Cyanotoxin Occurrence and Diversity in 98 Cyanobacterial Blooms from Swedish Lakes and the Baltic Sea.

The Drinking Water Directive (EU) 2020/2184 includes the parameter microcystin LR, a cyanotoxin, which drinking water producers need to analyze if the water source has potential for cyanobacterial blooms. In light of the increasing occurrences of cyanobacterial blooms worldwide and given that more than 50 percent of the drinking water in Sweden is produced from surface water, both fresh and brackish, the need for improved knowledge about cyanotoxin occurrence and cyanobacterial diversity has increased. In this study, a total of 98 cyanobacterial blooms were sampled in 2016-2017 and identified based on their toxin production and taxonomical compositions. The surface water samples from freshwater lakes throughout Sweden including brackish water from eight east coast locations along the Baltic Sea were analyzed for their toxin content with LC-MS/MS and taxonomic composition with 16S rRNA amplicon sequencing. Both the extracellular and the total toxin content were analyzed. Microcystin's prevalence was highest with presence in 82% of blooms, of which as a free toxin in 39% of blooms. Saxitoxins were found in 36% of blooms in which the congener decarbamoylsaxitoxin (dcSTX) was detected for the first time in Swedish surface waters at four sampling sites. Anatoxins were most rarely detected, followed by cylindrospermopsin, which were found in 6% and 10% of samples, respectively. As expected, nodularin was detected in samples collected from the Baltic Sea only. The cyanobacterial operational taxonomic units (OTUs) with the highest abundance and prevalence could be annotated to Aphanizomenon NIES-81 and the second most profuse cyanobacterial taxon to Microcystis PCC 7914. In addition, two correlations were found, one between Aphanizomenon NIES-81 and saxitoxins and another between Microcystis PCC 7914 and microcystins. This study is of value to drinking water management and scientists involved in recognizing and controlling toxic cyanobacteria blooms.

New efficient methodology for screening of selected organic micropollutants in raw- and drinking water from 90 Swedish water treatment plants.

A new, efficient method for analysis of organic micropollutants (OMPs) in water samples was developed, validated and applied in a nationwide survey. The goal with the survey was to identify common compounds with relatively high concentrations to be used as markers e.g. for routine monitoring of removal efficiencies. The method comprises sample concentration by evaporation, and large volume injection on a standard UHPLC-MS/MS system. The OMPs selected for this approach were mainly semi-polar and non-volatile, with molecular weights below 300 Da. Except one outlier, the limit of detection (LoD) ranged from 0.01 to 1 ng/L which is sufficient for most surface waters, and also useful for many ground waters. The method requires low manual labor and comparably small sample volumes, enabling a cost-efficient nationwide screening. Raw- and drinking water from 90 Swedish water treatment plants (WTPs) were investigated for occurrence of the selected OMPs. Carbamazepine and tramadol were the most widespread compounds, detected in around 50% of the surface waters. Ground water from rock aquifers were least contaminated, while soil aquifers were more similar to surface waters. Due to the frequent use of ground water in Sweden, many samples did not contain any of the investigated compounds (i.e. below LoD). In the positive samples, the median estimated concentrations of individual OMPs were generally <1 ng/L in raw water and <0.5 ng/L in drinking water. Swedish waters were in general less contaminated than those investigated in similar Brazilian, Chinese, pan-European and US studies. Altogether, the presented methodology gave a cost-efficient overview on the occurrence and estimated concentrations of OMPs in raw- and drinking water on a national level in Sweden. From the data, WTPs can find suitable OMPs to monitor at their site, for example for measuring removal efficiencies on a routine basis.

[Leukapheresis and chronic inflammatory bowel disease: an additional obligation for the nephrologist]. / La leucocitoaferesi nella patologia infiammatoria cronica intestinale: un ''impegno'' aggiuntivo per il nefrologo.

The current treatment of chronic inflammatory bowel diseases involves the administration of different immunosuppressive drugs, whose use is associated with several side effects. Among the treatment alternatives, clinicians are attracted by leukapheresis, a method able to selectively remove from the circulation molecules involved in the onset and maintenance of inflammation. From 2007 to 2008, six patients were recruited from our clinics; four patients were affected by ulcerative colitis and two by Crohn's disease. They presented symptoms including abdominal pain and diarrhea despite treatment with steroids and sulfasalazine. Leukapheresis sessions were performed weekly (1 hour/week) for five consecutive weeks. The leukapheresis sessions resulted in a significant improvement in the patients' clinical as well as general conditions. The abdominal pain disappeared and significant reduction of diarrhea and fecal calprotectin levels was observed. No side effects occurred. The clinical benefits were supported by resolution of ulcerative lesions. After six months of follow-up no disease relapse was observed. The leukapheresis treatment has also prevented surgical interventions in all patients enrolled in the study. Our results suggest that leukapheresis may be helpful in patients affected by inflammatory bowel diseases, allowing early reduction of immunosuppressive drug administration.

[Management of IgA nephropathy]. / La terapia della glomerulonefrite a depositi mesangiali di IgA (IgAN).

The best treatment of IgA nephropathy (Berger's disease) is not well defined and at present no causal therapy is available. Although initially considered benign, we now recognize it as a common cause of end-stage renal disease and the natural history of IgA nephropathy is quite variable. Standard care includes angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) and corticosteroids, in some cases combined with immunosuppressive drugs. The antiproteinuric and renoprotective effects of ACEIs and ARBs in IgA nephropathy have been firmly established. Treatment with corticosteroids is effective in reducing proteinuria and renal injury. The addition of cytotoxic immunosuppressive agents (cyclophosphamide and azathioprine) can be of benefit in patients with a rapidly progressive disease course. Little information is available about the clinical efficacy of tonsillectomy on long-term renal survival in patiens with IgA nephropathy; at present it cannot be recommended. The treatment of the disease is a work in progress; only better knowledge of its pathogenesis will eventually offer novel therapeutic approaches.

Spinal cord stimulation in hemodialysis patients with critical lower-limb ischemia.

BACKGROUND: Spinal cord stimulation (SCS) has been proposed for the treatment of ischemic pain and the prevention or delay of amputation in patients with peripheral arterial occlusive disease (PAOD) who are unsuitable for vascular reconstruction. PAOD is common in patients with end-stage renal disease and is associated with substantial morbidity and mortality. Furthermore, many patients are not candidates for limb-sparing procedures and have to undergo primary amputation. METHODS: We report our experience with SCS in 8 hemodialysis patients with chronic lower-limb ischemia and not suitable for either primary surgical or angioplastic intervention or reintervention. Intensity of ischemic pain, quality of life, use of analgesic medications, limb survival, and outcome of skin ischemic lesions were evaluated before implantation of an SCS device and after 6 and 12 months of follow-up. RESULTS: No complications from SCS device implantation occurred. Both intensity of pain and quality of life significantly improved during follow-up. SCS allowed a decrease in pain medication intake in all patients. Limb survival at 1 year was 75%. Ischemic skin lesions before implantation of an SCS device did not ameliorate during the follow-up period, but the appearance of new lesions was not observed. CONCLUSION: Implantation of an SCS device in patients with end-stage renal disease with critical limb ischemia dramatically improves quality of life and pain relief. In patients assessed at Leriche-Fontaine stage 2 or 3, the treatment might delay the appearance of ischemic skin lesions and amputation. At these stages, presumed long-term benefits could justify the cost of SCS.

The Italian Registry for Therapeutic Apheresis. A report from the Apheresis Study Group of the Italian Society of Nephrology.

Many clinical indications and different technical issues have been reported on therapeutic apheresis: much criticism has also been recorded in several instances, mainly due to the lack of large clinical trials to validate collected data. A Registry where all the available data can be organized and analyzed therefore becomes a priority for all the professionals involved in apheresis. The purpose of this report is to describe the data submitted from 1994 to 2004 from 15,285 treatments on 1,477 patients from 44 Centers, including mainly, but not exclusively, Nephrological Units, collected by the Apheresis Study Group of the Italian Society of Nephrology in 15 Italian regions. Plasma exchange accounted for 56.2% of the procedures, and of these 50.4% were performed by filtration. Plasma treatment was used in 40.1% of procedures, namely with Protein A immunoadsorption (14.6%), LDL-Cholesterol dextran sulfate adsorption (9.7%), and semiselective cascade or double filtration (12.6%). Cell apheresis, limited to photopheresis, was used in 0.85% of cases, and whole blood treatment (direct adsorption lipoprotein, and molecular adsorption recirculating system) in 2.7%. The procedures analyzed here account for less than 20% of estimated therapeutic apheresis performed in Italy, according to the national survey of activity performed for year 2000 by the Italian Apheresis Society. Notwithstanding that the data are largely incomplete, they are sufficiently informative for a definite trend: plasma treatment with filtration on fractionation filters and adsorption must be used as often as possible, instead of plasma exchange, thus obtaining the most selective removals.

Red blood cells may contribute to hypercoagulability in uraemia via enhanced surface exposure of phosphatidylserine.

BACKGROUND: The exposure of phosphatidylserine (PS) on the outer leaflet of the erythrocyte membrane may have several pathophysiological consequences, including the development of a procoagulant phenotype, a finding that seems relevant to the thrombotic risk seen in many disorders. METHODS: Because PS externalization increases in erythrocytes from patients suffering from chronic uraemia, which is frequently associated with a prothrombotic state, the possible relationship between erythrocyte PS exposure, erythrocyte procoagulant activity and plasma levels of several haemostatic markers was studied in a group of haemodialysed patients. RESULTS: Uraemic erythrocytes displayed increased procoagulant activity, which proved to be correlated directly with erythrocyte PS exposure. Pre-incubation of uraemic erythrocytes with annexin V, a protein with high affinity and specificity for PS, strongly inhibited in vitro thrombin generation induced by erythrocytes as compared with untreated red cells. Thrombin generation and activation of fibrinolysis were found to occur in uraemic patients, as substantiated by increased plasma levels of markers for thrombin generation (prothrombin fragment F1.2 and thrombin-antithrombin complex) and fibrinolysis (D-dimer and plasmin-antiplasmin complex), respectively. Significant correlations between prothrombin fragment F1.2 and D-dimer suggested that hyperfibrinolysis was secondary to thrombin generation. Correlations were also found between erythrocyte PS levels and plasma levels of haemostatic markers, including prothrombin fragment F1.2 (P = 0.007), thrombin-antithrombin complex (P = 0.00009), plasmin-antiplasmin complex (P = 0.0009) and D-dimer (P = 0.005). CONCLUSIONS: Our study suggests that increased PS exposure may cause a pathological erythrocyte procoagulant phenotype, which may be a factor inducing a hypercoagulable state in uraemia.