Adverse events linked with the use of chimeric and humanized anti-CD20 antibodies in children with idiopathic nephrotic syndrome.

AIMS: Anti-CD20 antibodies are increasingly being used to treat idiopathic nephrotic syndrome (INS) in children. While they may allow steroid and calcineurin inhibitor withdrawal, repeated infusions of anti-CD20 antibodies are often required to maintain remission. Data on their potential toxicity in INS are needed, to consider repeated infusions. METHODS: We investigated the side effects associated with the use of rituximab (a chimeric antibody; 130 patients) and ofatumumab (a humanized antibody; 37 patients) in children with INS (steroid-dependent and steroid/calcineurin inhibitor-dependent disease) treated at a national referral centre over a 9-year period (400 treatments; follow-up 1-9 years). RESULTS: Infusion reactions were mainly absent in children with steroid-dependent disease. Rash, dyspnoea, fever, cough and itchy throat (5% and 18% following rituximab and ofatumumab infusion, respectively) were resolved by using premedication with salbutamol. Other short-term reactions (up to 3 months), including arthritis (2%) and lung injury (1%), were more common with rituximab. Infections were observed 3-9 months following infusion, were similarly common in the two groups and resolved with targeted therapies [antibiotic, fluconazole, immunoglobulins (Igs), etc.]. The number of circulating CD19/20 cells fell to 0 at month 1 and were reconstituted at month 3; circulating IgG antibodies remained within the normal range for 1 year. Tetanus and hepatitis B virus immunization was not modified by either treatment; Epstein-Barr virus and John Cunningham virus activation markers were occasionally observed. CONCLUSION: Overall, the toxicity of anti-CD20 monoclonal antibodies was limited to post-infusion side effects in children with more complex disease. The relatively safe profile of anti-CD20 antibodies supports their use as steroid-sparing agents in children with INS.

Proteome profile of peritoneal effluents in children on glucose- or icodextrin-based peritoneal dialysis.

BACKGROUND: We compared the proteome profile of peritoneal effluents obtained with icodextrin (Ico) or glucose (Glu) in paediatric patients and defined the oxido-redox status of proteins. METHODS: Sixteen patients underwent two 14-h daytime dwells performed on subsequent days with 7.5% Ico and 3.86% Glu solutions. Protein composition was analysed by two-dimensional electrophoresis and mass spectrometry; oxidized products were evaluated by cyanine labelling. RESULTS: Peritoneal transport kinetics of ß2-microglobulin and cystatin C was linear for both solutions, but was significantly higher with Ico than with Glu, suggesting a better efficiency for these molecules. There was a linear correlation between total protein removal during Ico and Glu dialysis in the same patient, suggesting that it is a function of peritoneal membrane characteristics. The ratio between proteins removed by Ico and by Glu solutions was higher at low removal rate. Image gel analysis revealed 1064 and 774 spots, respectively, in Ico and Glu solutions; 524 were common, and 314 were higher in Ico than Glu effluents. Analysis of protein oxido-redox status showed a greater amount of oxidized albumin in Ico dialysate that was correlated with lower serum levels. CONCLUSIONS: Our results indicate a better efficiency of Ico in removing small proteins. Removal of big proteins and their oxidized isoforms reflects potentially opposite effects. The long-term clinical consequences of removing also potentially important molecules are to be defined.

Hyperinsulinemia and insulin resistance, early cardiovascular risk factors in children with chronic kidney disease.

BACKGROUND/AIMS: Pediatric chronic kidney disease (CKD) is associated with increased risk of cardiovascular disease. Still, hyperinsulinemia and insulin resistance, common cardiovascular risk factors, are not extensively investigated in children with CKD. We hypothesize that insulin abnormalities are present also in pediatric mild to moderate CKD, and associated with inflammation and malnutrition. METHODS: We enrolled 26 children with CKD, and 34 healthy controls for analyses of blood samples and body composition. Insulin resistance was assessed using the homeostasis model assessment for insulin resistance (HOMA-IR). RESULTS: The patients had higher insulin levels and HOMA-IR compared to the controls (p < 0.01 and p < 0.005), and they correlated inversely with estimated glomerular filtration rate (rho = -0.52, p < 0.01; rho = -0.37, p = 0.08). No association was found with inflammation or malnutrition. CONCLUSION: High insulin levels and HOMA-IR appear to be common in pediatric CKD patients, already in mild to moderate renal failure. We hypothesize that hyperinsulinemia and insulin resistance alone might be important risk factors for cardiovascular disease in children with CKD.

Molecular and Cellular Mechanisms for Proteinuria in Minimal Change Disease.

Minimal Change Disease (MCD) is a clinical condition characterized by acute nephrotic syndrome, no evident renal lesions at histology and good response to steroids. However, frequent recurrence of the disease requires additional therapies associated with steroids. Such multi-drug dependence and frequent relapses may cause disease evolution to focal and segmental glomerulosclerosis (FSGS) over time. The differences between the two conditions are not well defined, since molecular mechanisms may be shared by the two diseases. In some cases, genetic analysis can make it possible to distinguish MCD from FSGS; however, there are cases of overlap. Several hypotheses on mechanisms underlying MCD and potential molecular triggers have been proposed. Most studies were conducted on animal models of proteinuria that partially mimic MCD and may be useful to study glomerulosclerosis evolution; however, they do not demonstrate a clear-cut separation between MCD and FSGS. Puromycin Aminonucleoside and Adriamycin nephrosis are models of glomerular oxidative damage, characterized by loss of glomerular basement membrane polyanions resembling MCD at the onset and, at more advanced stages, by glomerulosclerosis resembling FSGS. Also Buffalo/Mna rats present initial lesions of MCD, subsequently evolving to FSGS; this mechanism of renal damage is clearer since this rat strain inherits the unique characteristic of overexpressing Th2 cytokines. In Lipopolysaccharide nephropathy, an immunological condition of renal toxicity linked to B7-1(CD80), mice develop transient proteinuria that lasts a few days. Overall, animal models are useful and necessary considering that they reproduce the evolution from MCD to FSGS that is, in part, due to persistence of proteinuria. The role of T/Treg/Bcells on human MCD has been discussed. Many cytokines, immunomodulatory mechanisms, and several molecules have been defined as a specific cause of proteinuria. However, the hypothesis of a single cell subset or molecule as cause of MCD is not supported by research and an interactive process seems more logical. The implication or interactive role of oxidants, Th2 cytokines, Th17, Tregs, B7-1(CD80), CD40/CD40L, c-Mip, TNF, uPA/suPAR, Angiopoietin-like 4 still awaits a definitive confirmation. Whole genome sequencing studies could help to define specific genetic features that justify a definition of MCD as a "clinical-pathology-genetic entity."

Interstitial 11q24 deletion: a new case and review of the literature.

We describe a 19-month-old male presenting with right stenotic megaureter, anemia and thrombocytopenia, cardiac and ophthalmologic abnormalities. Analysis with array-based comparative genomic hybridization (aCGH) revealed an interstitial deletion of about 2.4 Mb of chromosome 11q24.2q24.3. We compared the phenotype of our patient with that of recently reported patients studied by aCGH, who showed an overlapping deletion. We also analysed the gene content of the deleted region in order to investigate the possible involvement of specific genes in the clinical phenotype.

Hyponatremic-hypertensive syndrome with extensive and reversible renal defects.

Two young children with renal artery stenosis and severe hypertension who presented with the so-called hyponatremic-hypertensive syndrome (HHS), with marked urine and solute loss during the acute phase, are described. Both children also presented with severe high molecular proteinuria, glycosuria, and hypercalciuria, only the first symptom having prompt remission after normalization of blood pressure. In children with renal artery stenosis, HHS is associated with severe proteinuria due to hyperfiltration and more extensive tubular functional alterations. Hyponatremia and acute tubulopathy may mask the presenting clinical picture of renal artery stenosis.

Homocysteine, folate, vitamin B12 levels, and C677T MTHFR mutation in children with renal failure.

Hyperhomocysteinemia is well documented in chronic renal failure (CRF) and premature and progressive occlusive vascular disease is common in CRF. The combined effects of renal failure, folate and vitamin B(12) levels, and a common mutation (C677T) in the methylenetetrahydrofolate reductase (MTHFR) gene that leads to total plasma homocysteine (tHcy) elevation in CRF children were investigated. Forty-two children (15 females) with CRF, mean age 10.3+/-4.7 years, were included. The mean glomerular filtration rate (GFR) was 37.3+/-16.9 ml/min per 1.73 m(2). The control group comprised 33 children (18 females) with a mean age of 8.6+/-3.4 years. There were 40% of CRF patients with hyperhomocysteinemia. Folate and vitamin B(12) deficiencies were identified in 14% (n=6) and 5% (n=2), respectively, of all patients. On univariate analysis, the tHcy serum concentration was negatively correlated with the plasma folate concentration (P<0.05) in controls, and with GFR (P<0.05) in patients. On multiple regression analysis for the predictors of tHcy serum concentrations, folic and vitamin B(12 )were significant in controls, whereas only GFR was significant in CRF children. In our patients no effect of the MTHFR polymorphism on tHcy levels was seen This result, in addition to the limited number of patients, may partially be explained by the low prevalence of folate deficiency in our patients.

Acute effects of peritoneal dialysis with dialysates containing dextrose or dextrose and amino acids on muscle protein turnover in patients with chronic renal failure.

Whether changes in substrate and insulin levels that occur during peritoneal dialysis (PD) have effects on muscle protein dynamics was evaluated by studying muscle protein synthesis (PS), breakdown (PB), and net protein balance (NB) by the forearm perfusion method associated with the kinetics of 3H-phenylalanine in acute, crossover studies in which PD patients served as their own controls. Studies were performed (1) in the basal state and during PD with dialysates that contained dextrose alone in different concentrations (protocol 1: eight patients), (2) during PD with dialysates that contained dextrose alone or dextrose and amino acids (AA) (protocol 2: five patients), and (3) in time controls (five patients). PD with dextrose alone induced (1) a two- to threefold increase in insulin, as well as a 20 to 25% decrease in AA, mainly BCAA, levels; (2) an insulin-related decline (-18%) in forearm PB (P<0.002); (3) a 20% decrease in muscle PS (P<0.04), which was related to arterial BCAA and K+ (P<0.02 to 0.05); (4) a persistent negative NB; and (5) a decrease in the efficiency of muscle protein turnover, expressed as the ratio NB/PB. PD with dextrose+AA versus PD with dextrose induced (1) similarly high insulin levels but with a significant increase in total arterial AA (+30 to 110%), mainly valine; (2) a reduced release of AA from muscle (P<0.05); and (3) a decrease in the negative NB observed during PD with dextrose, owing to an increase (approximately 20%) in muscle PS, without any further effect on muscle PB. This study indicates that in PD patients in the fasting state, the moderate hyperinsulinemia that occurs during PD with dextrose alone causes an antiproteolytic action that is obscured by a parallel decrease in AA availability for PS. Conversely, the combined use of dextrose and AA results in a cumulative effect, because of the suppression of endogenous muscle PB (induced by insulin) and the stimulation of muscle PS (induced by AA availability). The hypothesis, therefore, is that in patients who are treated with PD, when fasting or when nutrient intake is reduced, muscle mass could be maintained better by the combined use of dextrose and AA.

Free amino acids in plasma, red blood cells, polymorphonuclear leukocytes, and muscle in normal and uraemic children.

BACKGROUND: The aims of this study were to investigate free amino acid (AA) concentrations in plasma, red blood cells (RBC), polymorphonuclear granulocytes (PMN), and muscle, sampled at the same time, in normal and uraemic children. METHODS: Twelve apparently well-nourished chronically uraemic children (five females) aged a mean of 9.4+/-4.8 (range 1.7--17.7) years and 13 age-matched normal children were studied. Venous blood and muscle samples for AA analyses were taken simultaneously after an overnight fast. RESULTS: The intracellular AA patterns in the three cellular compartments were qualitatively similar, but the absolute intracellular concentrations were higher in muscle than in PMN, which had higher values than in RBC. The AA patterns in plasma, RBC, PMN, and muscle in the uraemic children have many similarities; typical features being low branched-chain AA (BCAA), tyrosine, and serine concentrations and variably high concentrations of some non-essential AA. Among the individual AA, there were only few correlations between their concentrations in the three cell compartments. CONCLUSIONS: The lack of correlation between the concentrations in RBC, PMN, and muscle for most of the AA indicates that there is no close association in the same subject between individual free AA concentrations in various types of cells, presumably because of differences in metabolism and function. Consequently, one should be cautious in assuming that AA concentrations, determined in RBC or PMN, reflect the concentrations in muscle cells. Therefore, these preliminary observations do not support the hypothesis that RBC and PMN AA analysis can be considered as a suitable alternative to muscle AA determination.

Reconstrucción mamaria: nuestra experiencia con distintas técnicas / Breast reconstruction: our experience using several procedures

Se presentan los métodos más usados para reconstrucción mamaria, incluyendo en la casuística un caso de malformación congénita con agenesia mamaria (sindrome de Poland) y tratándose los casos restantes de pacientes mastectomizadas por cáncer de mama. En total se analizan 21 casos. Se establecen como premisas básicas para la reconstrucción la buena calidad de los tejidos locales, debiéndose realizar el aporte de piel, tejido celular y músculos de regiones adyacentes (colgajos musculares y músculo-cutáneos), en caso de lecho cicatrizal fibroso, piel retraída y adherida a la pared torácica

Reconstrucción del esternón / Reconstruction of the sternum

La infección y/o dehiscencia de la esternotomía mediana, aunque poco frecuentes, tienen elevada morbimortalidad si no se trata adecuadamente. En aquellos pacientes que no mejoran con la técnica de la irrigación cerrada y que antes eran abiertos y mechados con gran riesgo vital y prolongada hospitalización, hemos tenido excelentes resultados utilizando los colgajos musculares descritos. De nuestra pequeña serie de 8 pacientes, hemos tratado 2 casos de mediastinitis y dehiscencia de la esternostomía y 6 casos de condroosteítis esternal supurada crónica, con mortalidad cero. El acortamiento del período de hospitalización es otro de los beneficios derivados del uso de estas técnicas