Pathogenic role of antibodies against monomeric C-reactive protein in tubulointerstitial nephritis and uveitis syndrome.

Antibodies against monomeric C-reactive protein, which is a target antigen expressed both in kidney tubules and uveal cells, have been recently detected in patients with active tubulointerstitial nephritis and uveitis syndrome. We report the case of an 65-year-old woman with acute renal failure caused by biopsy-proven tubulointerstitial nephritis and the onset of uveitis 21 months later. The expression of monomeric C-reactive protein in kidney oligobiopsy was confirmed by immunohistochemical staining using mouse monoclonal antibody against human monomeric C-reactive protein. The levels of antibodies against monomeric C-reactive protein were 117% of the reference during the flare and 22% during the remission of the disease. The difference in the levels of antibodies against monomeric C-reactive protein during flare and remission, and above all positive biopsy staining, supports their pathogenic role in this disease.

Impact of donor-dependent genetic factors on long-term renal graft function.

Our aim was to study the association of donor genetic features with long-term graft function as well as the impact of donor age, gender compatibility, cold ischemia time (CIT), and delayed graft function (DGF). We observed the outcomes of 125 kidney recipients for a minimum of 12 months (mean, 30.9 +/- 13.0 months). Grafts were obtained from 89 donors who underwent profiling for AHSG 1/2, MMP9 -1562C/T, IL6 -174G/C, IL1beta 3954C/T, MTHFR 677C/T, MTHFR 1298A/C, NOS3 -786C/T, and PAI1 4G/5G single-nucleotide polymorphisms (SNPs) using sequence-specific probe (SSP) polymerase chain reaction (PCR) and MPO -463G/A and CRP -390C/T/A with restriction fragment length polymorphism (RFLP) analysis. NOS3 IVa/b VNTR polymorphism was genotyped by gel electrophoresis of the respective PCR-generated DNA fragment. The presence of the aa eNOS genotype was connected with worse graft function. The aa genotype was also linked to acute rejection episodes. The lowest values of glomerular filtration rate (GFR) were displayed by recipients of grafts from donors with homozygotic PAI1 gene 5G polymorphism, linking paradoxically with lower PAI-1 synthesis suggesting that the intensity of proteolysis led to increased alloantigen specificity stimulating alloresponses. Graft function depended significantly on donor age with an influence of gender matching. GFR showed a significant dependence on DGF. Genetic features of the donor influenced long-term graft function. Variant eNOS gene polymorphism, which produced decreased eNOS activity, was linked to worse remote graft function. A similar negative impact was observed in the case of donor PAI1 polymorphism, with the functional consequence of lower gene product synthesis.

Recipient genetic determinants of inflammatory process and nonstandard atherosclerosis risk factors affect kidney graft function early posttransplantation.

We analyzed the connections between recipient genetic features and 12-month graft function. The gene polymorphisms of myeloperoxidase (MPO), interleukin (IL)-1beta, IL-6, C-reactive protein (CRP), fetuin A, and homocysteine and their gene product concentrations were correlated with 12-month kidney transplant function. The 125 kidney recipients had at least 12 months of follow-up (average, 30.9 +/- 13.0 months). IL6-174G/C, IL1beta 3954C/T, MTHFR 677C/T, MTHFR 1298A/C, AHSG 1/2 SNPs were determined using SSP-polymerase chain reaction (PCR) and MPO-463G/A and CRP- 390C/T/A with RLFP analysis. Enzyme-linked immunosorbent assay (ELISA) was applied to estimate MPO, fetuin A, IL-6, and IL-1beta; FPIA was applied for L-homocysteine concentrations. The highest CRP values were linked to the presence of the TT genotype. We observed a positive correlation of CRP concentrations and GFR. Lower fetuin A concentrations were linked to the 256Ser allele, and higher levels to better graft function. Worse graft function was inversely associated with serum homocysteine concentrations. Two polymorphisms (CRP and fetuin A) showed functional consequences in recipients. None of the examined genetic determinations influenced long-term graft function. Higher values, although still within the normal range of CRP concentrations on the day of transplantation and 3 months thereafter, were related to greater values of eGFR at 12 months, suggesting that the higher intensity of the inflammatory reaction may be a manifestation of more effective healing of an ischemia reperfusion injury. Both homocysteine and fetuin A showed long-term prognostic importance.

The abnormal superficial radial artery does not restrict the successful creation of hemodialysis forearm arteriovenous fistula.

Anatomical variations of the radial artery are of clinical importance in end-stage renal disease patients awaiting creation of native arteriovenous fistula for hemodialysis. As radial-cephalic direct wrist fistula is a vascular access of choice, atypical localization of the distal part of the radial artery may lead to the false assumption of severe atherosclerotic lesions and prevent creation of such an access, despite good vessel conditions and convenient surgical approach. We present 7 patients with radial artery variations. In 5 patients with superficial radial artery, radial-cephalic direct wrist access was created. One patient, due to an anomaly misdiagnosis, had radial-cephalic fistula created on the contra lateral wrist. In the patient with hypoplastic radial artery brachial-basilic upper arm transposition was created.

Variability in donor-specific alloantibody production after transplantation.

The role of de novo donor-specific alloantibodies (DSAs) in renal allograft injury is still unclear. The aims of this study were as follows: to assess the development of DSAs during the first year after transplantation, to determine the cause of DSA production, and to evaluate the association of DSA with allograft function. The study included 78 consecutive transplant recipients with negative cross-matches before transplantation. Recipient serum samples were assayed for DSA at 2 weeks as well as at 1, 3, 6, 9, and 12 months using a complement-dependent lymphocytotoxic (CDC) cross-match technique with donor lymphocytes. Among 545 cross-match tests performed after transplantation, there were 79 positive results. DSA appeared de novo in 44.8% of recipients: in 20 patients at 2 weeks; in 23 patients at 1 month; in 14 patients at 3 months; in 9 patients at 6 months; in 5 patients at 9 months; and in 8 patients at 12 months. Between month 3 and 9 after transplantation, DSA disappeared in 22 patients and appeared in 11 others. In 20 patients (57.1%) the appearance of DSA was associated with an acute rejection episode. In 11 of these, C4d deposition was found. In comparison with 43 patients without DSA, the serum creatinine levels during the first year after transplantation were significantly higher among patients with DSA. Transplant recipients produce antidonor alloantibodies. The highest rate occurs during the first month with the incidence diminishing at 3 months after transplantation. The development of DSAs in more than half of the patients was associated with rejection episodes. Patients with antidonor alloreactivity showed worse renal function.

C4D deposition and positive posttransplant crossmatch are not necessarily markers of antibody-mediated rejection in renal allograft recipients.

UNLABELLED: The aim of the study was to search for serologic, immunopathologic, and morphologic evidence of antibody-mediated rejection (AMR) among patients with acute renal allograft dysfunction. The study included 19 patients with episodes of acute rejection (ARE) within the first year after transplantation. All patients had negative crossmatch tests before transplantation. Patients underwent biopsy for histologic and C4d examinations. All patients were monitored for donor-specific HLA alloantibodies during the first posttransplant year. Complement-dependent cytotoxic crossmatches were performed with donor lymphocytes. In eight patients, the crossmatch test results changed to positive during ARE. In all biopsies except one with cortical infarction, we observed C4d staining (group 1). The biopsies of four patients showed histologic changes of AMR, and all of their grafts were lost. In one patient, cellular and vascular rejection (Banff II) were present; in two, Banff I; and in one, borderline lesions. These results were compared with 11 patients with ARE but negative posttransplant crossmatches and negative staining for C4d (group 2). The histologic findings in the biopsies of these patients were cellular interstitial and vascular rejection (Banff I and Banff II). With no features suggestive of AMR. During the first year after transplantation, the creatinine levels of group 1 patients, were significantly higher than group 2 patients. One-year graft survival was 50% in group 1 and 91% in group 2. CONCLUSIONS: C4d and a positive posttransplant crossmatch were not associated with histologic features of AMR in half of the ARE. Nevertheless, C4d deposition and positive posttransplant crossmatches correlated with allograft injury among renal transplant patients.

Risk factors for glucose metabolism disorders after kidney transplantation with uneventful course.

A wide range of glucose metabolic disorders (GMDs) often arise after renal transplantation that predispose to graft dysfunction, infections, and cardiovascular disease. This study evaluated the risk factors for GMDs among 50 patients including 30 males and overall mean age 44.9 +/- 12.1 years. All 50 subjects displayed normal glucose tolerance tests pretransplantation and no family history of diabetes. They were selected from the 99 consecutive patients transplanted from April 2005 to January 2006 based upon uneventful posttransplantation course, without rejection episodes or hepatitis C virus (HCV) infections. The study concentrated on risk factors originating during the dialysis period. Even in this selected group, the risk of posttransplant GMD development was high (28%). Patients with GMDs showed significantly worse renal function at 1 month after transplantation (serum creatinine concentration: 1.70 +/- 1.67 mg/dL in the GMD group vs. 1.44 +/- 0.96 mg/dL in the group without GMDs [P = .027] and eGFR, 56.68 +/- 22.70 mL/min/1.73 m(2) versus 71.29 +/- 27.37 mL/min/1.73 m(2), respectively, [(P = .099)]. In a logistic regression model, a statistically significant difference between the groups was shown only for cold ischemia time (P = .037). In the logistic regression model with two independent variables, statistical significance was observed (P = .038) for body mass index at the time of transplantation. In this model, a lower pretransplant serum insulin concentration showed an influence that bordered on significance (P = .074). This study confirmed that the etiology of GMD after kidney transplantation is multifactorial, and at least in part connected with the pre-transplantation period.

A new technique for autogenous brachiobasilic upper arm transposition for vascular access for hemodialysis.

PURPOSE: Conventional brachiobasilic fistula creation consists of the mobilization and preparation of the brachial part of the basilic vein along its whole length, the vein transposition on the anterior surface of the arm and anastomosis using the brachial artery. In case of late thrombosis, the reparation of such a fistula is almost impossible. METHODS: To avoid total vein clotting in the case of thrombosis we decided to prepare only a short part of the vein in our method and not to mobilize the other part of the vein. The brachiobasilic fistula with our modification was performed as a two-stage procedure in 18 patients (8 females and 10 males), aged from 37-78 yrs (60 +/- 13.6 yrs). RESULTS: In two patients early thrombosis occurred. The reparation procedure was not performed in two patients (the first patient died due to pneumonia; the second patient did not give his permission for further intervention). In 16 patients brachiobasilic fistula creation was successful. Late thrombotic complications occurred in three patients (in the 3rd, 8th and 12th months). A new successful fistula, a few centimeters proximally to the original one, was per-formed in 2 patients 24hr and in 1 patient 48 hr after fistula clotting. On the following day after the procedure the fistula was ready to be used. The primary, assisted primary and cumulative secondary patency rates after 12 months of follow-up were 74, 89 and 100%, respectively. CONCLUSION: In comparison with standard brachiobasilic techniques our method offers the possibility of a reparation procedure in the case of late thrombosis, which could improve the long-term patency of brachiobasilic fistulas. However, a prospective controlled study is necessary to establish if this new technique is superior to the traditional surgical procedure.

Outcome of autogenous fistula construction in hemodialyzed patients over 75 years of age.

BACKGROUND: There are controversies regarding the feasibility of autogenous vascular access creation in elderly hemodialysis (HD) patients. The aim of this retrospective study was to evaluate the results of creating different types of autogenous arteriovenous fistulas (AVFs) in a consecutive series of HD patients over 75 years of age. METHODS: The analysis was performed in 131 patients (65 females, 66 males, average age 79.1 +/- 3.6 years) in whom the creation of an autogenous AVF was considered within a 6-year period (February 1998 to February 2004). Among them, 26.7%were diabetics, 66.3% had hypertension, 30.7% were smokers, and 35.6% were obese. Patient survival and primary and secondary AVF patency were assessed. RESULTS: The survival rates for patients were 94, 88, 66, and 45% at 6 months and at 1, 3, and 5 years, respectively. Successful autogenous AVF formation was finally achieved in 107 patients (81.6%): in 99 patients in the forearm and in 8in the upper arm. A Kaplan-Meier analysis showed primary AVF patency rates of: 74 +/- 4.3% (+/- SE) at 1 month; 70 +/- 4.7% at 6 months; 59 +/- 4.9% at 1 year; 59 +/- 4.9% at 2 years; 59+/- 4.9% at 3 years; 59 +/- 4.9% at 4 years, and 58 +/- 4.9% at 5 years. The secondary patency rates were: 95 +/- 2.0; 92 +/- 2.2; 84 +/- 3.3; 79 +/- 4.0; 72 +/- 4.3; 71 +/- 4.4, and 69 +/- 4.5% in the corresponding periods, respectively. All postoperative complications in 10 patients were treated surgically, if applicable, without endovascular techniques. CONCLUSIONS: By exploiting all suitable types of autogenous AVF it is possible to establish the best form of vascular access even in the majority of elderly patients.

Influence of autologous arteriovenous fistula on the blood supply to the hand in very elderly hemodialyzed patients.

INTRODUCTION: Arteriovenous fistula (AVF) creation for hemodialysis (HD) could predispose to local arterial insufficiency of the hand (steal syndrome). Patients with diabetes mellitus, peripheral arterial disease and elderly patients tend to have a higher risk of hand ischemia. PURPOSE AND METHODS: To estimate the influence of AVF on the blood supply to the hands in the elderly population and to identify steal syndrome cases by non-invasive diagnostics (finger photoplethysmography (PPG), pulse volume recording (PVR), Doppler analysis and pulseoxymetry). The evaluation was carried out in 25 random patients (10 females, 15 males) >75 yrs of age (79.6 +/- 3.87 yrs), whose functioning autologous AVFs had been placed at least 1 month previously. RESULTS: Mean PPG and PVR amplitudes did not differ in statistical analysis (p > 0.05) between hands with and without an AVF. One patient (4%) with end-to-side anastomosis was diagnosed with steal syndrome (typical manifestation confirmed in PPG, Doppler and pulseoxymetry). Two other patients with high brachio-cephalic anastomosis presented subclinical steal syndrome (only low PPG and PVR). CONCLUSIONS: Even in the very elderly, AVF creation should be considered due to a lesser influence on the blood supply to the hands. Non-invasive diagnostics used by us seemed to be useful in identifying steal syndrome after AVF creation.

Vascular abnormalities in patients with autosomal dominant polycystic kidney disease--the influence on arteriovenous fistula creation.

AIM: Patients with autosomal dominant polycystic kidney (ADPKD) present a number of vascular abnormalities, including cerebral aneurysms, heart valve lesions, coarctations of aorta and abdominal aortic aneurysms. The aim of our study was to investigate whether vascular abnormalities that occur in wrist vessels, make native arteriovenous fistula creation difficult in this group of patients. PATIENTS AND METHODS: The problem was analyzed retrospectively in 783 patients with chronic kidney failure who had had arteriovenous fistula created in our centre in the period between 1991 and 2001. ADPKD was the cause of terminal renal failure in 57 patients (7.3%). These were 31 men and 26 women aged 28 - 69 years (52 +/- 16 years on average). RESULTS: A difference between left and right radial artery diameters and a narrow radial artery (below 2 mm), unsuitable for fistula creation, occurred in 12% of patients with ADPKD and in 0.38% of other patients. Instead of a cephalic vein in the typical place, a few small vessels were present in 14% of patients with ADPKD and in 2.17% of patients with other causes of renal failure. CONCLUSION: Our experience shows a higher incidence of wrist vascular abnormalities in patients with ADPKD. This decreases the possibility of wrist native arteriovenous fistula creation in this group of patients.

[Prolonged use of the femoral catheter as a temporary access for hemodialysis]. / Dlugotrwale utrzymywanie cewnika w zyle udowej do celów hemodializy.

Cannulation of the femoral vein is the safest method of acute vascular access. It is recommended the removal of the femoral catheter after 72 h. The trial was undertaken, if it is possible a safe prolonged use of the femoral cannulation. The observations were performed in 70 patients (31 F, 39 M, age 3-70 years) with acute and chronic renal failure (RF). The femoral catheter was left in place for the period from 7 to 104 days, mean 21 days. None complications occurred in the group of 16 patients in whose the cannula was left up to 14 days. Bt duration of the cannulation above 15 days (54 patients) exist site infections appeared in 10 patients, catheter thrombosis in 12 patients and fiber in 6 patients (all with the catheter in place above 21 days). Noteworthly chronic RF patients were dialysed mostly on the ambulatory basis. Femoral catheter can be left safely in place for 14 days.

The variety of clinical and histopathologic presentations of glomerulonephritis associated with latent syphilis.

Glomerulonephritis is a well established but rather uncommon complication of latent secondary syphilis. We present three cases of glomerulopathies associated with luetic infection, observed and managed in our institutions in the past three years. They illustrate a variety of clinicopathologic presentations of this nephropathy, from acute nephrotic syndrome through membranous glomerulopathy up to rapidly progressive glomerulonephritis. Regardless of the clinical course and histologic type, they were all characterized by strongly positive results of serologic tests for syphilis. Our observations suggest the necessity of eliminating luetic infection in aetiologic considerations of each newly diagnosed case of nephrotic syndrome.

[Changes in rubidium and cesium levels in the blood of patients on long-term dialysis and decreased velocity of neural conduction]. / Zmiany stezenia rubidu i cezu we krwi chorych dlugotrwale dializowanych a zwolnienie szybkosci przewodzenia nerwowego.

In 19 patients aged 19 to 45 years on long-term dialysis treatment during 12.6 +/- 18.2 months the concentrations of Rb and Cs were determined by atomic spectrometry in whole blood before and behind the dialyser at the beginning and end of dialysis. At the same time the concentrations of these elements were determined in the dialysing fluid. In all patients the velocity of conduction in the motor fibres in the upper and lower extremities was determined before and after dialysis. Damage to the peripheral neurons was demonstrated in the lower extremities mainly in 79% of cases. Increased velocity of motor conduction in at least one nerve related directly proportionally to the Cs concentration of the serum was demonstrated in 56-70% of the patients after one dialysis.