Clinical parameters, LysoGb3, podocyturia, and kidney biopsy in children with Fabry disease: is a correlation possible?

BACKGROUND: Fabry disease is an X-linked lysosomal storage disorder caused by α-galactosidase enzyme deficiency. We present clinical, biochemical, and histologic findings in children with classical phenotypic presentation of Fabry disease. METHODS: A retrospective analysis was performed using charts from 14 children with confirmed diagnosis. Clinical parameters were evaluated. Globotriaosylsphingosine -lysoGb3- detection in plasma, podocyturia, and kidney biopsy were carried out in all cases. RESULTS: All patients except one demonstrated at least one symptom of Fabry disease. LysoGb3 levels were above the normal range in all patients. Podocyturia was documented in all patients. Kidney biopsy revealed glomerular, interstitial, vascular, and tubular changes on light microscopy in nearly all patients. Electron microscopy showed podocyte inclusions in all patients. CONCLUSIONS: No difference in symptomatology was discernible between boys and girls. Podocyturia was detectable in children serving as a possible early marker of kidney injury. LysoGb3 was elevated in all cases, emphasizing the importance for diagnosis especially in female patients with normal αGal A activity. A possible association between lysoGb3 and symptom severity and histological involvement in kidney biopsy should be assessed in prospective studies with enough statistical power to determine if lysoGb3 can be used to predict nephropathy in children with Fabry disease.

[Rapidly progressive crescentic glomerulonephritis in the elderly]. / Glomerulonefritis rápidamente progresiva en ancianos.

Rapidly progressive glomerulonephritis (RPGN) is a syndrome characterized by glomerular lesions giving rise to acute renal injury that develops within a brief period of time, usually days or a few months. It is classified according to the underlying mechanism of injury and the immunofluorescence findings into four main disorders. In the last decade, nephrologists have witnessed a steady rise in the mean age of the patients diagnosed with RPGN. This observation may reflect an increase in the incidence of this entity and also a more timely diagnosis. We present 3 cases of RPGN in elderly patients, diagnosed within a 3 month period at our institution which illustrates the spectrum of these conditions.

Glomerulonefritis rápidamente progresiva en ancianos / Rapidly progressive crescentic glomerulonephritis in the elderly

La glomerulonefritis rápidamente progresiva (GNRP) es un síndrome clínico que se caracteriza por la presencia de signos urinarios de enfermedad glomerular e insuficiencia renal de desarrollo en un lapso de días a pocos meses. La inmunofluorescencia permite clasificar a las GNRP en cuatro tipos según se identifiquen o no depósitos inmunes y, si están presentes, de acuerdo con su naturaleza. En la última década se ha demostrado un aumento constante en el promedio de edad de los pacientes con GNRP. Este fenómeno podría reflejar tanto una mayor incidencia de la enfermedad, como un incremento en la tasa de diagnóstico. Se presentan 3 casos de GNRP en adultos mayores de 65 años, diagnosticados en un periodo de 3 meses en nuestra institución.(AU)

Rapidly progressive glomerulonephritis (RPGN) is a syndrome characterized by glomerular lesions giving rise to acute renal injury that develops within a brief period of time, usually days or a few months. It is classified according to the underlying mechanism of injury and the immunofluorescence findings into four main disorders. In the last decade, nephrologists have witnessed a steady rise in the mean age of the patients diagnosed with RPGN. This observation may reflect an increase in the incidence of this entity and also a more timely diagnosis. We present 3 cases of RPGN in elderly patients, diagnosed within a 3-month period at our institution which illustrates the spectrum of these conditions.(AU)

Glomerulonefritis rápidamente progresiva en ancianos / Rapidly progressive crescentic glomerulonephritis in the elderly

La glomerulonefritis rápidamente progresiva (GNRP) es un síndrome clínico que se caracteriza por la presencia de signos urinarios de enfermedad glomerular e insuficiencia renal de desarrollo en un lapso de días a pocos meses. La inmunofluorescencia permite clasificar a las GNRP en cuatro tipos según se identifiquen o no depósitos inmunes y, si están presentes, de acuerdo con su naturaleza. En la última década se ha demostrado un aumento constante en el promedio de edad de los pacientes con GNRP. Este fenómeno podría reflejar tanto una mayor incidencia de la enfermedad, como un incremento en la tasa de diagnóstico. Se presentan 3 casos de GNRP en adultos mayores de 65 años, diagnosticados en un periodo de 3 meses en nuestra institución.

Rapidly progressive glomerulonephritis (RPGN) is a syndrome characterized by glomerular lesions giving rise to acute renal injury that develops within a brief period of time, usually days or a few months. It is classified according to the underlying mechanism of injury and the immunofluorescence findings into four main disorders. In the last decade, nephrologists have witnessed a steady rise in the mean age of the patients diagnosed with RPGN. This observation may reflect an increase in the incidence of this entity and also a more timely diagnosis. We present 3 cases of RPGN in elderly patients, diagnosed within a 3-month period at our institution which illustrates the spectrum of these conditions.

Glomerulonefritis rápidamente progresiva en ancianos. / [Rapidly progressive crescentic glomerulonephritis in the elderly].

Rapidly progressive glomerulonephritis (RPGN) is a syndrome characterized by glomerular lesions giving rise to acute renal injury that develops within a brief period of time, usually days or a few months. It is classified according to the underlying mechanism of injury and the immunofluorescence findings into four main disorders. In the last decade, nephrologists have witnessed a steady rise in the mean age of the patients diagnosed with RPGN. This observation may reflect an increase in the incidence of this entity and also a more timely diagnosis. We present 3 cases of RPGN in elderly patients, diagnosed within a 3 month period at our institution which illustrates the spectrum of these conditions.

Diffuse hyperplastic perilobar nephroblastomatosis.

Nephroblastomatosis is a rare preneoplastic lesion defined as the presence of diffuse or multifocal nephrogenic rests. They are divided into 4 categories: perilobar, intralobar, combined, and universal. The aim of this report is to describe a case of diffuse hyperplastic perilobar nephroblastomatosis. A 1-year-old boy presented with an abdominal mass on the left side. Computed tomography scan showed a homogeneous, isointense enlarged left kidney. A fine needle aspiration cytology was reported as Wilms tumor. After chemotherapy, the left kidney was excised. Nephrectomy specimen presented a thick cortical rim of hyperplastic nephrogenic tissue, well delineated from preserved renal parenchyma without pseudocapsule. Nephroblastomatosis is a rare condition affecting renal parenchyma. Diagnosis is based on imaging studies, such as ultrasound, computed tomography scan, and magnetic resonance imaging. Fine needle aspiration cytology is of limited value. Therapeutic management is controversial. Chemotherapy is used preoperatively, and surgical excision may be an alternative for refractory cases.

Myocardial involvement during the early course of type 2 diabetes mellitus: usefulness of myocardial performance index.

To evaluate whether myocardial performance index detects a subclinical impairment of left ventricular systolic and diastolic function in patients with early stage of type 2 diabetes, without coronary artery disease, with or without hypertension. Furthermore, to evaluate whether some echocardiographic parameters relate to the metabolic control. Fourty-five consecutive male patients (mean age 52.5 years) with type 2 diabetes mellitus of recent onset (23 hypertensives and 22 normotensives) and 22 age matched healthy controls males were analysed. All participants had normal exercise ECG. All subjects underwent standard and Doppler echocardiography for the assessment of the isovolumic Doppler time interval and Doppler-derived myocardial performance index. In all diabetic patients a glycated haemoglobin test was also performed. No differences were observed in blood pressure, heart rate, and conventional echocardiographic parameters comparing the 2 subgroups of diabetic patients and the controls. Myocardial performance index was significantly higher in diabetic patients independently of the hypertension occurrence, compared to the controls (0.49 and 0.49 diabetic normotensives and hypertensives respectively vs. 0.39, p < 0.01). Myocardial performance index correlated to glycated haemoglobin significantly (r = 0.37, p < 0.01) in both diabetic subgroups. Thus, an early involvement of left ventricular performance was shown by myocardial performance index in patients with type 2 diabetes of recent onset without coronary artery disease, independently of the hypertension presence. These abnormalities can provide a feasible approach to detect a pre-clinical diabetic cardiomyopathy and could be useful for an indirect assessment of the metabolic control.

Dual renin-angiotensin system blockade plus oral methylprednisone for the treatment of proteinuria in IgA nephropathy.

Renin-angiotensin system inhibition is a widely accepted approach to initially deal with proteinuria in IgA nephropathy, while the role of immunosuppressants remains controversial in many instances. A prospective, uncontrolled, open-label trial was undertaken in patients with biopsy-proven IgA nephropathy with proteinuria > 0.5 g/day and normal renal function to assess the efficacy of a combination treatment of angiotensin converting enzyme inhibitors plus angiotensin receptor blockers enalapril valsartan coupled with methylprednisone to decrease proteinuria to levels below 0.5 g/day. Twenty patients were included: Age 37.45 +/- 13.26 years (50% male); 7 patients (35%) were hypertensive; proteinuria 2.2 +/- 1.86 g/day; serum creatinine 1.07 +/- 0.29 mg/dl; mean follow-up 60.10 +/- 31.47 months. IgA nephropathy was subclassified according to Haas criteria. Twelve patients (60%) were class II; seven (35%) were class III and one (5%) class V. All patients received dual renin-angiotensin system blockade as tolerated. Oral methylprednisone was started at 0.5 mg/kg/day for the initial 8 weeks and subsequently tapered bi-weekly until the maintenance dose of 4 mg was reached. Oral steroids were discontinued after 24 weeks (6 months) of therapy but renin-angiotensin inhibition remained unchanged. At 10 weeks of therapy proteinuria decreased to 0.15 +/- 0.07 g/day (P < 0.001) while serum creatinine did not vary: 1.07 +/- 0.28 mg/dl (P = ns). After a mean follow-up of 42.36 +/- 21.56 months urinary protein excretion (0.12 +/- 0.06 g/day) and renal function (serum creatinine 1.06 +/- 0.27 mg/dl) remained stable. No major side effects were reported during the study. Renin-angiotensin blockade plus oral steroids proved useful to significantly decrease proteinuria to < 0.5 g/day in patients with IgA nephropathy without changes in renal function.

Dual renin-angiotensin system blockade plus oral methylprednisone for the treatment of proteinuria in IgA nephropathy / Doble bloqueo del sistema renina-angiotensina más metilprednisona oral para el tratamiento de la proteinuria en la nefropatía por IgA

Renin-angiotensin system inhibition is a widely accepted approach to initially deal with proteinuria in IgA nephropathy, while the role of immunosuppressants remains controversial in many instances. A prospective, uncontrolled, open-label trial was undertaken in patients with biopsy-proven IgA nephropathy with proteinuria more than 0.5 g/day and normal renal function to assess the efficacy of a combination treatment of angiotensin converting enzyme inhibitors plus angiotensin receptor blockers enalapril valsartan coupled with methylprednisone to decrease proteinuria to levels below 0.5 g/day. Twenty patients were included: Age 37.45 more or less 13.26 years (50% male); 7 patients (35%) were hypertensive; proteinuria 2.2 more or less 1.86 g/day; serum creatinine 1.07 more or less 0.29 mg/dl; mean follow-up 60.10 more or less 31.47 months. IgA nephropathy was subclassified according to Haas criteria. Twelve patients (60%) were class II; seven (35%) were class III and one (5%) class V. All patients received dual reninangiotensin system blockade as tolerated. Oral methylprednisone was started at 0.5 mg/kg/day for the initial 8 weeks and subsequently tapered bi-weekly until the maintenance dose of 4 mg was reached. Oral steroids were discontinued after 24 weeks (6 months) of therapy but renin-angiotensin inhibition remained unchanged. At 10 weeks of therapy proteinuria decreased to 0.15 more or less 0.07 g/day (P less than 0.001) while serum creatinine did not vary: 1.07 ± 0.28 mg/dl (P=ns). After a mean follow-up of 42.36 more or less 21.56 months urinary protein excretion (0.12 more or less 0.06 g/day) and renal function (serum creatinine 1.06 more or less 0.27 mg/dl) remained stable. No major side effects were reported during the study. Renin-angiotensin blockade plus oral steroids proved useful to significantly decrease proteinuria to less than 0.5 g/day in patients with IgA nephropathy without changes in renal function.

El doble bloqueo del sistema renina-angiotensina con inhibidores de la enzima convertidora de angiotensina junto a bloqueadores del receptor tipo I de angiotensina II es aceptado como tratamiento en la proteinuria de la nefropatía por IgA, ya que el rol de los inmunosupresores continúa siendo controvertido. Estudio prospectivo, no controlado, abierto para pacientes con nefropatía por IgA con proteinurias major que 0.5 g/día y creatininas séricas menor que 1.4 mg/dl, para evaluar la eficacia de tratamiento de enalapril más valsartán asociado a metilprednisona vía oral para disminuir las proteinurias a menor que 0.5 g/día. Fueron incluidos 20 pacientes: Edad: 37.45 más o menos 13.3 años (50% hombres); 7 pacientes (35%) eran hipertensos; proteinuria inicial 2.2 más o menos 1.86 g/día; creatinina inicial 1.07 más o menos 0.29 mg/dl; seguimiento promedio: 60.10 más o menos 31.47 meses (5 más o menos 2.62 años). La nefropatía por IgA fue subclasificada según Haas: 12 pacientes (60%) clase II; 7 (35%) clase III y 1 (5%) clase V. Todos recibieron enalapril más valsartán según tolerancia más metilprednisona vía oral en dosis de 0.5 mg/kg/día durante las primeras 8 semanas y subsecuentemente se redujo cada dos semanas hasta llegar a 4 mg. Se discontinuaron los esteroides luego de 24 semanas (6 meses). La inhibición del sistema renina angiotensina prosiguió indefinidamente. A las 10 semanas la proteinuria disminuyó de 2.2 más o menos 1.86 g/día a 0.15 más o menos 0.7 g/día (p menor que 0.001); la creatinina no varió significativamente (1.07 más o menos 0.29 mg/dl vs. 1.07 más o menos 0.28 mg/dl) (P=ns). Luego de 10 semanas y con un seguimiento de 42.36 más o menos 21.56 meses la proteinuria (0.12 más o menos 0.006 g/día) y la función renal (creatinina 1.06 más o menos 0.27mg/dl) permanecieron estables. No se informaron efectos adversos durante el estudio. El doble bloqueo del sistema renina angiotensina más bajas dosis de metilprednisona resultó útil para reducir...

Growth hormone promotes glomerular lipid accumulation in bGH mice.

BACKGROUND: Bovine growth hormone (bGH) transgenic mice develop progressive glomerulosclerosis and exhibit abnormalities in hepatic lipid metabolism. We have previously shown that growth hormone up-regulates the low-density lipoprotein (LDL) receptor and 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGR) in mouse mesangial cells. However, a role of lipid abnormalities in bGH kidney disease has not yet been demonstrated. METHODS: Groups of bGH mice (5 and 11 months old) presenting with, respectively, moderate and severe degrees of glomerulosclerosis were compared to age-matched controls. Neutral lipid content in kidney cortex was determined by oil red-O staining, serum cholesterol, and triglycerides by enzymatic assays, relative mRNA expression of LDL receptors, HMGR, and scavenger receptor by real-time reverse transcription-polymerase chain reaction (RT-PCR), and HMGR protein expression by immunoblotting. Two younger (5 and 12 weeks old) groups of mice were used to study scavenger receptor expression at earlier time points. RESULTS: Serum cholesterol was significantly increased in bGH mice at 5 months, but triglycerides were lower than control levels at both 5 and 11 months. Renal cortex HMGR expression was elevated at the mRNA but not at the protein level in the 11-month-old bGH group compared to controls. However, glomerular neutral lipid staining and scavenger receptor mRNA expression were markedly increased in all bGH mice, including those at 5 weeks of age compared to respective controls. CONCLUSION: The bGH mouse exhibits an increased mesangial lipid content and elevated scavenger receptor mRNA expression as early as at 5 weeks of age, suggesting that an increased kidney uptake of oxidized LDL could play a role in the development of glomerulosclerosis in this mouse model.

Glomerular hypertrophy is associated with hyperinsulinemia and precedes overt diabetes in aging rhesus monkeys.

BACKGROUND: Rhesus monkeys have a high prevalence of obesity and spontaneous type 2 diabetes mellitus after the age of 10 years. These monkeys go through a defined, sequential set of metabolic phases, including fasting hyperinsulinemia, impaired glucose tolerance, and fasting hyperglycemia. Using these monkeys, we addressed the hypothesis that renal structural features characteristic of diabetic nephropathy might precede the appearance of overt diabetes. METHODS: We carried out a quantitative analysis of renal tissue, using light microscopy and electron microscopy, from 6 metabolically normal young monkeys, 7 metabolically normal aged monkeys, 7 hyperinsulinemic monkeys, and 18 diabetic monkeys. RESULTS: Glomerular volume was increased significantly in hyperinsulinemic monkeys and diabetic monkeys compared with aged normal monkeys. In the normal monkey, glomerular basement membrane (GBM) width rises with age but reaches a plateau at about 20 years of age; the presence of diabetes was associated with markedly increased GBM width. Glomerular tuft volume and GBM width were correlated most closely with age and with glucose tolerance. CONCLUSION: Diabetic monkey kidneys are characterized by glomerular enlargement, glomerulosclerosis, and thickening of the GBM. Glomerular hypertrophy begins in the prediabetic hyperinsulinemic phase. This finding suggests that early intervention may be required in human patients to preserve normal glomerular structure.

[Association of non-compacted myocardium and patent ductus arteriosus in a young asymptomatic male patient: findings in screening for contact sport eligibility]. / Associazione di miocardio non compatto e di persistenza del dotto arterioso in giovane asintomatico: rilievo in corso di screening per idoneità sportiva agonistica.

Spongy or noncompacted myocardium is a rare congenital cardiomyopathy characterized by parietal myocardial structural alterations secondary to intrauterine arrest of myocardial fiber compaction. It can be associated with other congenital cardiovascular malformations or manifest as an isolated disease. It is characterized by a wide variety of clinical presentations that range from complete absence of symptoms to thromboembolic manifestations, ventricular arrhythmias and congestive heart failure; the short- and mid-term prognosis is quite severe. We here describe a casual finding of an advanced form of noncompacted myocardium associated with patent ductus arteriosus in a young asymptomatic athlete during a routine visit for agonistic sports eligibility. Although the patient had a normal functional capacity, transthoracic echocardiography showed left ventricular dilation with a moderately depressed contractile function and the presence of numerous prominent trabeculae and deep intertrabecular recesses which communicated with the left ventricular cavity. These findings which were confirmed by further echocardiographic examinations, and the absence of other cardiovascular disorders associated with this disease, led us to the diagnosis of noncompacted myocardium. The patient was not allowed to perform sports activities and underwent percutaneous closure of the patient ductus arteriosus. He was asymptomatic and because in the recent literature there are no data regarding pharmacological therapy in these patients, the subject was submitted to routine clinical follow-up evaluation with no medical therapy.

Epidermolisis ampollar adquirida y lupus eritematoso sistémico: autoinmunidad mediada por anticuerpos contra colágeno tipo VII / Acquired bullous epidermolysis and systemic lupus erythematosus: autoimmunity mediated by type VII collagen antibodies

La epidermolisis ampollar adquirida (EAA) es una enfermedad autoinmune provocada por autoanticuerpos contra el colágeno tipo VII de la sublámina densa de la dermis. Sus manifestaciones clínicas exigen especial atención para diferenciarla del lupus ampollar (LA), el penfigoide ampollar (PA) y la porfiria cutánea tarda (PCT). La clínica, la histopatología, la inmunofluorescencia directa (IFD) y la inmunofluorescencia indirecta (IFI) con la técnica de salt-split son de gran ayuda para el diagnóstico. El caso de una paciente con EAA y lupus eritematoso sistémico (LES) plantea la discusión sobre las diferencias y semejanzas entre el LA y la EAA. La presencia de mecanismos inmunopatogénicos comunes y la asociación de LES y EAA permitiría suponer que se trata de expresiones clínicas de una misma afección (AU)

Epidermolisis ampollar adquirida y lupus eritematoso sistémico: autoinmunidad mediada por anticuerpos contra colágeno tipo VII / Acquired bullous epidermolysis and systemic lupus erythematosus: autoimmunity mediated by type VII collagen antibodies

La epidermolisis ampollar adquirida (EAA) es una enfermedad autoinmune provocada por autoanticuerpos contra el colágeno tipo VII de la sublámina densa de la dermis. Sus manifestaciones clínicas exigen especial atención para diferenciarla del lupus ampollar (LA), el penfigoide ampollar (PA) y la porfiria cutánea tarda (PCT). La clínica, la histopatología, la inmunofluorescencia directa (IFD) y la inmunofluorescencia indirecta (IFI) con la técnica de salt-split son de gran ayuda para el diagnóstico. El caso de una paciente con EAA y lupus eritematoso sistémico (LES) plantea la discusión sobre las diferencias y semejanzas entre el LA y la EAA. La presencia de mecanismos inmunopatogénicos comunes y la asociación de LES y EAA permitiría suponer que se trata de expresiones clínicas de una misma afección

Enfermedad antimembrana basal glomerular en un paciente trasplantado renal con enfermedad de Alport / Anti glomerular basement membrane disease in a renal transplant patient with Alport syndrome

Se comunica un caso de enfermedad anti membrana basal glomerular (anti MBG) en un paciente com síndrome de Alport que recibió un trasplante de riñón cadavérico. Luego de alcanzar una función renal normal al mÛs del trasplante, deterioró progresivamente la función a partir del 3er mÛs y la punción biopsia renal mostró formación de semilunas y depósitos lineales de inmunoglobulinas. El estudio del suero demostró anticuerpos contra la cadena alfa 5 del colágeno tipo IV y recibió tratamiento con plasmaféresis, lográndose estabilización funcional durante un año. Al cabo de dicho lapso una infección respiratoria requirió interrupción de la inmunosupresión y el paciente debió reingresar al programa de hemodiálisis crónica. Se discuten los posibles mecanismos que condicionaron la especificidad de los anticuerpos circulantes en este caso, ya que difiere de la prevalente en la enfermedad anti MBG idiopática, en la que los anticuerpos circulantes están habitualmente dirigidos contra la cadena alfa 3. (AU)

Enfermedad renal quistica adquirida. Entidad polisindromatica causa de progresion no unmunológica de insuficiencia renal / Acquired renal cystic disease. Polysyndromatic entity as cause of non-immunological progression of renal failure

Se comunica un paciente con una glomerulonefritis rápidamente progresiva que después de inmunosupresión y hemodiálisis recuperó parcialmente la función renal. Ocho años más tarde una TAC demostró una enfermedad renal quística adquirida (ERQA), entidad caracterizada por el desarrollo de numerosos quistes en los riñones de pacientes con diferentes nefropatias crónicas que no tienen historia de enfermedad quística hereditaria. La ERQA puede cursar en forma asintomática o como ocurrió en este caso con diferentes complicaciones derivadas de los quistes tales como poliuria-polidipsia, quiste renal hemorrágico, hematoma retroperitoneal y carcinoma de riñon a células claras. En doce años de seguimiento se observó una declinación lenta de la función renal que podría atribuirse a la ERQA. Se sugiere que la ERQA puede convertirse en un factor de progresión no inmunológico que condicionaria pérdia de la función renal cuando se instala en pacientes con insuficiencia renal moderada. (AU)