was 9.8/10 high power fields (hpf) for the whole group, 4.66 for class II, 11.89 for class III, and 11.51 for class IV. The mean count of tryptase-positive cells was 18.6/10 hpf for the whole group, 7.65 for class II, 25.57 for class III, and 21.23 for class IV. The differences between lupus nephritis classes were significant both for chymase- and tryptase-positive cells. Tryptase- but not chymase-positive cell counts showed a correlation with the creatinine level (R = 0.35). These results suggest that mast cells are involved to a different degree in the pathogenesis of lupus nephritis depending on the class of the disease.

Osteoprotegerin, trail and osteoprotegerin/trail ratio in patients at early phase of acute pancreatitis

AIM

Our aim was to determine serum concentrations of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) and its decoy receptor osteoprotegerin (OPG) in patients with mild and moderate to severe acute pancreatitis (AP) in the early phase of the disease.

MATERIALS AND METHODS

We included 40 patients with AP (16 women, 24 men) admitted to Ist Department of Surgery, Jagiellonian University Medical College, Krakow. Twenty-eight had mild (MAP) and twelve moderate to severe form of AP (SAP). Serum concentrations of OPG and TRAIL were measured by ELISA at admission and on days 3, 5 and 7.

RESULTS

Both TRAIL and OPG were elevated in AP patients as compared to reference values. Starting from day 3 of the study, OPG concentrations were significantly higher in SAP than in MAP. Also, day 3 OPG was higher in patients who died from AP. OPG positively correlated with Glasgow score, C-reactive protein (CRP) concentrations and length of hospital stay. Day 3 OPG cut-off of 713 pg/mL enabled to differentiate between SAP and MAP with sensitivity of 71% and specificity of 80%. Area under ROC curve was 0.795, comparable to that achieved for CRP (0.838; p >0.05). In contrast, serum concentrations of TRAIL were not associated with AP severity.

CONCLUSIONS

Determination of serum OPG concentrations may help in early prediction of severity of AP. However, diagnostic utility of the measurements seems too low to use OPG as a single clinically reliable predictor. Serum TRAIL is not useful in the differentiation between mild and severe form of AP.

[Risk factors of non melanoma skin cancers in kidney transplant patients]

Non melanoma skin cancers (NMSC) represent a major challenge within the ever growing group of different organs recipients. The aim of the study was to evaluate risk factors influencing on frequency appearance of NMSC in patients after kidney transplantation. The clinical dermatological examination was performed in 486 patients after kidney transplantation consisted of 296 man (60.9%) and 190 woman (30.1%) in the mean age 46.1 +/- 13.1 (18-74 years) with median time after transplantation 74.3 +/- 52.1 months. Most of them (80.7%) before transplantation were treated by maintenance hemodialysis. Patients after kidney transplantation were checked by dermatologist for all skin abnormalities based on iniciated skin cancers screening program. All discovered abnormalities were described, their type, size, localization and results of histopathological examination were collected. The obtained results were analyzed based on t-Student's, Mann-Whitney's, chi-square and Fisher tests. Out of 486 studied patients, 53 NMSC were diagnosed in 25 kidney recipients including 39 basal cell carcinoma (BCC), 13 squamous cell carcinoma (SCC) and 1 Bowen's disease. The proportion of BCC to SCC was 2.79. NMSC occurred more often on sun skin exposure area, especially on the face. Almost all (96.2%) of the cancers were diagnosed in patients older than 50 years of age. Patients with NMSC comparing with those without were significantly older (52.8 +/- 7.8 vs. 41.0 +/- 7.8; p < 0.0001), have longer post-transplant period and have more frequent positive anamnesis of this cancer. There was no significant relationship between NMSC appearance and sex, cause of kidney failure, HLA mismatch, blood group as well as Rh factor.

CONCLUSIONS

Older age of patients while transplantation, longer time of immunosuppressive therapy and previous NMSC are independent predictors of new skin cancers appearance.

Determination of hepatocyte growth factor at early phase of acute pancreatitis

AIM

The aim of this study was to assess the diagnostic value of hepatocyte growth factor (HGF) as a new predictor of severity in patients with acute pancreatitis (AP) at early phase of disease.

MATERIALS AND METHOD

The studied group involved 40 patients (16 women and 24 men) with AP admitted to Ist Dept. of Surgery Jagiellonian University Medical College in Krakow. Twenty-four patients had mild and twelve severe form of AP. Glasgow and Imrie scores were calculated to evaluate severity of AP. HGF concentrations were measured by ELISA (R&D Systems) on days 1, 3 and 5 after admission within 48 hours after onset of symptoms.

RESULTS

Serum median concentrations of HGF was significantly higher in patients with severe versus mild clinical course of AP on each of the study days (7.61 vs 3.30 ng/mL, p = 0.05 on day 1; 7.19 vs 3.43, p = 0.04 on day 3 and 5.76 vs 2.42, p = 0.02 on day 5). HGF positively correlated with Glasgow and Imrie scores (R = 0.57 and R = 0.51). HGF negatively correlated with fetuin A, a negative acute phase protein (R = -0.60 on day 3 and R = -0.45 on day 5) and positively with CRP (R = 0.93; R = 0.80), SAA (R = 0.78; R = 0.82), IL-6 (R = 0.61; R = 0.77; R = 0.85 on day 1, 3 and 5, respectively) and PMN-elastase (R = 0.58; R = 0.64; R = 0.77). On day 1 of the study, HGF reached the diagnostic sensitivity of 100% and specificity of 50% for the detection of severe and moderate AP.

CONCLUSIONS

Serum HGF correlates with several inflammatory markers and clinical scores (Glasgow, Imrie) in patients with AP and may be considered a new promising tool in assessing the severity of acute pancreatitis.

[The changes in complete blood count in patients treated with sunitinib malate for metastatic clear cell renal cell carcinoma]

Renal cell carcinoma (RCC) accounts for approximately 3% of adult malignancies. For stage I - III RCC surgery is the primary treatment. Systemic therapy is used in the patients with disseminated disease (stage IV). Sunitinib malate is commonly used in the patients with clear cell renal cell carcinoma (ccRCC) rated as 'low' or 'intermediate' risk according to the Motzer scale. Treatment with sunitinib malate is associated with myelotoxicity. To assess its clinical significance we conducted a pilot study in a group of 10 patients. We noticed a gradual decrease in the mean haemoglobin level during subsequent treatment cycles. Alternations in the platelet count were of no clinical significance. Episodes of the neutropenia were noticed in the study group. In some patients neutrophil count decreased to the level that put them at risk of the infectious complications.

[Uromodulin - can it be a new marker of kidney damage?]

Uromodulin (Tamm-Horsfall protein) is the most abundant protein excreted in the urine under physiological conditions. It is exclusively produced in the kidney and secreted into the urine via proteolytic cleavage. Its biological function is stillnot fully understood. Uromodulin has been linked to waterl electrolyte balance and to kidney innate immunity. Also, studies in knockout mice demonstrated that it has a protective role against urinary tract infections and renal stone formation. Mutations in the gene encoding uromodulin lead to rare autosomal dominant diseases, collectively referred to as uromodulin-associated kidney diseases. They are characterized by progressive tubulointerstitial damage, impaired urinary concentrating ability, hyperuricemia, renal cysts, and progressive renal failure. Novel in vivo studies point at intracellular accumulation of mutant uromodulin as a key primary event in the disease pathogenesis. Recently, genome-wide association studies identified uromodulin as a risk factor for chronic kidney disease (CKD) and hypertension, and suggested that the level of uromodulin in the urine could represent a useful biomarker for the development of CKD.

[Acute pancreatitis and red cell distribution width (RDW)I at early phase of disease]

During last decade, many new biomarkers have been proposed for early diagnosis of acute pancreatitis and prognosis of its severity. However clinical availability of many markers are limited due to costly and time. consuming laboratory methods used, for their assessment, including ELISA technique. Recent studies revealed the usefulness of red cell distribution width (RDW), as a predictor of unfa vorable prognosis in many disease states. RDW is an easily available index generated automatically as a part of standard complete blood count In our group of 40 acute pancreatitis patients, RDW values assessed du ring first 5 days of disease, correlated positively with the duration of hospital stay and the severity of disease as well as with the concentration of selected inflammatory markers. Patients who died had significantly higher RDW comparing to survivors. Our results indicate that RDW may be helpful in early prediction of clinical course of acute pancreatitis.

[Factors influencing on the prevalence frequency of infectious skin changes of bacterial and fungal origin in patients after kidney transplantation]

Infective skin changes are frequent complications in patients after kidney transplantation receiving immunosuppressive therapy. The aim of the study was to evaluate factors influencing on frequency and type of skin infections of bacterial and fungal origin in patients after kidney transplantation. The study was performed in 486 patients, 296 male (60.9%) and 190 female (39.1%) aged 46.1 +/- 13.1 years (18-74 years) 74.3 +/- 52.1 months after kidney transplantation remain mainly on triple immunosupresive therapy. Type, size and localization of skin changes revealed during dermatological evaluation were described according age, sex, and applied immunosuppression. The obtained results were analyzed based on t-Student's, Mann-Whitney's, chi-square and Fisher tests. It was shown that fungal infective skin changes in patients after kidney transplantation are more frequent in older population (48.4 +/- 11.8 vs. 45.2 +/- 13.4 years; p < 0.017). The significant differences concern interdigitale mycoses 49.7 +/- 11.1 vs. 45.4 +/- 13.3 years; p < 0.009, nail mycoses 51.5 +/- 10.4 vs. 45.5 +/- 13.2 years; p < 0,004 and foot mycoses 51.8 +/- 10.7 vs. 45.5 +/- 13.2 years; p < 0.0005. In male more frequent as compare with female were also fungal infections (30.7% vs. 18.4%; p < 0.002) including pityriasis versicolor 37.0% vs. 9.5%; p < 0.016 and interdigitale mycoses 18.6% vs. 9.0%; p < 0.004.

CONCLUSIONS

Infective skin changes frequency in patients after kidney transplantation on immunosuppressive therapy depends on advanced age, male sex, and applied immunosuppressive therapy.

[Evaluation of the interdependence between homocystein and folic acid levels in patients after kidney transplantation during a 2 year observation period]

Patients on maintenance dialysis have increased heomocystein (Hcy) serum levels. The aim of the study was to evaluate the interdependence between Hcy and folic acid (FA) levels in renal transplant patients (pts) at various time periods during a two year observation period after kidney transplantation (Ktx).

PATIENTS AND METHODS

The study included 51 pts (17 F, 34 M) aged 15-62 years (median 38.1) after deceased donors Ktx. Before Ktx, 46 pts were treated with maintenance hemodialysis (HD), while 5 by peritoneal dialysis (PD). The mean observation period equaled 21.2 months (6-24 months); while total observation period was 90 person/years. Hcy level was measured using high performance liquid chromatography (HPLC). FA level was measured using chemiluminesence method (standard methods) using the Immulite 2000 analyzer. Patients blood was drawn before Ktx and 3, 6, 9, 12, 15, 18, 21 and 24 months after procedure.

RESULTS

An increased Hcy level (>15 micromol/l) - mean 28.5 +/- 17.8 micromol/l (range from 10.2 micromol/l to 116.8 micromol/I) was noted in the blood of 44 pts before Ktx (86.3% of the examined population). In 31 pts after Ktx (60.8% of the examined population), mean Hcy level remained increased above 15 micromol/I (mean Hcy - 19.2 +/- 5.8 micromol/I). A negative correlation was found between the levels of Hcy and FA directly before Ktx (R= -0.28, p<0.05). A statistically significant drop of FA level of 72.6% (mean 220.5 +/- 395.1 ng/ml to 60.3 +/- 129.8 ng/ mi) was noted 3 months after Ktx in the examined group (p<0.001 in the Wilcoxon test). However, in the following period time after Ktx, FA levels did not differ statistically (ANOVA Friedmana p=NS). Mean concentrations of Hcy after Ktx did not correlate significantly with levels of FA (R = -0.12, p = NS). No significant differences between mean levels of FA after Ktx in pts with normal and increased mean levels of Hcy were found; but one must note that presence of hiperhomocysteinemia (HHcy) was associated with a 42% lower concentration of FA in relation to patients who had Hcy >15 micromol/l (36.4 ng/ml vs. 62.5 ng/ml).

CONCLUSIONS

Statistically significant decrease of Hcy concentration was observed after Ktx as compare with values before procedure, however not reached normal values. Significant decrease of FA concentration after Ktx is most likely associated with the discontinuation of FA supplementation, as well as due to the restoration of the erythropoietic line.

[Performance neutrophil gelatinase-associated lipocalin in clinical settings]

Acute kidney injury (AKI) is largely asymptomatic, and establishing the diagnosis in thisin creasingly common disorder currently hinges on functional biomarkers such as serum creatinine. Early neutrophil gelatinase-associated lipocalin (NGAL) measurements can identify patients with sub-clinical AKI who have an increased risk of adverse outcomes, even in the absence of diagnostic increases in serum creatinine. NGAL is emerging as an excellent biomarker in the urine and plasma, for the early prediction of AKI, for monitoring clinical trials in AKI, and for the prognosis of AKI in several common clinical scenarios. Also numerous studies have also demonstrated that NGAL may be a potential biomarker for the diagnosis, prediction, prevention, and prognosis of non-AKI diseases such as chronic kidney diseases, vascular disorders, cancer, preeclampsia, and allergies. The current status of the most promising of novel biomarkers in medicin as NGAL is appraised in this review.

Are CD34+ cells found in renal interstitial fibrosis?

BACKGROUND

The CD34 antigen is a marker of precursor myeloid cells and endothelial cells, but also of a subset of spindle cells.

METHODS

To establish the possible role of CD34+ cells in the progression of glomerulonephritis, 30 renal biopsies were investigated. Immunohistochemistry for CD34 and smooth muscle actin (SMA) were performed by standard methods. The results were assessed semiquantitatively. The relative interstitial volume (RIV) was evaluated by the point counting method. Clinical data such as sex, age, serum creatinine and urea levels were taken into account.

RESULTS

CD34+ spindle cells and SMA+ myofibroblasts were present in the renal interstitium in all but one case. In membranous, membranoproliferative and segmental-proliferative glomerulonephritis, CD34+ cells were seen in clusters, while in IgA nephropathy and in segmental and focal glomerulosclerosis, single, scattered cells were seen. The density of CD34+ cells showed a positive correlation with the myofibroblast density and the RIV. Serum creatinine and urea levels were associated with the RIV of the kidney and to a smaller degree with the number of myofibroblasts and CD34+ cells.

CONCLUSION

These results show that in glomerulonephritis, CD34+ spindle cells appear in the interstitium. At present, their possible role can only be speculated.

[Results of kidney transplantation in Krakow in 1992-2000]

The aim of the study was an analysis of renal transplantation results in the Krakow Transplant Center during 1992-2000. The analysis concerned 94 cadaveric transplant recipients. The study group included 31 females aged 23 to 61 years (mean 40.4 years) and 63 males aged 16 to 60 years (mean 41.8 years). The time of pre-transplant renal replacement therapy ranged from 4 to 120 months (mean 32 months). The mean time of total ischaemia was 22 hours 20 minutes. The majority of the recipients had three identical antigens out of six typed. Most of the recipients were treated with three immunosuppressive drugs including: Cyclosporine A, Azathioprine and steroids. Immediately after kidney transplantation 25.6% of the patients had urine output and did not require dialysis. Acute renal failure (ARF) of the graft was observed in 73.2% recipients. The average number of hemodialysis sessions in patients presenting ARF was 10. Acute rejection was diagnosed in 41.5% of the patients. The most frequent complications were: CMV (cytomegalovirus) infection, UTI (urinary tract infection) and policytemia. In the study group 1-year survival rate of the patients was 97.8% and 1-year graft survival was 93.61%. The 5-year survival rates both in the patients and the grafts were very satisfactory (96.96% and 87.7% respectively).

Cytomegalovirus infection in kidney transplant patients: clinical manifestations and diagnosis

Cytomegalovirus (CMV) infection is an important cause of morbidity and mortality after solid organ transplantation. CMV infection after kidney transplantation was confirmed in 19 (54.3%) out of 35 patients. 16 of these (84.2%) developed CMV disease. CMV infection was diagnosed based on a fourfold or greater increase of anti-CMV IgG antibody titre, detection of CMV-IgM antibodies and/or virus isolation. Primary infection was observed in 3 patients, reactivation in 9 and an undefined type of infection in 7. In most patients (63%), infection was diagnosed in the first 2 months, and in 3 patients, after 3, 5 and 9 years following kidney transplantation. The most frequent symptoms of CMV disease were fever (58%), pneumonitis (26.3%) and enterocolitis (15.8%). In 53% of the patients, CMV infection co-occurred with other pathogens such as Candida albicans. Cryptococcus neoformans, bacteria or viruses (HBV, HCV, HSV). Treatment with polyvalent globulin (Sandoglobin) or hyperimmune globulin (Cytotect), in combination with ganciclovir in 7 patients, resulted in a regression of CMV disease.