Increased plasma angiogenin level is associated and may contribute to decreased T-cell zeta-chain expression in hemodialysis patients.

Hemodialysis (HD) patients are characterized by impaired T-cell function at least in part because of T-cell zeta-chain downregulation due to inflammation. Angiogenin responds as an acute phase reactant, is increased in HD patients, suppresses T-cell function and increased angiogenin level is co-localized with T-cell zeta-chain downregulation in various pathologies. Angiogenin can inhibit translation of proteins, which lack internal ribosomal entry sites in the corresponding mRNAs. In this study, the possible effect of angiogenin on T-cell zeta-chain downregulation was evaluated. Thirty HD patients and 21 healthy volunteers participated. T-cell zeta-chain expression was assessed with flow cytometry, plasma angiogenin and serum IL-6 with ELISA and serum C-reactive protein with an immunoturbidimetric method. Two available software tools were used for predicting the presence or not of internal ribosomal entry sites in T-cell zeta-chain mRNA sequence. In silico analysis of T-cell zeta-chain mRNA sequence failed to reveal the presence of internal ribosomal entry sites. T-cell zeta-chain expression was lower in HD patients than in healthy volunteers (1.86 ± 0.63 vs. 4.73 ± 3.22). In HD patients, C-reactive protein as well as IL-6 were higher than in healthy volunteers (10.04 ± 15.13 mg/L vs. 3.43 ± 0.98 mg/L and 15.06 ± 13.08 pg/mL vs. 2.11 ± 2.10 pg/mL respectively). Angiogenin was higher in HD patients than in healthy volunteers (483.20 ± 154.07 ng/mL vs. 259.98 ± 64.15 ng/mL). Neither C-reactive protein, nor IL-6 was associated with angiogenin or T-cell zeta-chain expression. Angiogenin concentration was negatively related to the expression of T-cell zeta-chain (r = -0.410, P = 0.025). Increased angiogenin may contribute to decreased T-cell zeta-chain expression in HD patients.

A case of a primary cutaneous plasmacytoma presenting in adolescence.

Primary cutaneous plasmacytoma is defined as monoclonal proliferation of plasma cells that arises primarily in the skin without evidence of systemic disease. We present an extremely rare case of a young adult diagnosed with solitary plasmacytoma. A 20-year-old woman presented with a pruritic erythematosquamous indurated plaque on the inner aspect of her right thigh. She had undergone a biopsy 5 years ago, and under the diagnosis of Nekam disease, she was treated with topical steroids followed by intralesional injections of triamcinolone acetonide. A new skin biopsy revealed infiltration of the epidermis by small T lymphocytes while plasma cell accumulations were found in the dermis. Immunostains for light and heavy chains [kappa, lambda, immunoglobulin (Ig) G, IgA, and IgM] demonstrated IgG/κ monoclonality of the plasma cells. On molecular analysis, T-cell receptor and immunoglobulin heavy chain rearrangements were polyclonal. Serum protein electrophoresis, immunofixation, and quantitative assessment of serum Igs were normal. Bone marrow biopsy, skeletal survey, and body computed tomography scan were unremarkable. A diagnosis of primary solitary cutaneous plasmacytoma was made. The lesion was removed surgically, and the patient remains in remission up to now. Primary cutaneous plasmacytoma represents only 2%-4% of extramedullary plasmacytomas. The rarity and the nonspecific presentation of cutaneous plasmacytomas does not allow a definite clinical diagnosis. Only histopathology reveals the typical pattern of a dense monomorphic dermal plasmacytic infiltrate, whereas immunohistochemistry shows monoclonality of the neoplastic cells.

Isolated Splenic Mycobacterial Disease: A Cause of Persistent Fever in a Hairy Cell Leukemia Patient.

We describe a 69-year-old male patient who was referred for the investigation of long-lasting fever, anemia and neutropenia. Hairy cell leukemia was diagnosed and treated successfully. However, fever persisted despite thorough investigation and use of broad-spectrum antibiotics. Four months after the initial diagnosis, the patient underwent explorative laparotomy and splenectomy. Spleen biopsy revealed multiple necrotizing mycobacterial granulomata while the patient's fever disappeared permanently. Isolated splenic mycobacterial disease is very rare. This case report emphasizes that investigation of chronic fever in hairy cell leukemia requires a high level of clinical suspicion. Early diagnostic procedures for evidence of atypical mycobacterial infection should be considered. When everything else fails, surgery can be helpful in selected cases.

Paricalcitol reduces basal and lipopolysaccharide-induced (LPS) TNF-alpha and IL-8 production by human peripheral blood mononuclear cells.

INTRODUCTION: Vitamin D and its analogues proved to exert immunomodulatory effects. Paricalcitol is a vitamin D analogue that is safe. It has been used for years in the treatment of secondary hyperparathyroidism in hemodialysis patients and, importantly, it is less calcemic than vitamin D. In this study the immunomodulatory/anti-inflammatory properties of paricalcitol were evaluated in vitro. SUBJECT AND METHODS: Ten healthy volunteers enrolled into the study. Peripheral blood mononuclear cells (PBMC) at a concentration of 10(6) cells per well were cultured for 48 h in the presence or not of lipopolysaccharide (LPS) (100 ng/ml) and in the presence or not of paricalcitol (10(-8) M). TNF-alpha and IL-8 were measured in the supernatants by ELISA. RESULTS: Basal TNF-alpha concentration (50.3 +/- 22 pg/ml) was reduced by paricalcitol (44.1 +/- 23.2 pg/ml). LPS increased TNF-alpha concentration (150.0 +/- 81.7 pg/ml), but paricalcitol reduced it (121.1 +/- 69.0 pg/ml). The effect of paricalcitol on IL-8 production was more profound. Basal IL-8 concentration (1926 +/- 455 pg/ml) was reduced by paricalcitol (1273 +/- 472 pg/ml). LPS increased IL-8 concentration (2361 +/- 385 pg/ml), but paricalcitol returned it to its basal level (1849 +/- 417 pg/ml). CONCLUSION: The in vitro inhibition of transforming growth factor alpha and interleukin 8 by paricalcitol confirms the immunomodulatory properties of this vitamin D analogue.

Decreased CD3+CD16+ natural killer-like T-cell percentage and zeta-chain expression accompany chronic inflammation in haemodialysis patients.

AIM: Clinical and experimental data indicate a deficient immune response in haemodialysis (HD) patients. Natural killer-like (NKL) T cells express on their surface both the T-cell antigen receptor (TCR) and a diverse set of NK-cell receptors (NKR) and share properties of both T cells and NK cells. zeta-Chain phosphorylation is an early event that follows TCR activation or some NKR activation. The zeta-chain of both T cell and NK cells is downregulated in many chronic inflammatory states, HD included. In the present study, NKL T-cell percentage and zeta-chain expression in HD patients were evaluated. METHODS: Thirty-three stable HD patients and 30 healthy volunteers were enrolled into the study. NKL T-cell percentage and NKL T-cell zeta-chain mean fluorescence intensity (MFI) were evaluated with flow cytometry. The inflammatory markers C-reactive protein, interleukin-6 and tumour necrosis factor-alpha were measured in the serum by means of enzyme-linked immunosorbent assay. RESULTS: All the evaluated markers of inflammation were increased in HD patients. In these patients, NKL T-cell percentage (1.71 +/- 1.69% vs 3.94 +/- 3.86%) and zeta-chain MFI (3.66 +/- 2.79 vs 7.03 +/- 7.91) were decreased. CONCLUSIONS: NKL T-cell percentage and zeta-chain expression is decreased in HD patients. Taking into consideration the continuously increasing age of the HD patients and that normally NKL T-cell numbers increase with age counteracting the impaired T-cell and NK-cell function accompanying advancing age, the above NKL T-cell disturbances could contribute to the impaired immune response in this population. Measures towards alleviating chronic inflammation could partially restore NKL T-cell impairment.

The role of hepcidin in iron homeostasis and anemia in hemodialysis patients.

Anemia is a common complication in hemodialysis (HD) patients. Despite the great success of recombinant human erythropoietin in clinical practice, resistance to this therapy is common. Additionally, nephrologists frequently witness a rapid and significant drop in their patients' hematocrit during the course of various acute events that regularly take place in this sensitive population. Hepcidin, a recently identified peptide, may mediate this development in many instances. Hepcidin production is regulated by hypoxia/anemia, iron status, and importantly, inflammation. This peptide can block iron absorption by the duodenum, iron release from both the liver (the main iron storage pool) and, more significantly, the macrophages interrupting iron recycling between senescent red cells and the reticuloendothelial system. The decreased availability of iron for erythropoiesis leads to the anemia of chronic disease or, in HD patients, aggravate an already existing anemia HD is now widely considered an inflammatory state probably accounting for the increased serum hepcidin levels that have been associated with it. The physiology of hepcidin and its possible contribution to the pathogenesis of anemia in HD patients are the subject of this review.

The impact of chronic inflammation on bone turnover in hemodialysis patients.

BACKGROUND: Renal osteodystrophy is very common in hemodialysis (HD) patients. HD is a chronic inflammatory state. Studies in other pathological entities have shown an impact of chronic inflammation on bone metabolism. In the present study, the impact of chronic inflammation on bone turnover in HD patients was evaluated. PATIENTS AND METHODS: Thirty-three anuric HD patients free of other pathological conditions or medications that affect immune system or bone metabolism and 30 healthy volunteers enrolled into the study. Intact parathyroid hormone (iPTH), the markers of inflammation IL-6 and CRP, as well as the markers of bone turnover osteocalcin (OCN) and beta-isomerized C-terminal cross-linked peptide of collagen type I (beta-CTx) were measured in the serum. RESULTS: All evaluated factors were increased in HD patients. In the HD group, the serum marker of osteoblastic activity OCN was related inversely to patients' age (r = -0.469, p = 0.006), CRP (rho = -0.460, p = 0.007), and IL-6 (r = -0.485, p = 0.004) but positively to iPTH (r = 0.707, p < 0.001). Similarly, the serum marker of osteoclastic activity beta-CTx was related inversely to patients' age (r = -0.383, p = -0.028), CRP (rho = -0.466, p = 0.006), and IL-6 (r = -0.460, p = 0.007) but positively to iPTH (r = 0.657, p < 0.001). Multiple linear regression analysis revealed that IL-6 affects bone turnover independently of PTH and to the opposite direction. CONCLUSION: Chronic inflammation has a negative impact on bone turnover in HD patients. Certainly, further research and large clinical trials are needed for definite conclusions and for clarifying the exact molecular mechanisms implicated in the interaction between the immune system and bone metabolism in HD patients.

Chronic inflammation and CD16+ natural killer cell zeta-chain downregulation in hemodialysis patients.

BACKGROUND: Natural killer (NK) cell activity is decreased in hemodialysis (HD) patients. Zeta-chain phosphorylation is an early event that follows the triggering of some NK cell-activating receptors. NK cell zeta-chain is downregulated in patients with cancer due to chronic inflammation. HD is also a chronic inflammatory state. NK cell zeta-chain expression in HD was evaluated. PATIENTS AND METHODS: Thirty-three HD patients and 30 healthy volunteers were enrolled into the study. The CD3-CD16+ subpopulation was examined, since it corresponds to 90% of all NK cells and has the highest cytotoxicity.NK cell count and zeta-chain mean fluorescence intensity were evaluated with flow cytometry. The inflammatory markers C-reactive protein, IL-6 and tumor necrosis factor-alpha were measured with ELISA. RESULTS: The inflammatory markers were increased in HD patients. NK cell count did not differ between HD patients and healthy volunteers. NK cell zeta-chain mean fluorescence intensity was decreased in the patient group. CONCLUSIONS: Chronic inflammation could be responsible for the NK cell zeta- chain downregulation in HD patients, contributing to the decreased NK cell activity.

Effect of one-year oral alpha-tocopherol administration on the antioxidant defense system in hemodialysis patients.

Oxidative stress is increased in hemodialysis (HD) patients and contributes to the increased morbidity and mortality in this population. Vitamin E is an antioxidant agent. In the present study the effect of prolonged oral alpha-tocopherol administration on the antioxidant defense system was evaluated. The antioxidant factors plasma total antioxidant status (TAS), red blood cell superoxide dismutase (SOD) activity and glutathione peroxidase (GPX) activity were evaluated with spectrometry in 27 HD patients. Measurements were performed before and after oral administration of alpha-tocopherol at a dose of 500 mg/d for a one-year period. Twenty HD patients received a placebo and 22 healthy volunteers served as controls. TAS was increased in HD patients. No difference was detected in SOD and GPX activity between HD patients and healthy volunteers. Tocopherol administration induced a significant decrease in TAS and SOD activity. Levels of GPX activity remained unaffected. All the evaluated factors remained stable in the HD patients receiving a placebo. Prolonged oral alpha-tocopherol administration in HD patients induces a decrease in some components of the antioxidant defense system, raising the possibility for a pro-oxidative role of vitamin E. Vitamin E is an antioxidant agent, but it is also known to have pro-oxidant action under special conditions that can be encountered in HD patients.

Successful treatment of extramedullary gastric plasmacytoma with the combination of bortezomib and dexamethasone: first reported case.

We report a case of a 68-year-old man presented with upper-gastrointestinal bleeding. Endoscopy showed a large ulcerated gastric mass. Histological examination of the gastric biopsies revealed a k monoclonal extramedullary plasmacytoma (EMP). Further staging was negative for multiple myeloma. The patient was managed with bortezomib at a dose of 1.3mg/m2 on days 1, 4, 8 and 11 of a 21-day cycle in combination with dexamethasone 20mg p.o. on days 1, 2, 4, 5, 8, 9 and 11, 12 of each cycle. After 4 cycles of treatment, no endoscopic or histological findings of EMP were found. Thirteen months after diagnosis the patient is in complete remission with no evidence of local relapse or evolution to multiple myeloma. This is the first reported case of EMP successfully managed with the combination of bortezomib and dexamethasone.

Chronic inflammation and T cell zeta-chain downregulation in hemodialysis patients.

BACKGROUND: Clinical and experimental data indicate a deficient immune response in hemodialysis (HD) patients. zeta-Chain phosphorylation is an early and central event in the process that follows antigen recognition by the T cell antigen receptor (TCR). T cell zeta-chain is downregulated in many chronic inflammatory states, such as cancer, autoimmune disease and chronic infection. HD is also characterized as a chronic inflammatory state. The aim of the present study was to evaluate T cell zeta-chain expression in HD patients. PATIENTS AND METHODS: Thirty-three stable HD patients and 30 healthy volunteers were enrolled into the study. T cell count, the percentage of zeta-chain-positive T cells, as well as T cell zeta-chain mean fluorescence intensity (MFI) were evaluated with flow cytometry. The inflammatory markers C-reactive protein, interleukin-6 and tumor necrosis factor-alpha were measured in the serum by means of ELISA. RESULTS: All the evaluated markers of inflammation were increased in HD patients. In these patients, T cell zeta-chain MFI was decreased. CD3-epsilon MFI did not differ between the two groups indicating that among the TCR complex constituents, zeta-chain is selectively downregulated. CONCLUSIONS: HD is a state of chronic inflammation. Like in other pathological chronic inflammatory conditions, T cell zeta-chain is downregulated in HD patients. Since zeta-chain plays a key role in the transduction of the signal that follows antigen recognition by the TCR, its downregulation could be responsible for the deficient cellular immune response observed in HD patients.

Disturbances of acquired immunity in hemodialysis patients.

Acquired immunity disturbances in hemodialysis (HD) patients are many and diverse. They are caused by uremia per se, the HD procedure, chronic renal failure complications, and therapeutic interventions for their treatment. Current data suggest that acquired immunity disturbances in HD patients concern mainly the T-lymphocyte and the antigen-presenting cell (APC). The T-lymphocyte-dependent immune response is deficient, predisposing to infections and inadequate response to vaccinations. In addition, APCs are preactivated, which seems to be responsible for the malnutrition-inflammation-atherosclerosis syndrome, and also affects T-lymphocyte function. At the molecular level it is assumed that the interaction between the APC and the T-lymphocyte is impaired. This disturbance is likely to concern the signal that results from the interaction between the major histocompatibility complex:peptide complex on APC surfaces and T-cell receptors on T-lymphocyte surfaces, or the signal that results from the interaction among the co-receptors of these two cells. The aim of the present review was to collect and classify the available clinical and experimental data in this area. Although many pieces are still missing from the puzzle, a better understanding of the responsible molecular mechanisms, will potentially lead to increased survival and a better quality of life in HD patients.

Hypochromic erythrocytes (%): a reliable marker for recognizing iron-restricted erythropoiesis and predicting response to erythropoietin in anemic patients with myeloma and lymphoma.

The aim of the study was to evaluate the role of hypochromic erythrocytes (HYPO%) compared to "traditional" and novel markers of iron status and erythropoiesis in recognizing iron-restricted erythropoiesis (IRE) and predicting response to erythropoietin (rHuEPO) in anemic patients with myeloma and lymphoma. Forty-one newly diagnosed patients who received epoetin-beta at a subcutaneous weekly dose of 30,000 IU for 6 weeks were studied. Response to rHuEPO was observed in 27 patients (65.8%). Twelve non-responders received, additionally, 200 mg of IV iron sucrose, weekly, for 4 weeks. Evaluation of markers was performed at baseline and on weeks 1, 2 and 6 for all patients and also on weeks 7-10 for non-responders to rHuEPO. Baseline HYPO%, at a cut-off value of <5%, and an increment in reticulocyte absolute number (RETICS-AB) >or= 50,000/microl and reticulocyte hematocrit (RETICS-Hct) >or= 50%, between baseline and week 2, were independent predictive factors for response to rHuEPO. We found that these markers had superior predictive value for response to rHuEPO than four widely used predictive models. Furthermore, a baseline HYPO% count of above 5% proved superior over serum ferritin < 100 ng/ml and transferrin saturation < 20% in recognizing IRE. In conclusion, baseline HYPO% either alone or in combination with RETICS-AB or RETICS-Hct after 2 weeks of rHuEPO treatment could be reliably used in predicting response to rHuEPO. Additionally, HYPO% has proved a reliable marker for recognizing IRE before rHuEPO treatment and, thus, could be used for identifying patients who will benefit from IV iron supplementation.

Does hepcidin affect erythropoiesis in hemodialysis patients?

INTRODUCTION: Prohepcidin is the precursor of hepcidin, a liver-derived peptide involved in iron metabolism by blocking its intestinal absorption and its release by the reticuloendothelial system. Iron overload and inflammation increase hepcidin expression, whereas anemia and hypoxia suppress it. In the present study prohepcidin levels were determined in the serum of hemodialysis (HD) patients and its correlations with iron metabolism markers, C-reactive protein (CRP) and hematocrit (Hct) were assessed. PATIENTS AND METHODS: Forty-sixHD patients and 22 healthy volunteers were enrolled in the study. Hct, serum prohepcidin, CRP, iron, ferritin, transferrin saturation and transferrin receptors were measured. The weekly erythropoietin dose, last-month intravenous iron dose and the patients' demographics were recorded. RESULTS: In comparison to the healthy volunteers, the HD patients had higher serum ferritin, transferrin receptors and CRP, lower serum iron and similar transferrin saturation and prohepcidin levels. In the patient group prohepcidin levels were negatively correlated with Hct but not with any other of the examined parameters. Multiple linear regression analysis considering age, inflammation, iron adequacy, erythropoietin dose and prohepcidin levels revealed that prohepcidin was the predominant determinant of Hct. CONCLUSIONS: Taking into account the low Hct levels in the HD patients of our study, it seems plausible that the prohepcidin levels assessed in this group are inappropriately high. These functionally high prohepcidin levels may be associated with the factors that inhibit erythropoiesis in HD patients. On the other hand, the absence of other expected correlations indicates that further studies are needed in order to definitely clarify this aspect.

Major histocompatibility complex class I restricted T-cell autoreactivity in human peripheral blood mononuclear cells.

During selection in the thymus or any subsequent response, T-cells recognize peptides bound to major histocompatibility complex (MHC) molecules. Peptides produced by lysosomes or by proteasome/immunoproteasome stimulate CD4+ or CD8+ T-cell, respectively. Inflammation alters components of both antigen-processing pathways resulting in the production of different peptides. The role of such changes in self/non-self discrimination was examined in autologous mixed peripheral blood mononuclear cell cultures. Stimulator cells were incubated in the presence or absence of INF-gamma, with or without lysosome inhibitors (ammonium chloride/chloroquine), cathepsin inhibitor (E-64), or proteasome/immunoproteasome inhibitor (epoxomicin). Responder cells were added and zeta-chain phosphorylated forms were used as read out. INF-gamma did not affect zeta-chain phosphorylated forms, which means that the expected INF-gamma induced alterations in antigen processing machinery do not influence self/non-self discrimination. Surprisingly, the completely phosphorylated 23-kDa zeta-chain was always present except in the case of epoxomicin, indicating the presence of MHC class I restricted autoreactive CD8+ T-cells but not of MHC class II restricted autoreactive CD4+ T-cells, possibly due to more efficient negative selection in the thymus of the latter. Autoimmunity is prevented due to absence of help by CD4+ T-cells. This conclusion was confirmed by the lack of differences in IL-2 levels in cell culture supernatants, as well as, by the absence of differences in cell proliferation under the various conditions described above.