Ketogenic diet as a potential intervention for lipedema.

Lipedema (LI) is a common yet misdiagnosed condition, often misconstrued with obesity. LI affects women almost exclusively, and its painful and life-changing symptoms have long been thought to be resistant to the lifestyle interventions such as diet and exercise. In this paper, we discuss possible mechanisms by which patients adopting a ketogenic diet (KD) can alleviate many of the unwanted clinical features of LI. This paper is also an effort to provide evidence for the hypothesis of the potency of this dietary intervention for addressing the symptoms of LI. Specifically, we examine the scientific evidence of effectiveness of adopting a KD by patients to alleviate clinical features associated with LI, including excessive and disproportionate lower body adipose tissue (AT) deposition, pain, and reduction in quality of life (QoL). We also explore several clinical features of LI currently under debate, including the potential existence and nature of edema, metabolic and hormonal dysfunction, inflammation, and fibrosis. The effectiveness of a KD on addressing clinical features of LI has been demonstrated in human studies, and shows promise as an intervention for LI. We hope this paper leads to an improved understanding of optimal nutritional management for patients with LI and stimulates future research in this area of study.

FKBP12 associates tightly with the skeletal muscle type 1 ryanodine receptor, but not with other intracellular calcium release channels.

This study compared the relative levels of ryanodine receptor (RyR) isoforms, inositol 1,4,5-trisphosphate receptor (IP(3)R) isoforms, and calcineurin, plus their association with FKBP12 in brain, skeletal and cardiac tissue. FKBP12 demonstrated a very tight, high affinity association with skeletal muscle microsomes, which was displaced by FK506. In contrast, FKBP12 was not tightly associated with brain or cardiac microsomes and did not require FK506 for removal from these organelles. Furthermore, of the proteins solubilised from skeletal muscle, cardiac muscle and brain microsomes, only skeletal muscle RyR1 bound to an FKBP12-glutathione-S-transferase fusion protein, in a high affinity FK506 displaceable manner. These results suggest that RyR1 has distinctive FKBP12 binding properties when compared to RyR2, RyR3, all IP(3)R isoforms and calcineurin.

Dysfunctional intracellular calcium homoeostasis: a central cause of neurodegeneration in Alzheimer's disease.

The clinical symptoms of all forms of Alzheimer's disease (AD) result from a slowly progressive neurodegeneration that is associated with the excessive deposition of beta-amyloid (A beta) in plaques and in the cerebrovasculature, and the formation of intraneuronal neurofibrillary tangles, which are composed primarily of abnormally hyperphosphorylated tau protein. The sequence of cellular events that cause this pathology and neurodegeneration is unknown. It is, however, most probably linked to neuronal signal transduction systems that become misregulated in the brains of certain individuals, causing excessive A beta to be formed and/or deposited, tau to become aggregated and hyperphosphorylated and neurons to degenerate. We hypothesize that a progressive alteration in the ability of neurons to regulate intracellular calcium, particularly at the level of the endoplasmic reticulum, is a crucial signal transduction event that is linked strongly to the initiation and development of AD pathology. In this chapter we will discuss the key findings that lend support to this hypothesis.

Inhibition of DNA hybridization following partial dUTP substitution.

Carry-over contamination from PCR products can yield persistent false-positive results leading to significant problems in the resolution of true positive results. Commercial kits used in many laboratories help prevent carry-over contamination. We present data on the effects of dUTP substitution on the hybridization properties of amplified DNA using alkaline phosphatase conjugated oligonucleotide probes. We observe a pronounced depression in hybridization signal intensity in some dUTP-substituted PCR products. The magnitude of the decreased hybridization signal intensity appears proportional to both the dUTP concentration in the amplification reaction and the fraction of thymidylate residues in the probe binding site. The hybridization signal is nearly eliminated from PCR products synthesized in the presence of dUTP only and where the probe binding site is particularly rich in thymidylate residues. The decrease in hybridization signal is not always restored with less stringent hybridization conditions. Conditions that permit efficient hybridization and detection of bound probe but do not compromise carry-over protection are discussed.

An empirical method for the estimation of nonspecific PCR primer derived genomic reactivity.

A total of 36 PCR primers were subjected to thermal cycling, in a reaction composed of a single primer only, in order to assess their individual tendencies toward "nonspecific" amplification of human genomic DNA background. Nonspecific amplification of genomic DNA was estimated by Southern hybridization of the amplification products with an Alu-specific DNA probe. The yield of amplified Alu-hybridizing material was estimated by scanning densitometry. In this way a quantitative estimate of "mispriming" was obtained for the primers tested. Human Alu and total primate GenBank databases were scanned in order to obtain an estimate of the prevalence of homologous primer binding sites for each primer. Database searches were conducted at both 70% primer binding site homology and 100% homology at the 3'-terminal third of the primer. The observed levels of amplified, Alu-hybridizing material correlated best, but only marginally, with homology-based estimates of potential cross-reactivity at the 3' terminus of the primer (R = 0.193). A set of p53 tumor suppressor gene primers, exhibiting low and high extremes of background amplification, were tested for sensitivity in the presence and absence of added genomic DNA. The primer that gave the highest level of background amplification was the one whose performance was most severely affected by added genomic DNA. Empirical assessment of the tendencies of individual primers to amplify irrelevant DNA at low levels of the intended target may permit a useful "noise-specific" adjunct to primer design by computational methods.

Aluminum-related bone disease. Correlation between symptoms, osteoid volume, and aluminum staining.

In order to correlate symptoms, osteoid volume, and aluminum deposition in bone, 46 methacrylate-embedded biopsy specimens from 26 hemodialysis patients were examined. Osteoid volume was measured using computer-assisted morphometric analysis, and aluminum was detected using the Aluminon stain. Positive staining for aluminum was present in biopsies from 21 patients. Osteoid volume did not correlate with duration of dialysis therapy or ingestion of aluminum hydroxide but displayed a logarithmic relationship with dialysate aluminum exposure. Patients with bone pain at the time of biopsy had a greater degree of hyperosteoidosis than asymptomatic subjects. Osteoid volume in patients with fractures and positive aluminum staining decreased on withdrawal from aluminum-rich dialysate. The Aluminon staining technic is a convenient method of confirming aluminum overload.

The significance of platelets with increased RNA content (reticulated platelets). A measure of the rate of thrombopoiesis.

Direct flow cytometric measurement of nucleic acid content in individual platelets is possible using the fluorescent dye Thiazole Orange (Becton-Dickinson, San Jose, CA). When applied to studies of thrombocytopenic patients, platelets with elevated nucleic acid content ("reticulated platelets") can be identified and quantitated. Labeling of these platelets is saturable and is abolished by treatment with RNAse. It has been suggested that, similar to the erythrocyte reticulocyte response to anemia, the number of these platelets appearing in the circulation may provide an estimate of the rate of thrombopoiesis. The authors studied 229 thrombocytopenic patients, measuring both reticulated platelets and platelet-associated immunoglobulin. The results show that for the subset of patients with normal levels of platelet-associated immunoglobulin, the average absolute number of reticulated platelets is independent of platelet count and remains in the normal range. For those with elevated levels of platelet-associated immunoglobulin, the absolute number of reticulated platelets increases in patients who are moderately thrombocytopenic (60 to 100 x 10(9)/L) but decreases to normal or subnormal levels as thrombocytopenia worsens. The latter finding has been duplicated in studies of mice made thrombocytopenic by injection of anti-platelet antiserum. These results are consistent with the hypothesis that reticulated platelets are subject to peripheral destruction at the same rate as mature platelets, and that in the severely thrombocytopenic patient their level may decrease despite an appropriate marrow thrombopoietic response.

Glomerulonephritis after ventriculo-atrial shunt.

We describe five patients with glomerulonephritis (GN) associated with cerebrospinal fluid shunt insertion to relieve hydrocephalus. A ventriculo-atrial (V-A) shunt had been placed on average 12.5 years prior to the diagnosis of nephritis (range 0.5-21 years). Four patients developed membranoproliferative glomerulonephritis (MPGN) with associated hypocomplementaemia. A single patient developed focal proliferative glomerulonephritis. Coagulase-negative staphylococci were cultured in four patients, either from blood or from the shunt. Four patients had their shunts removed, two of whom also received antibiotics. The other patient received antibiotics alone for infective endocarditis due to staphylococcal bacteraemia which originated in the shunt. All patients had substantial renal impairment at the time of diagnosis (GFR, glomerular filtration rate, 20-45 ml/min). There was significant improvement in renal function after appropriate treatment; four of the five patients doubled their GFRs and two patients regained normal function.

Familial adult medullary cystic disease with spastic quadriparesis: a new disease association.

We present two cases of familial adult medullary cystic disease with spastic quadriparesis, an association not previously described. Previous extrarenal associations of the nephronophthisis-medullary cystic disease complex were reported exclusively in childhood cases. Both patients have undergone successful cadaveric renal transplantation, with no evidence of their renal disease recurring. Further work is needed to elucidate the complex genetics of nephronophthisis.

The management of hydrothorax in continuous ambulatory peritoneal dialysis (CAPD).

Four patients on continuous ambulatory peritoneal dialysis (CAPD) developed large, symptomatic pleural effusions after commencing peritoneal dialysis. Pleuroperitoneal fistula in each case was diagnosed by the presence of a high glucose content in pleural fluid, with a normal corresponding blood sugar, and was confirmed by isotope or contrast peritoneography. Two patients had their effusions drained percutaneously, and then underwent pleural sclerosis with intracavitary tetracycline. Two patients had a thoracotomy performed, of which no fistula was identified in one case, and the other patient underwent pleurectomy. All four patients successfully recommenced CAPD several weeks after therapy, without recurrence of effusions. We conclude that pleuroperitoneal connections associated with CAPD do not mandate cessation of peritoneal dialysis and conversion to maintenance haemodialysis. Definitive diagnosis requires aspiration of pleural effusions for glucose estimation. Contrast or isotopic peritoneography is helpful in localising the fistula, but in our experience did not alter management. Simple sclerotherapy is effective and avoids the need for a formal thoracotomy.

Production of monoclonal antibodies specific for platelet activation antigens and their use in evaluating platelet function.

Monoclonal antibodies (MAb) were used to identify platelet membrane molecules that are expressed after platelet activation. Balb/C mice were immunized with fixed thrombin-activated human platelets and their spleen cells were fused with the murine myeloma cell line NS1-Ag4/1. The resulting hybridomas were screened for antibody production against fixed thrombin-activated platelets and fixed resting platelets by flow cytometry. Two MAbs 2C8 (an IgM) and 1E3 (an IgG2a) demonstrated significant binding to fixed thrombin-activated platelets while reacting minimally with fixed resting platelets. The reactivity of 2C8 and 1E3 were compared to MAb's S12 and AC1.2, both of which have known specificity for an alpha-granule membrane protein (GMP-140) expressed on the surface of activated platelets. In radioimmunoprecipitation studies, both 2C8 and 1E3 immunoprecipitated a protein of approximately 140 kDa similar to that precipitated by S12 and AC1.2. Immunodepletion studies, with S12, AC1.2, 1E3, and 2C8 confirm that they all react with the same antigen. 2C8 may recognize the same epitope as S12, whereas 1E3 appears to recognize a different epitope of the same molecule. The use of these MAbs to measure platelet activation in whole blood correlates well with the results of conventional platelet aggregometry.

Systemic vasculitis with renal involvement--a review.

Twenty five patients with renal vasculitis presenting over an eight year period were reviewed. Ten had microscopic polyarteritis, 6 classic polyarteritis, 5 overlap syndrome, 2 Churg-Strauss syndrome and 2 Wegener's granulomatosis. Clinical features included hypertension, pulmonary involvement, neurological involvement and arthralgia. Serum creatinine was over 500 umol/l in 13 patients, 10 of whom required dialysis. Visceral angiography was positive in 80% of those studied, Focal and segmental necrotising glomerulonephritis was the commonest renal lesion. Treatment consisted of corticosteroids and cytotoxic agents in most cases. Plasmapheresis was used for rapidly progressive renal failure, severe pulmonary haemorrhage or cerebral vasculitis. Improvement or stabilisation of renal function was seen in 68% of patients treated. There were 4 early deaths and one late death. The diagnosis, histology, treatment and outcome of renal vasculitis is discussed. The importance of early diagnosis and treatment is emphasised in this potentially reversible cause of acute renal failure.

Living related renal transplantation in Ireland: a sixteen year review.

Between January 1972 and December 1987, a total of 777 transplants were performed of which 135 (17%) were living related. There were 108 sibling donors, 25 parent to child and 2 child to parent. All sibling transplants were HLA identical. Conventional immunosuppression with Prednisone and Azathioprine was used in all cases. Actuarial patient survival were 95%, 91% and 88% at 1, 5 and 10 years respectively. Corresponding actuarial graft survivals were 90%, 80% and 60%. Graft survival in the sibling compared to the parent to child group was 87% versus 60% at 5 years. There were 13 deaths during the study interval and 32 grafts were lost. Five year patient/graft survivals of 91/80% compare favourably with other reported series. The poorer outcome in parent to child transplants has led us to modify the immunosuppressive protocol to include Cyclosporin A in this group. The increased availability and improved survival of cadaveric grafts in recent years and our one year patient/graft survival of 92/88% has led us to reduce emphasis on living related transplantation in our renal replacement programme.

The use of cyclosporin A in adult nephrotic syndrome: nine cases and literature review.

Nine adult patients with resistant nephrotic syndrome were treated with cyclosporin A (CyA). All had failed to respond to high dose corticosteroids with or without cyclophosphamide. Three patients had minimal change disease, 3 had focal sclerosing glomerulosclerosis (FSGS), 2 had mesangiocapillary GN, and one had membranous nephropathy. The mean age of the patients was 26.4 years (range 16 to 39 years). CyA was given orally twice daily at a mean dose of 6.7 mg/kg/24 hours (range 6-10 mg/kg/24 hours). Four patients achieved full remission, two patients went into partial remission and three failed to respond. Two patients developed clinical nephrotoxicity, which reversed on dose reduction or cessation of CyA. All 3 patients with minimal change disease who responded subsequently relapsed after stopping CyA, but remitted rapidly on reintroduction of the drug. We suggest that the mode of action of CyA in nephrotic syndrome may be related to intra-renal vasoconstriction in addition to its direct immunosuppressive effect. In this limited series, we found that CyA can be an effective therapy for otherwise refractory nephrotic syndrome, although relapse on withdrawal of CyA may well be a significant clinical problem.

Skin cancer in an Irish renal transplant population.

One hundred and forty-nine renal transplant patients attending 2 centres in Dublin were examined. Twelve patients (8.1%) were found to have cutaneous malignancy while dysplastic lesions (premalignant and/or malignant) were identified in 34 (22.8%). The prevalence of cutaneous malignancy in this study is substantially greater than that of previous Irish studies. The introduction of cyclosporin A (CyA) as a new and more effective immunosuppressive agent in renal transplantation may in part explain this increase.

Paediatric renal transplantation in Ireland: 1980-1990.

Between 1980 and 1990, 862 renal transplants were performed at our unit. Forty-six of these were given to 38 children. The mean age of the children was 8.6 years. Reflux nephropathy accounted for 39% of the primary renal diseases, followed by congenital disorders (30%), and glomerulonephritis (16%). Seventy percent of the grafts were from cadaveric donors. The one year patient survival was 90%, and the one year graft survival 61%. Seven children received a second graft with a one year graft survival of 71%.

Lower prevalence of anti-hepatitis C antibody in dialysis and renal transplant patients in Ireland.

It is well recognised that haemodialysis and renal transplant patients are at increased risk of developing non-A, non-B hepatitis. Recently the genome of hepatitis C virus (HCV), the major causative agent for non-A, non-B hepatitis, has been isolated. Anti-HCV seroprevalence was assessed in all haemodialysis patients (266) in Ireland who in March 1990 had been dialysed for at least 6 months. For comparative purposes, 272 patients who had functioning renal transplants for greater than 6 months were also studied. Potential risk factors such as age, number of blood transfusions and time on dialysis were evaluated. The prevalence of HCV infection as evidenced by antibody detection was only 1.1% for transplant and 1.7% for haemodialysis patients. This compares to a reported incidence of between 10% and 50% found elsewhere. Two of the 5 anti-HCV positive haemodialysis patients and 2 of the 3 transplant patients had biochemical evidence of liver disease. From stored sera it was possible to ascertain when patients acquired HCV. Whether the very low prevalence of anti-HCV in Irish patients is due to the low prevalence of the virus in the general population, the policy of non reimbursement of blood donors, genetic or other factors, remains to be determined.

The rapid reversal of profound hypothermia using peritoneal dialysis.

Severe hypothermia is associated with serious patient morbidity and mortality. The groups most frequently affected are the elderly, the very young and substance abusers. We describe three such cases which were successfully treated using warmed peritoneal dialysis. Two patients recovered completely and were left with no long term deficits. The third patient recovered from the acute event, but succumbed later to an underlying medical condition. Warmed peritoneal lavage is an efficient, cost effective approach which is easily performed without specialist equipment, and involves minimal risk to the patient.

IgA nephropathy-An immunopathological study.

IgA nephropathy is described in 11 cases out of a total of 177 renal biopsies examined representing an incidence of 6.2 per cent.Reference is made to comparable studies from other centres. Clinical and pathological findings are presented and discussed.

Systemic lupus erythematosus: Renal involvement and prognosis.

In 20 cases of systemic lupus erythematosus the renal biopsy findings permitted morphological classification with features of prognostic value. Glomerulosclerosis and interstitial fibrosis correlated best with the clinical course. Renal involvement, with a 90% 5 year survival, may have less sinister implications for this population, in contrast with the poor prognosis reported in comparable series.