Multidisciplinary working group: key role for percutaneous endovascular AV fistula program. Point of view.

Chronic kidney disease is a progressive condition that affects more than 10% of the general population worldwide. Hemodialysis is the most common therapeutic option for kidney failure, which develops in around one out of 1000 individuals in the general population. Hemodialysis needs a vascular access to connect to the extracorporeal machine. In the last few years percutaneous endovascular arterio-venous fistula technique has been increasingly employed with very promising results. Several advantages have been demonstrated in comparison to the standard surgical creation of an arteriovenous fistula. The percutaneous endovascular arterio-venous fistula technique requires multidisciplinary team work. In our practice, we have organized a multidisciplinary team that includes nephrologists, play a key role, interventional radiologists, vascular surgeons, anesthesiologists, and dialysis nurses. Procedural outcomes and feedback received from patients and family members are evaluated periodically in order to improve results. Nephrologists are involved in each step of the management of the percutaneous endovascular arterio-venous fistula: selection, mapping, creation, and follow up. Patient empowerment, education and involvement is required at each step. A dedicated training program, involving patients and the caregiver team is therefore needed. Additional research is required to confirm the benefit of the multidisciplinary team management in end-stage kidney disease patients.

Unilateral temporary diaphragmatic paralysis secondary to bronchial artery embolization in a girl with cystic fibrosis and massive hemoptysis: a case report.

BACKGROUND: Massive hemoptysis is a serious complication in Cystic Fibrosis (CF), occurring commonly in older patients. Bronchial artery embolization (BAE) can be performed to stop the bleeding. BAE is generally safe and effective, but can sometimes lead to serious complications. We report the first case of temporary unilateral diaphragmatic paralysis associated to lung consolidation following BAE in a pediatric CF female patient. This complication worsened the lung function of the patient who underwent lung transplantation after 9 months. CASE PRESENTATION: A 14 years old female CF patient followed by the CF center of Florence presented low-grade fever, cough increase and recurrent episodes of major hemorrhages such as to carry out a BAE. Within 24 h the patient started to complain of severe thoracic pain in the right hemithorax, increased dyspnea and fever. A computed tomographic angiography and a dynamic fluoroscopic evaluation revealed the right diaphragmatic paralysis, not present before the procedure. After 4 days the clinical condition and radiological imaging had improved with restored mobility of the right hemidiaphragm. Nine months later, she required mechanical ventilation, and subsequently the initiation of extracorporeal membrane oxygenation (ECMO) for a pulmonary exacerbation with septic shock. Lung transplantation in ECMO was performed with success. CONCLUSION: Clinicians should be aware of the possibility of phrenic nerve injury with BAE in pediatric CF patients.

Role of metabolic polymorphisms NAT2 and CYP1A2 on urinary mutagenicity after a pan-fried hamburger meal.

In this work the phenotyping approach was used to study the influence of metabolic polymorphisms NAT2 and CYP1A2 on S9-mediated urinary mutagenicity, detected with Salmonella strain YG1024, in 50 subjects after a meal of pan-fried hamburgers. All 50 post-meal samples, but not pre-meal ones, were clearly mutagenic (number of urine samples able to double number of spontaneous revertants was 50 to 0, respectively). CYP1A2 positively influences urinary mutagenicity: a rise in CYP1A2 activity increases levels of post-meal urinary mutagens (1.16+/-0.91 vs 1.72+/-1.19 7-h minimum mutagenic doses (MMDs)/intake), especially in NAT2 slow acetylators (2.18+/-1.33 vs 0.90+/-0.54 7-h MMDs/intake, Mann-Whitney U-test, P<0.05). NAT2 rapid acetylators exert lower post-meal urinary mutagenicity than slow ones (1.41+/-1.02 vs 1.77+/-2.45 7-h MMDs/intake) and even more if the latter are extensive CYP1A2 metabolizers (1.41+/-1.02 vs 2.18+/-1.33 7-h MMDs/intake), but the difference did not reach statistical significance. In conclusion, this study indicates that CYP1A2 and NAT2 activities influence the presence of urinary mutagens after a meal of pan-fried hamburger (rich in HHAs) and consequently their potential genotoxic risk.

Influence of GSTM1 genotypes on anti-BPDE-DNA adduct levels in mononuclear white blood cells of humans exposed to PAH.

OBJECTIVE: Association between genetic deletion polymorphism of GSTM1 (*0/*0 or active) and levels of anti (+/-)-r-7,t-8-dihydroxy-t-9,10-oxy-7,8,9,10-tetrahydrobenzo[a]pyrene (anti-BPDE)-DNA adducts in the peripheral blood lymphocyte plus monocyte fraction (LMF) of PAH-exposed subjects was investigated. METHODS: A total of 94 Caucasian subjects comprised the sample population: 13 coke-oven workers, 19 chimney sweeps, 36 aluminum-anode plant workers, and 26 non-occupationally PAH-exposed subjects (controls). PAH exposure was assessed in each group by means of the urinary excretion of 1-pyrenol (mean group levels 1.2, 0.7, 0.3, and 0.1 mumol/mol creatinine in coke-oven workers, chimney sweeps, aluminum-anode plant workers, and control subjects, respectively). Anti-BPDE-DNA adducts were detected by HPLC/fluorescence analysis of anti-BPDE tetrols (tetrol I-1) released after acid hydrolysis of DNA samples. RESULTS: In coke-oven workers the percentage of cases with adduct levels exceeding the 95th percentile control value (4.4 adducts/10(8) nucleotides) was significantly higher in the subgroup with the null GSTM1 genotype (*0/*0) (100%) than in that with active GSTM1 (43%; chi 2 test, P < 0.05). In the other groups with different and lower levels of PAH exposure the percentages of positive samples were always higher in the subgroup with GSTM1 *0/*0 than in the active one, although the differences were not statistically significant. Univariate (odds ratio) and multivariate (relative risk) analyses showed that the risk of having high anti-BPDE-DNA levels increased with occupational exposure to PAH. Such risks, moreover, were further significantly increased by the lack of GSTM1 activity (RR = 5.94; CI = 1.15-30.7; P < 0.05). In coke-oven workers, chimney sweeps, and aluminum workers, respectively, the multiplicative effect of the null genotype with occupational PAH exposure gives risks of 162 (= 27.2 x 5.94), 10 (= 1.70 x 5.94), and 3 (= 0.50 x 5.94) times higher probability (risk) of high BPDE-DNA adduct formation than that of non-exposed subjects with the active GSTM1 genotype. CONCLUSION: Our results indicate a greater risk of anti-BPDE-DNA adduct formation resulting from occupational high-level PAH-exposure in GSTM1 null (GSTM1 *0/*0) workers.

Influence of metabolic genotype GSTM1 on levels of urinary mutagens in patients treated topically with coal tar.

Fifteen hospitalized, non-smoking, dermatological patients were treated with ointment containing 2% coal tar (CT) in order to assess the influence of metabolic genotype GSTM1 on urinary mutagen levels. Urinary 1-pyrenol, the main metabolite of pyrene, was used to check the high exposure to PAH of this population. The mean levels of urinary 1-pyrenol found in the 24-h urine of our patients were 467. 8+/-211.0 nmoles-24 h (range 94.6-890.1 nmoles-24 h). Mutagenicity was assessed on urine samples collected over a period of 24 h, after three consecutive days of topical application, using the bacterial mutagenesis test on Salmonella typhimurium strains TA98 and YG1024 in the presence of microsomal enzymes. The latter strain turned out to be more sensitive than the former in revealing urinary mutagens in these patients (42 693+/-30 867 vs. 6877+/-6040 net revertants-24 h). The mutagenicity on YG1024 strain and 1-pyrenol levels of urine samples were correlated (Spearman's rank correlation coefficient=0. 6678, P<0.01, z=2.795). The influence of genotype GSTM1 on urinary mutagen levels was assessed on strain YG1024. The values of urinary mutagenicity of subjects with genotype GSTM1-null (n=6) were on average higher than those of GSTM1-positive subjects (n=9) (55 498+/-45 957 vs. 34 156+/-11 933 net rev.-24 h), a non-significant statistical difference. The mean total excretion of mutagens corrected for PAH exposure (net rev./nmoles of urinary 1-pyrenol) in GSTM1-null patients was double that of GSTM1-positive ones (136. 8+/-34.7 vs. 70.8+/-23.3 net rev./nmoles of urinary 1-pyrenol; one-tailed Mann-Whitney U-test, U=11.5, P<0.05). These results indicate a greater body burden of promutagens, resulting from skin application of CT, in GSTM1-null subjects.

Influence of GSTM1, GSTT1, GSTP1, and EPHX gene polymorphisms on DNA adduct level and HPRT mutant frequency in coke-oven workers.

To evaluate the influence of individual susceptibility factors on the level of polyaromatic (PAH) hydrocarbon DNA adducts and hypoxanthine guanine phosphoribosyl transferase (HPRT) mutants in peripheral lymphocytes, 70 coke-oven workers exposed to PAH were genotyped for four metabolic enzyme polymorphisms of potential importance in PAH metabolism. The examined genetic polymorphisms concerned glutathione S-transferases M1 (GSTM1; gene deletion; 96 workers), T1 (GSTT1; gene deletion), P1 (GSTP1; Ile-->Val substitution at codon 104 or Ile-->Val at codon 104 and Val-->Ala at codon 113), and microsomal epoxide hydrolase (EPHX; Tyr-->His substitution at codon 113 and His-->Arg at codon 139). The workers were classified in a high- and low-exposure group on the basis of urinary concentration of 1-pyrenol. The GSTM1 null genotype increased the number of DNA adducts in smoking coke-oven workers with high PAH exposure. DNA adducts were affected by PAH-exposure in non-smokers and in GSTM1 null smokers and by smoking in GSTM1 null individuals. In a multiple linear regression analysis, the interaction of the GSTM1 genotype was statistically significant (p = 0.04) with smoking (yes/no) and of borderline significance (p = 0.06) with PAH-exposure (high/low). As smoking also increased urinary 1-pyrenol, the genotype modification seemed to concern DNA adducts due to smoking rather than occupational exposure. GSTT1 positive individuals showed an elevated level of DNA adducts in comparison with GSTT1 null subjects (p = 0.04), and EPHX genotypes associated with slow hydroxylation reaction yielded a higher (p = 0.05) HPRT mutant frequency than fast EPHX genotypes; these findings were, however, based on small numbers of subjects and need to be clarified in further studies. In conclusion, our findings indicate that homozygous deletion of GSTM1 results in an increased sensitivity to genotoxic PAHs in tobacco smoke, which is seen as an increase in aromatic DNA adducts in blood mononuclear cells.

Urinary mutagenicity on TA98 and YG1024 Salmonella typhimurium strains after a hamburger meal: influence of GSTM1 and NAT2 genotypes.

Mutagenicity on TA98 and YG1024 Salmonella typhimurium strains of pan-fried hamburger extracts and of 24 h post-meal urine from 32 non-smoking volunteers was evaluated. Each participant in the study was GSTM1 and NAT2 genotyped. After cooking the meat showed mutagenic activity (mean +/- SD) on strains TA98 and YG1024 of 114 +/- 129 and 1437 +/- 1536 net revertants/g respectively. Twenty three of 32 urine samples showed clear mutagenic activity (i.e. caused at least a doubling of the number of spontaneous revertants) on the O-acetyltransferase over-producing strain YG1024, while none of the post-meal 24 h urine samples was clearly mutagenic on strain TA98. Total 24 h post-meal YG1024-active urinary mutagens were well correlated with the levels of mutagen intake with the meal (r2 = 0.5977, F = 44.58, P < 0.01). In the group under study GSTM1 genotypes did not influence urinary mutagenicity. Highly exposed subjects (n = 15) with the NAT2-ss genotype showed significantly increased levels of urinary mutagenicity on strain YG1024 in comparison with NAT2-R subjects (mutagen intake-adjusted total 24 h mutagen excretion = 1.00 +/- 0.29 versus 0.66 +/- 0.32, Mann-Whitney U test, U = 12.5, P < 0.05). Our results suggest that the levels of urinary mutagens derived from diets rich in heterocyclic aromatic amines, which are specifically detected by the YG1024 Salmonella strain, are modulated by NAT2-dependent enzyme activity, slow acetylators having higher levels of mutagens in their urine. Subjects with the rapid acetylator genotype, who are known to be at risk for colon cancer, seem to be partially protected with respect to the risk of bladder cancer.

[The toxicology and prevention of the risks of occupational exposure to aromatic polycyclic hydrocarbons. III. The effects: epidemiological evidence, early effects. Individual hypersusceptibility. Health surveillance]. / Tossicologia e prevenzione dei rischi da esposizione professionale a idrocarburi policiclici aromatici. III. Effetti: evidenze epidemiologiche, effetti precoci. Ipersuscettibilità individuale. Sorveglianza sanitaria.

Adverse effects following occupational exposure to polycyclic aromatic hydrocarbons (PAH) are mainly carcinogenic. The available epidemiological data suggest that some substances and industrial processes, in which PAH exposure is frequent, are classified as carcinogenic to humans: primary aluminium industry, cola gasification, coke production, iron and steel foundry, coal tar, pitch, creosote, untreated mineral oils, asphalt, soot. The target organs are mainly lung, bladder, skin. Other relevant effects are skin lesions such as folliculitis. The studies on early biological effects (chromosomal aberrations, sister chromatid exchanges, micronuclei) have shown contradictory results, mainly because of differences in exposure intensity. The metabolic polymorphism may account for a higher susceptibility to lung and bladder cancer following exposure to risk factors; the role of PAH occupational exposure is however to be examined, and the use of indicators of genetic susceptibility is currently limited to research programs. Health surveillance for PAH exposed workers is funded on the Italian laws (DPR 303/56 and D.Lgs. 626/94) and it is mainly dedicated to prevention of carcinogenic effects. Preventive examinations should consider PAH target organs (skin, lung, bladder, larynx) and look for early signs and symptoms. Particular attention will be paid to life habits such as tobacco smoking or diseases which could represent condition of susceptibility. Periodical examinations (every six months) will similarly evaluate PAH target organs. Health surveillance is also programmed for formerly exposed workers and the institution of exposure and cancer registries is mandatory. On the basis of the current scientific data, it is not advisable the use of tumor markers or cytogenetic tests at the individual level as well as the screening of asymptomatic PAH exposed workers for early diagnosis of lung or bladder cancer. Information and formation activities will be part of medical examinations and will be included in specific programs in cooperation with other company functions.

[The toxicology and prevention of the risks of occupational exposure to aromatic polycyclic hydrocarbons. I. Guide lines for the prevention of the risks of occupational exposure to aromatic polycyclic hydrocarbons. Società Italiana Valori di Riferimento and Cattedra di Medicina del Lavoro, Università di Brescia]. / Tossicologia e prevenzione dei rischi da esposizione professionale a idrocarburi policiclici aromatici. I. Linee guida per la prevenzione dei rischi da esposizione professionale a idrocarburi policiclici aromatici. Società Italiana Valori di Riferimento e Cattedra di Medicina del Lavoro, Università di Brescia.

These guidelines mainly deal with prevention of carcinogenic effects following occupational exposure to polycyclic aromatic hydrocarbons (PAH). After some toxicological remarks, the guidelines define a possible method to demonstrate and evaluate occupational exposure to PAH. In particular, it is illustrated the strategy of environmental monitoring and indicated which PAH should be measured, with suggestion about the most appropriate analytical techniques. As regards biological monitoring, the 1-OH-pyreneseems to be currently the most useful indicator since it reflects the recent and global exposure to PAH. The guidelines also give elements to interpret monitoring data, taking into account environmental and biological reference and limit values suggested by some authors, Associations, or current regulations. The most important health effects are carcinogenic and excess risks have been described mainly for lung, bladder and skin cancer in some PAH exposed workers. The studies on cytogenetic effects showed contradictory results. On the basis of such information and current regulations, the guidelines show how to perform health surveillance in preventive and periodical examinations and how to proceed for the information and formation of exposed workers. It is not advisable, on the basis of the current scientific data, to screen asymptomatic PAH exposed workers for early diagnosis of lung or bladder cancer, nor it is opportune the use of tumor markers for health surveillance nor is genetic screening applicable for individual susceptibility evaluation outside research programs.

GSTM1 and NAT2 genotypes and urinary mutagens in coke oven workers.

The influence of the metabolic genotypes GSTM1 and NAT2 on the urinary excretion of mutagens in 46 coke oven workers (27 of them smokers) was studied. Exposure to polycyclic aromatic hydrocarbons (PAH) was estimated from urinary 1-pyrenol levels, which varied from 0.23 to 5.59 micromol/mol creatinine. Fourteen urine samples (30.4%), all but one belonging to smokers, were positive for mutagenic activity (i.e. at least one of the assayed doses was able to double the number of spontaneous revertants). Nine of the urine-positive subjects were both GSTM1-null and NAT2-ss (64.3%), while the same combination of genotypes was found in nine out of 31 urine-negative subjects (29.0%) (P < 0.05). Significantly more smoking workers with the genotype combination GSTM1-null/NAT2-ss showed positive urine mutagenicity than the other subjects (75.0 versus 28.6%, P < 0.05). Smokers with the slow acetylator genotype showed a significantly higher frequency of positive urine samples than smoking fast acetylators (64.7 versus 22.2%, P < 0.05). Our results suggest that smoking coke oven workers with genotypes unfavourable for detoxification of aromatic amines (NAT2-ss) and PAH (GSTM1-null) may have an increased risk of developing bladder cancer.

Mutagenicity and contents of polycyclic aromatic hydrocarbons in used and recycled motor oils.

Thirteen samples of used motor oil and 33 recycled fractions, obtained in the laboratory by means of a recovery process similar to that currently used in Italy (vacuum distillation followed by thermal clay treatment) were examined. The Ames test (standard and modified version according to Blackburn) was used to determine the mutagenicity of the extracts and their contents of polyaromatic fraction (PAF) (IP346/80 method) and polycyclic aromatic hydrocarbons (PAH) (Grimmer's method). Used motor oils are mutagenic, both directly and indirectly. The highest values have been found in used oils from motor vehicles using leaded petrol (up to 118.8 revertants/mg). Samples from vehicles using unleaded petrol or diesel fuel are less mutagenic (up to 31.1 and 16.4 rev/mg, respectively). The enrichment in mutagens due to the use of oil in the three types of engine ranges from mean values of 6.2, 1.1 and 0.4 rev/mg per 1000 km, respectively. Recycled oils are almost completely devoid of direct mutagenic activity (33 samples: mean +/- SD = 1.6 +/- 1.5 rev/mg). Most recycled distillates show considerable mutagenic activity in the presence of microsomial enzymes (up to 82.5 rev/mg), although this is reduced with respect to the original oils (recycled, mean +/- SD = 13.8 +/- 15.5 rev/mg; original oils, mean +/- SD = 30.7 +/- 35.2, Mann-Whitney U-test, z = 1.793, p < 0.05). Both PAF and PAH contents are high in used oils from the two types of petrol engine but not in those from diesel engines. Recycling reduces PAF contents only in used oils from petrol engines, from a mean value of 13.91 +/- 7.32 to 4.23 +/- 2.90% (comparison with original used oils, Mann-Whitney U-test, U = 8, p < 0.01). The light distilled fractions have greater concentrations of indirect mutagens, PAF and PAH than the others. The increase in PAH in light recycled products with respect to the original used oils is significant (Wilcoxon's t-test, z = 2.306, p < 0.05). Benzo[a]pyrene (BaP) is found in appreciable quantities (> 10 ppm) in all used oils from petrol engines and in most of their recycled products. Recycling generally recovers 50% of mutagens and PAF and about 80% of PAH. Considered together, recycled products have in any case contents of mutagens and PAF which are significantly lower than those in the parent oils, but not of PAH (Wilcoxon's t-test; mutagens, z = 2.935, p < 0.01; PAF, z = 3.145, p < 0.01; PAH, z = 1.397, not significant). Lastly, many recycled oils have PAH concentrations which are equal to or higher than those of the original used oils. The health risks linked to professional exposure to these types of oils and the inadequate recycling process currently used (redistillation and thermal clay treatment) in reducing mutagenic and cancerogenic substances from used motor oils are stressed.

Spontaneous length variation in microsatellite DNA from human T-cell clones.

Recently, much interest has been focused on instability of microsatellite DNA sequences such as di- and tri-nucleotide repeats in human cancers. Certain tumors show an increased frequency of mutation leading to repeat length variation at microsatellite loci, and it is thought that such instability may be a marker for the transformed phenotype. However, the spontaneous frequency by which repetitive DNA such as CA-repeats undergoes size changes in normal human somatic cells is not known. Therefore, it is not possible to decide if there is an increase in the frequency of microsatellite mutation in specific tumors or if the change observed simply reflects the frequency of microsatellite mutation in the cell population from which the tumor originates. To investigate this we have established panels of T-lymphocyte clones from 28 healthy males and determined the spontaneous length variations at three CA-repeat markers that are often used to investigate satellite instability: D2S123, D9S180, and D10S197. We found 3 T-cell clones with altered microsatellite size in a total of 178. This corresponds to a background frequency of 3 somatic microsatellite mutations in 1,028 alleles studied, i.e., 2.9 x 10(-3). This frequency is comparable to that found in many tumors of the breast, brain, ovary, and skin but is considerably lower than the frequency of microsatellite mutation in tumors related to hereditary non-polyposis colorectal cancer.

Weak genotoxicity of acrylamide on premeiotic and somatic cells of the mouse.

The effects of acrylamide (AA) were evaluated, under the EEC/STEP project 'Detection of Germ Cell Mutagens', by carrying out several cytogenetic assays on mouse germ and somatic cells. The spermatid micronucleus (MN) test was applied after treatment of meiotically dividing or premeiotic S phase cells. Acute treatments (50 and 100 mg/kg i.p.) as well as subchronic exposure to AA (4 x 50 mg/kg, 4 i.p. injections at 24-h intervals) were performed. A weak increase of MN was induced only by treatment with AA of cells in S phase. Sister-chromatid exchange (SCE) analysis in differentiating spermatogonia treated i.p. with 50 and 100 mg/kg confirmed the weak genotoxicity of AA in the premeiotic stages of spermatogenesis. The application of the MN test in peripheral blood reticulocytes of the same animals used for the spermatid MN assay indicated that the cytogenetic effects induced by AA in the somatic and the germ cell lines are comparable in magnitude. The results obtained in this study by applying the spermatid micronucleus assay are in very good agreement with those reported by two other laboratories with the same technique.

Evaluation of sister-chromatid exchanges in mouse spermatogonia: a comparison between the classical fluorescence plus Giemsa staining and an immunocytochemical approach.

Sister-chromatid exchanges (SCE) were analyzed in mouse spermatogonia using two different protocols for bromodeoxyuridine (BrdU) exposure and detection. With the classical approach, based on subcutaneous implantation of agar-coated BrdU tablets and fluorescence plus Giemsa (FPG) staining a satisfactory differentiation of spermatogonial metaphases was obtained with 50 or 25 mg BrdU per mouse (two or one tablets respectively). Alternatively, the immunodetection of BrdU was carried out after exposure to a very low BrdU concentration (three injections i.p., 3 mg/kg b.w. each, at 5-h intervals), and after exposure to one BrdU tablet; SCE frequencies evaluated in this way were lower than those found after classical FPG staining, even when the mice were exposed to the same BrdU concentration (one tablet, 25 mg BrdU). We concluded that the two methodologies may have different sensitivities with respect to SCE detection. In addition, when the effect of a treatment with mitomycin C was tested (1 mg/kg b.w., at time intervals ranging from 24 h to 5 days), no sister-chromatid differentiation was obtained with the multiple injection protocol, or with one BrdU tablet. By contrast, with two BrdU tablets and FPG, well differentiated metaphases were found at any time interval tested after MMC treatment, and the peak frequency of SCE (3.4 times the baseline) was observed at 55 h after treatment, as expected on the basis of cell cycle duration in spermatogonia. In summary, even though the use of medium-low concentrations of BrdU was successful in untreated animals, these protocols appeared inadequate to detect SCE induction by MMC. It is possible that, in the presence of cell cycle delay induced by the treatment, interferences with the rate of BrdU uptake produce an unsatisfactory differentiation of sister chromatids.