Effect of growth hormone therapy on nitric oxide formation in cystic fibrosis patients.

Airway nitric oxide production is decreased in cystic fibrosis. As growth hormone therapy has been shown to increase nitric oxide production in growth hormone-deficient patients, it may also affect nitric oxide production in patients with cystic fibrosis. The objective of the present study was to investigate the effect of growth hormone therapy on systemic and airway nitric oxide formation in patients with cystic fibrosis. Nitric oxide metabolites in serum and urine, amino acid concentrations in serum and sputum, as well as exhaled nitric oxide, were measured in children with cystic fibrosis before, during and after 1 yr of treatment with human growth hormone. Nitric oxide metabolite concentrations increased significantly in serum and urine during the treatment period. Serum amino acid concentrations (including l-arginine, the substrate for nitric oxide synthases) also increased during treatment. The systemic bioavailability of l-arginine for nitric oxide synthases, expressed as ratio of l-arginine/l-ornithine+lysine, remained unchanged. In contrast, l-arginine concentrations in sputum decreased significantly during growth hormone treatment, as did exhaled nitric oxide levels. Treatment with growth hormone in children with cystic fibrosis decreases exhaled nitric oxide by reducing the concentration of l-arginine in the airways.

Multi-exon deletions of the PKHD1 gene cause autosomal recessive polycystic kidney disease (ARPKD).

BACKGROUND: Autosomal recessive polycystic kidney disease (ARPKD) is caused by mutations in the PKHD1 (polycystic kidney and hepatic disease 1) gene on chromosome 6p12, a large gene spanning 470 kb of genomic DNA. So far, only micromutations in the 66 exons encoding the longest open reading frame (ORF) have been described, and account for about 80% of mutations. OBJECTIVE: To test the hypothesis that gross genomic rearrangements and mutations in alternatively spliced exons contribute to a subset of the remaining disease alleles. METHODS: Using DHPLC for alternatively spliced exons and quantitative real time polymerase chain reaction to detect genomic imbalances, 58 ARPKD patients were screened, of whom 55 were known to harbour one PKHD1 point mutation in the longest ORF. RESULTS: Three different heterozygous PKHD1 deletions and several single nucleotide changes in alternatively spliced exons were identified. The detected partial gene deletions are most likely pathogenic, while a potential biological function of the alterations identified in alternatively spliced exons must await the definition of transcripts containing alternative exons and their predicted reading frames. CONCLUSIONS: Gross PKHD1 deletions account for a detectable proportion of ARPKD cases. Screening for major genomic PKHD1 rearrangements will further improve mutation analysis in ARPKD.

Unusual manifestation of posttransplant lymphoproliferative disorder in the esophagus.

Early manifestations of posttransplant lymphoproliferative disorders (PTLD) are mainly associated with a primary Epstein-Barr virus (EBV) infection. Rapid increases in peripheral blood EBV DNA load are supposed to reliably predict PTLD. We report a boy who 6 months after living-related kidney transplantation presented with an extranodal esophageal manifestation of PTLD. Despite a primary EBV infection with tonsillitis, the peripheral blood EBV DNA remained low, hiding the progression to PTLD.

Evidence for a long-term effect of a single dose of praziquantel on Schistosoma mansoni-induced hepatosplenic lesions in northern Uganda.

Treatment with praziquantel reduces the prevalence and intensity of Schistosoma mansoni infection. However, reversibility of periportal fibrosis of the liver, which potentially leads to fatal complications, is not unequivocally substantiated. In the Nile District of Uganda, 460 patients were parasitologically (Kato-Katz method) and ultrasonographically examined during October 1991, October 1992, and May 1994. Treatment with praziquantel at a dosage of 40 mg per kilogram of body weight was given in October 1991 and October 1992 to 460 individuals (group A). Another 192 patients were seen during the baseline study in October 1991 and missed the follow-up in October 1992 but took part in the second follow-up in May 1994. Thus, they received praziquantel only once in October 1991 (group B) and had an interval of 2.7 years until the next investigation in May 1994. Periportal thickening (PT) of the liver was assessed by ultrasound at each time point. Praziquantel therapy reduced the prevalence of S. mansoni in group A from 84% in 1991 to 31% in 1992 and 30% in 1994. The respective intensities of infection (geometric means of egg output) were 81 eggs per gram (epg) of stool in 1991, 31 epg in 1992, and 30 epg in 1994. Periportal thickening was found in 46% of patients in 1991, 32% of patients in 1992, and 35% of patients in 1994. Reversibility of PT was influenced by age (markedly lower reversibility in individuals older than 30 years) and sex (women and girls responded less favorably than did men and boys). Surprisingly, no significant difference was detected between group A and group B with respect to reversibility of PT The outcome between the 2 groups did not differ significantly. This may indicate that a single dose of praziquantel (as given to group B) may have a longer lasting effect than previously thought, that is, more than 2.5 years.

Lack of ultrasonographic evidence for severe hepatosplenic morbidity in schistosomiasis mansoni in Mali.

The inhabitants of four villages endemic for Schistosoma mansoni in central Mali (n = 1,106 of both sexes, age range 2-80 years) and of two nonendemic villages in another part of the country were examined parasitologically and ultrasonographically to establish the prevalence of periportal liver fibrosis (PF) and other features of hepatosplenic schistosomiasis. The prevalence of S. mansoni infection ranged from 36% to 93% in the endemic villages. A severe infection (> 400 eggs/g of stool) was found in 16% of the infected individuals. No case of grade III PF (echogenic bands usually > 10 mm in diameter around the central part and major branches of the portal vein and streak-like fibrous bands that extended into the periphery of the liver) and only eight cases of grade II PF (echogenic bands usually > 10 mm in diameter around the central part and major branches of the portal vein) were found; no other signs of severe hepatosplenic disease were encountered. However, grade I PF (echogenic bands usually > 4 mm in diameter that were best visible in the area of the portal vein bifurcation and gall bladder neck) was detected in 21% of all individuals, mainly in adults. In the nonendemic villages, the prevalence of grade I PF in adults was 9%. Generally, there was no significant correlation between the grade of PF and S. mansoni egg output. In one village with a high endemicity level, however, the prevalence of grade PF I increased with the intensity of infection. Morphometric data revealed no significant influence of S. mansoni infection on portal vein stem diameter and spleen size.(ABSTRACT TRUNCATED AT 250 WORDS)

The public health significance of urinary schistosomiasis as a cause of morbidity in two districts in Mali.

Schistosoma haematobium-related morbidity was studied in the perennial irrigation area of Office du Niger and the small reservoirs area of Plateau Dogon in Mali. Questionnaire, clinical, parasitologic, and ultrasound examination data were collected from 1,041 individuals at the baseline survey in 1991; 705 were re-examined one year after treatment. At baseline, the overall prevalence of S. haematobium infection was 55.2%; half of those infected had no clinical symptoms and 30% had pathologic lesions. Both infection and morbidity were more frequent in children than in adults, with a peak prevalence at 7-14 years of age. The rates of lesions were more than twice as high in those heavily infected as in lightly infected individuals. Reagent strip testing for microhematuria was more sensitive in detecting individuals with pathologic lesions than in detecting individuals with infection. One year after treatment with praziquantel, more than 80% of the urinary tract lesions had cleared. It is concluded that S. haematobium-related morbidity is frequent in Mali, but passive case detection for treatment would not cover a great deal of early stages of the disease; active intervention using reagent strip testing for microhematuria at the most peripheral levels would be an efficient system for morbidity control and monitoring of control operations.

Renal function and morphology in Sudanese patients with advanced hepatosplenic schistosomiasis and portal hypertension.

The association between glomerular disease and hepatosplenic schistosomiasis is well documented in reports from South America. During the present hospital investigation in Sudan, 58 patients admitted for intercurrent complications of advanced hepatosplenic schistosomiasis were studied. The patients, median age 35 years, had no concurrent Schistosoma haematobium infection. Diagnostic criteria included an enlarged spleen (n = 58), at least 1 episode of hematemesis (n = 55) and/or melena (n = 36), endoscopical demonstration of gastroesophageal varices (29/29 studied), ultrasonographical imaging of hepatic periportal fibrosis (18/18 studied), and intraoperative liver biopsy with characteristic histological findings (11/16 biopsied). Serum creatinine, urea, electrolytes, cholesterol, total protein, and electrophoresis were within normal limits. Median urinary protein/creatinine ratio was 0.06 and thereby not significantly different from European reference values. Only 1 patient had proteinuria of 1.7 g/l. Minimal hematuria was found in 5 patients. Ten kidney biopsies were taken intraoperatively during a portal decompression procedure (Hassab operation). Light, immunofluorescence, and electron microscopy produced no evidence of glomerulonephritis. These findings indicate that S. mansoni induced nephrotic syndrome may be less frequent in Sudan than in South America. Renal involvement due to S. mansoni infection may therefore encompass geographical variances.

Genetic variations of the SLC7A9 gene: allele distribution of 13 polymorphic sites in German cystinuria patients and controls.

Cystinuria is a hereditary disorder of cystine and dibasic amino acid transport across the luminal membrane of renal tubules and intestine, resulting in recurrent nephrolithiasis. While mutations in the SLC3A1 gene cause type I cystinuria, patients with non-type I cystinuria carry mutations in the SLC7A9 gene. Both gene products form the renal amino acid transporter rBAT/b0,+AT affected in cystinuria. In the present study a total of 59 patients with different ethnic background were screened for sequence variations in SLC7A9, out of these 32 were of German origin. For determination of allele frequencies of detected polymorphisms, 58 healthy German controls were investigated. Molecular-genetic analysis was performed using single-strand conformation polymorphism analysis, restriction assays and sequencing. Allele frequencies were analyzed statistically for the detected polymorphisms. In addition to the 6 already known variants we identified 7 new polymorphisms. Statistical analyses showed a significantly different distribution of alleles between German patients and German controls in case of the polymorphisms c. 147C>T (exon 2), c.386C>T (exon 3), IVS3+22T>G, c.584C>T (exon 4), c.610T>C (exon 4), c.692C>T (exon 5), c.852C>A (exon 6) and c.872C>T (exon 6). In summary, our results show that cystinuria is a complex disease which is not only caused by mutations in SLC7A9 and SLC3A1, but also influenced by other modifying factors such as variants in SLC7A9.

The impact of cyclosporine on the development of immunosuppressive therapy--pediatric transplantation using cyclosporine.

Cyclosporine A (CsA) was introduced to pediatric renal transplantation more than 20 years ago, and it has greatly improved graft survival and made transplantation the treatment of choice for children with end-stage renal failure. Exposure to CsA was shown to be highly variable among transplant recipients. Therefore, major efforts have been employed to monitor CsA blood levels. The widely used trough levels had never been formally validated, and every center had defined its own target values. With the advanced microemulsion formula of CsA, drug exposure became more predictable, but scientifically evaluated monitoring concepts are still lacking. Monitoring the absorption phase using single time points (eg, 2 hours after ingestion) is promising, as shown in adult trials. In pediatric transplant recipients, randomized clinical trials have to be implemented urgently to fully exploit the potential of CsA in the prevention of graft rejection while minimizing toxicity. Although newer immunosuppressive drugs have been developed, further studies should be undertaken to define the role of CsA in combination protocols.

Medical and surgical aspects of pediatric renal transplantation using living donors.

The outcomes of 19 consecutive living-donor renal transplants (LD-RTx) was compared with 41 cadaveric grafts (CD-RTx) performed at our institution using basiliximab, cyclosporine, and prednisone as standard immunosuppression. LD-RTx significantly shortened the waiting time on dialysis. However, patient survival (100% in both groups), 1-year graft survival (94.7% vs 90%), and rejection-free graft survival (76.9% vs 73.5%) was not significantly different. LD-RTx showed better glomerular filtration rates in the early phase after transplantation, a difference that faded with time. Graft function was similar after 1 and 2 years. LD grafts with double renal arteries were used successfully in four cases; heparin therapy was administered to avoid graft thrombosis. A significantly greater number of lymphoceles was observed with LD grafts (7/19 vs 1/41, P < .01). In conclusion with improved immunosuppression producing better results with CD grafts, the advantages of LD-RTx have vanished. LD grafts with double arteries may be used successfully and LD-RTx allows a shorter dialysis period. The high incidence of lymphoceles in our series awaits further evaluation.

Search for mutations in SLC1A5 (19q13) in cystinuria patients.

To elucidate whether SLC1A5 is involved in the aetiology of cystinuria, we screened two non-type I cystinuria families without detectable mutations inSLC7A9 (and SLC3A1) but compatible with linkage to 19q13 for genomic variants in SLC1A5. Despite evidence for an involvement of SLC1A5 in the aetiology of cystinuria, we could not identify any mutation in this gene in the two families. With SLC1A5, a further candidate gene for cystinuria can be excluded as being involved in the pathogenesis of this disease in these two families. Of course, there remains the possibility that other genes are involved in cystinuria; further molecular studies will clarify the complex nature of this disorder.

Oral L-arginine supplementation in cystic fibrosis patients: a placebo-controlled study.

Exhaled nitric oxide (eNO) is decreased in cystic fibrosis (CF). The effect of oral L-arginine, the precursor of enzymatic nitric oxide (NO) formation, on airway NO in patients with CF was studied. In a pilot study, oral L-arginine was given in a single dose of 200 mg x kg(-1) body weight to eight healthy controls and eight CF patients. Subsequently, the same L-arginine dose was given to 10 patients with CF (five females) t.i.d. for 6 weeks in a randomised double-blind placebo-controlled crossover study. A single dose of oral L-arginine resulted in a 5.5-fold increase of L-arginine in plasma and a 1.3-fold increase of L-arginine in sputum after 2 h. Maximum eNO, within 3 h of L-arginine intake, increased significantly in both CF patients (5.4+/-2.1 ppb versus 8.3+/-3.5 ppb) and controls (18.0+/-8.1 ppb versus 26.4+/-12.3 ppb). Supplementation of L-arginine for 6 weeks resulted in a sustained increase in eNO compared to placebo (9.7+/-5.7 ppb versus 6.3+/-3.1 ppb). An effect of L-arginine supplementation on forced expiratory volume in one second was not observed. These data indicate that airway nitric oxide formation in cystic fibrosis patients can be augmented with oral L-arginine supplementation.

Circadian variation of ova excretion, proteinuria, hematuria, and leukocyturia in urinary schistosomiasis.

Urine samples from five boys (7 to 9 years) with urinary schistosomiasis were collected at 6 A.M. and thereafter at 3-hr intervals until 9 P.M. on 5 consecutive days. Ova excretion in the urine, proteinuria (PU), erythrocyturia (EU), and leucocyturia (LU) were assessed quantitatively. Egg excretion followed a circadian rhythm with a peak at 12 noon and was paralleled closely by pathological PU. Maximal erythrocyturia occurred at 6 P.M., whereas leucocyturia revealed two distinct peak times. Taking the congruent patterns of egg excretion and PU together with the results of qualitative urinary protein analysis into account, it was concluded that PU was linked causally to ova excretion and could be explained by bleeding and exudation of serum proteins during penetration of ova through the bladder mucosa. In contrast, EU and LU seemed to be caused by different pathological mechanisms. EU followed a time-delayed circadian rhythm, possibly induced by persistent bleeding, whereas LU may have indicated a concomitant inflammatory component of the bladder.

Color Doppler energy--a new technique to study tissue perfusion in renal transplants.

Information on renal tissue perfusion after transplantation remains important for renal allograft monitoring. Findings obtained by conventional Doppler sonography are limited to vascular resistance (RI). The new technique color Doppler energy (CDE) is Doppler angle independent, omits flow velocity and direction, and is proportional to the returning signal strength. The aim of our study was to standardize the application of this technique and to analyze the information obtained. Forty-six CDE studies were performed with an Acuson 128XP in 28 children (mean age 12.4+/-5.3 years) between 4 days and 10 years after renal transplantation. The most-reproducible information was obtained with a 5-MHz linear probe and a constant area of 2x3 cm (log compression 40 dB, filter 3). CDE provided a high-resolution cross-sectional display of perfused cortical tissue vessels. According to the density of signals, the perfusion could be grouped into six perfusion scores (PS). The interobserver concordance was more than 85%. No correlation was found between PS and RI or blood pressure. However, there was a significant correlation between PS and glomerular filtration rate (r=-0.78, P<0. 001). These first results demonstrate a significant relationship between PS and chronic rejection. Non-rejection-related functional impairment exhibited no decrease in PS. We conclude that our proposed standardized CDE renal study is observer independent. CDE is a promising new technique that provides information on renal allograft dysfunction that is different from classical color Doppler findings. Further studies will clarify its role in renal transplant monitoring and its ability to replace more-invasive techniques.