Genetic and serologic characterization of HIV type 1 prevailing in Myanmar (Burma).

To study the molecular epidemiology of HIV-1 spread in Myanmar and the interplay with the epidemic in surrounding Southeast Asian countries, we determined the HIV-1 subtypes prevailing in Myanmar. Thirty HIV-positive blood specimens were sampled in the capital city, Yangon, and an additional 459 sera were collected nationwide in 1995. Genetic subtyping based on the env C2/V3 sequence and serologic data, using a V3 peptide enzyme immunoassay (PEIA), revealed three patterns of HIV spread in different geographic regions in Myanmar: (1) in the capital city, Yangon, HIV-1 subtype B' ("Thai-B" cluster within subtype B) predominated both in IDUs and heterosexuals; (2) in the cities near the border with Thailand, including Tachelaik and Kawthaung, where heterosexual transmission is a major pathway of HIV-1 spread, HIV-1 subtype E was predominantly distributed among the commercial sex workers and heterosexuals; (3) in central and northeast Myanmar, both HIV-1 subtypes B' and E occurred in a mixed distribution, without showing any significant segregation by risk group. In addition, the PEIA data implied the occurrence of other subtype(s) in these areas. The interperson nucleotide sequence variations in env C2/V3 regions of B' and E, prevailing in Yangon, were 6.7 +/- 2.1 and 7.1 +/- 0.7%, respectively. They were similar to those levels observed in Thailand. These findings are consistent with the view that HIV spread in Myanmar might have taken place at about the same time as that in Thailand, and that multiple entries and exchanges of HIV-1 with neighboring countries are important factors contributing to the current distribution of subtypes in Myanmar.

Low-density lipoprotein apheresis retards the progression of hyperlipidemic overt diabetic nephropathy.

BACKGROUND: Hyperlipidemia has recently received attention as being involved in the progression of diabetic nephropathy (DN). Low-density lipoprotein apheresis (LDL-A) can remove a large amount of plasma lipid directly from the patients in a short time. METHODS: Fifteen type 2 diabetic patients with overt nephropathy received LDL-A in two different manners: short-term intensive therapy (SIT) for nine patients and long-term intermittent therapy (LIT) for six patients. RESULTS: The changes in the monthly decline rates of reciprocal serum creatinine (1/Cr) were -0.035 +/- 0.020 in the three-month period before SIT, 0.047 +/- 0.041 during and until two weeks after SIT, and -0.035 +/- 0.015 after a period of two weeks from the therapy. The mean duration of LIT in six patients was 8.2 +/- 7.4 months, and the mean monthly decline rates of 1/Cr significantly decreased during the period of LIT as compared with the six-month period before the treatment. CONCLUSION: LDL-A can retard the progression of overt DN, especially when it is performed repeatedly for a long period at two-week intervals.

Initial remission-inducing effect of very low-dose cyclosporin monotherapy for minimal-change nephrotic syndrome in Japanese adults.

AIM: Cyclosporin A (CsA) in combination with corticosteroids can be used effectively in steroid-sensitive nephrotic syndrome. However, reports documenting the effectiveness ofCsA monotherapy against such a condition have been scarce. In 11 adults with minimal-change nephrotic syndrome, we have tried very low-dose CsA in the hope of inducing remission without using either corticosteroid or any other immunosuppressive drugs. PATIENTS AND METHODS: Indications for treatment included steroid-sensitive relapsing nephrotic syndrome (7 patients) and first-episode nephrotic syndrome (4 patients). In all patients, corticosteroid and cytotoxic agents had not been given before entry. CsA was administered orally at an initial dose of 2.4 (range 1.5 - 3.1) mg/kg per day. RESULTS: Analysis of the clinical course revealed that 8 of 11 patients entered complete remission after a mean duration of 44 +/- 31 days, whereas 3 patients failed to enter remission to CsA alone, resulting in complete remission combined with methylprednisolone pulse therapy without conventional oral prednisolone. CsA dosages and trough levels between responders and non-responders were similar. Non-responders had much higher levels of serum total cholesterol and higher daily urinary excretion of protein than those of responders, respectively. No patients had significant decrease in creatinine clearance, development of hypertension or suffered from other CsA associated serious side-effects. CONCLUSION: The present data suggest that CsA monotherapy at a very low dose could induce complete remission in adult patients with minimal-change nephrotic syndrome. Conversely, severe hypercholesterolemia would be likely to inhibit the action of CsA against nephrotic conditions.

Influence of erythropoietin treatment on hemoglobin A1c levels in patients with chronic renal failure on hemodialysis.

We studied the influence of erythropoietin (EPO) treatment on hemoglobin A1c (HbA1c) levels under conditions which eliminate the effect of changes in the blood glucose concentration. HbA1c levels, blood glucose, hematocrit (Hct) and reticulocyte counts were serially measured every two weeks after starting or stopping EPO administration in 15 non-diabetic hemodialysis patients. EPO treatment significantly influenced HbA1c levels, and the more erythropoiesis fluctuated by changing the dose of EPO, the more HbA1c levels changed, though there were no significant changes in blood glucose levels during the study period. The changes in HbA1c during the 2-week period correlated inversely with both the changes in Hct during the same 2 weeks and the reticulocyte counts at that time. We concluded that the change in Hct should be kept in mind when the HbA1c level is evaluated in EPO-treated patients and a formula should be proposed to correct HbA1c levels based on the change in Hct or the reticulocyte count.

[Effect of dietary protein restriction and influence of proteinuria on progression of type 2 diabetic renal failure].

PURPOSE: This study investigated the effect of dietary protein restriction on disease progression and how it is influenced by proteinuria in patients with type 2 diabetic nephropathy(DN) and renal failure. METHODS: One hundred and six type 2 DN patients whose baseline creatinine clearance(Ccr) values were 29 +/- 12 ml/min/1.73 m2 were maintained on a diet containing 0.66 +/- 0.05 g/kg/day of protein. They were classified into 3 groups according to mean dietary protein intake(DPI) estimated from urinary urea nitrogen excretion during the follow-up period of 23 +/- 14 months(I, < 0.7 g/kg/day; II, 0.7-0.89 g/kg/day; III, > or = 0.9 g/kg/day). Furthermore, they were divided into 3 subgroups according to mean urinary protein excretion(UP) during the follow-up period (a, > or = 5.0 g/day; b, 2.0-4.99 g/day; c, < 2.0 g/day). Their rates of decline of Ccr(D-Ccr) and the changes in UP were examined. RESULTS: There were no significant differences in D-Ccr among Group Ia, IIa, and IIIa(1.1 +/- 0.6, 1.5 +/- 0.7, 1.2 +/- 0.6 ml/min/1.73 m2/month), among Group Ib, IIb, and IIIb(0.6 +/- 0.3, 0.7 +/- 0.4, 0.8 +/- 0.4 ml/min/1.73 m2/month), and also among Group Ic, IIc, and IIIc(0.1 +/- 0.3, 0.2 +/- 0.2, 0.2 +/- 0.6 ml/min/1.73 m2/month). On the other hand, significant differences were revealed in D-Ccr among Group Ia, Ib, and Ic, among Group IIa, IIb, and IIc, and among Group IIIa, IIIb, and IIIc. There were no significant differences in final UP and minimum UP during follow-up among 3 groups of different DPI levels in patients with 5.0 g/day < or = baseline UP(n = 49) and in patients with 2.0 < or = baseline UP < 5.0 g/day(n = 37). However, significant correlations were demonstrated between D-Ccr and the relative changes in UP between baseline and minimum during the follow-up period in both patients(r = 0.49, 0.48, p < 0.001, p < 0.01). CONCLUSIONS: Irrespective of the level of dietary protein restriction, proteinuria has a great influence on disease progression, and the reduction in UP correlates with retardation of renal function loss in patients with type 2 DN and renal failure.

[Charge selectivity of peritoneal transport in CAPD patients under stable states and during peritonitis].

To investigate charge selectivity of peritoneal transport in CAPD, dialysate/plasma concentration ratios (D/P) were calculated for creatinine (Cr) and 3 amino acids with almost the same molecular weight but quite different charges: glutamic acid (Glu: negatively charged), glutamine (Gln: near neutrally charged) and lysine (Lys: positively charged). The study population consisted of 23 stable patients and 11 patients with peritonitis on CAPD. In the stable patients, the samples of dialysate were taken at 2 and 4 hours and blood samples were obtained at 4 hours after the infusion of 2 liters of 2.27 or 2.5% glucose CAPD dialysate; the samples of patients with peritonitis were obtained at 4.1 +/- 1.1 hours of dwell time. In stable patients, D/P of Glu was much lower than the values for Gln, Lys and Cr at both 2 and 4 hours (p < 0.01), and D/P of Lys was significantly lower than that of Gln (p < 0.01). There was no significant difference in D/P between Gln and Cr. In patients with peritonitis, D/P of Glu was also significantly lower than the values for Gln and Cr (p < 0.05 and p < 0.01), however, no significant differences were found between D/P of Lys and the values of Glu and Gln. Ratios of both [D/P Glu]/[D/P Lys] and [D/P Glu]/[D/P Gln] were much higher in peritonitis patients than in stable patients. In conclusion, peritoneal transport in stable CAPD patients shows charge selectivity, and the order of molecular charge for transperitoneal mobility among small solutes is neutral > positive > negative. The selectivity, however, is decreased or lost during peritonitis.

[Relationship of renal lesions with urinary protein excretion in patients with overt diabetic nephropathy].

We investigated the relationship of renal lesions with the degrees of proteinuria in 57 type 2 diabetic patients with overt proteinuria (urinary protein excretion rate (UP) >> 0.5 g/day). Creatinine clearance (Ccr) ranged from 25.4 to 131.0 ml/min/1.73 m2. Kidney specimens were obtained and the diagnosis of diabetic nephropathy was made in all patients. The degree of each of the following histologic changes were evaluated: diffuse or nodular lesion, the type of nodular change, mesangiolysis, arteriolar hyalinosis and interstitial damage. We divided the patients into the following 4 groups according to Ccr and UP: group A with Ccr >> 60 and UP >> 3 g/day (n = 10), group B with Ccr >> 60 and UP < 3 g/day (n = 10), group C with Ccr < 60 and UP >> 3 g/day (n = 23) and group D with Ccr < 60 and UP < 3 g/day (n = 14), and compared the histologic parameters among the 4 groups. Diffuse index in group A was greater than those in group B (p = 0.05), while those in groups C and D were not different. Nodular index, percentage of patients with nodular lesion did not differ among the 4 groups, however the percentage of glomeruli with complicated nodules (nodular lesion with mesangiolysis and/or microaneurysm) in group C was greater than those in group D (p < 0.05). Hyalinosis index did not differ between group A and B, nor between group C and D, respectively. Interstitial index in group A and B did not differ, however that in group C was greater than in group D (p < 0.05). In addition, the rate of Ccr decrease between renal biopsy and after 12 months was significantly greater in group A and C than in group B and D, respectively (both p < 0.01). These results suggest that 1) mesangial expansion was associated with the degree of proteinuria in patients with slight impaired renal function, 2) tubulointerstitial involvement was associated with the degree of proteinuria in patients with advanced impaired renal function, and 3) these structural changes might be associated with decrease in renal function in diabetic nephropathy.

[Evaluation of fat nutrition in the energy intake on low protein diets for patients with chronic renal failure].

Low protein diet has been proven to retard the progression of chronic renal failure. In this diet, the energy intake depends mainly on fats and carbohydrates instead of protein, and precautions should be taken against increasing risks of both lipid nephrotoxicity and atherosclerosis. In order to assess the adequacy of fat nutrition in a low protein diet for patients with chronic renal failure, we evaluated the total amounts of dietary fat intake, dietary individual fatty acid intake and serum individual fatty acid concentrations in 16 patients, whose mean creatinine clearance was 21.3 +/- 12.1 ml/m, serum creatinine 3.8 +/- 2.2 mg/dl and serum urea nitrogen 41.5 +/- 18.6 mg/dl. The percentage ratio of fat intake to total energy intake was 26.7 +/- 5.2%. The ratio of intake of saturated fatty acids, monounsaturated fatty acids and polyunsaturated fatty acids was 1:2:1.8, and n-6/n-3 was 8.5 +/- 9.3. These were significant correlations between dietary intake and the serum concentrations in both EPA and the ratio of EPA/AA. Consequently, it might be considered that polyunsaturated fatty acids intake should be lowered and patients with chronic renal failure on a low protein diet should be advised about the proper selection of foods containing animal protein and plant-derived oil. It may be beneficial to recommend the intake of more EPA and lowering the ratio of n-6/n-3 intake might be useful in improving the fat nutrition to adequate levels in these patients.

[Serial changes in body composition in patients with chronic renal failure on peritoneal dialysis].

Nutritional status is one of the most important factors affecting mortality and morbidity in chronic dialysis patients. There are, however, few data on serial body composition changes in these patients. To investigate serial changes in body composition in patients on peritoneal dialysis, we measured intracellular fluid volume(ICF), extracellular fluid volume(ECF), body protein volume(BPV), body fat volume(BFV) and bone mineral content(BMC) using multifrequency bioelectrical impedance analysis (MF-BIA). MF-BIA was performed in 35 patients, consisting of 21 men and 14 women with a mean age of 51.3 +/- 10.9 years, before and after one year of observation. At the baseline in male patients, ICF was 37.0 +/- 3.4%, ECF 19.7 +/- 1.6%, BPV 20.7 +/- 1.7%, BFV 18.1 +/- 6.6% and BMC 4.5 +/- 0.4% of body weight, and in female patients ICF was 34.4 +/- 2.6%, ECF 17.8 +/- 1.9% BPV 19.0 +/- 1.6%, BFV 24.4 +/- 6.2% and BMC 4.5 +/- 0.4% of body weight. In the group of patients whose body weight increased more than 3 kilograms(n = 9), the increase rate of BFV was 32.3 +/- 20.2%, significantly higher than that of the other segments(p < 0.001). On the other hand, in the group of patients whose body weight decreased more than 3 kilograms(n = 5), each segment showed the same extent of decrease and there was no significant difference in the decrease rates among each segment. In the group of patients whose body weight was stable(n = 21), changes in each body composition segment were extremely small. It could be concluded that the body weight increase is due mainly to increase in BFV and body weight decrease results from a concurrent decrease in each body composition segment in peritoneal dialysis patients.

Work intensities of different modes of exercise testings in clinical use.

Several different exercise testings with treadmill, bicycle ergometer and two-step were carried out by healthy Japanese men to study oxygen consumption per minute and circulatory responses. Stress imposed on the heart by dynamic leg exercise varied depending on the mode of exercise even if energy expenditure expressed in VO2 was identical. This should be fully taken into consideration in comparison of results of different modes of exercise testing. For estimation of VO2 during treadmill slope walk, an equation was derived by multiple regression analysis with use of belt speed and slope as independent variables.

Echocardiographic evaluation of right ventricular anterior wall motion in the Wolff-Parkinson-White syndrome.

Echocardiographic motions of right ventricular anterior wall (RVAW) were investigated in 71 patients with Wolff-Parkinson-White (WPW) syndrome. According to the criteria of Rosenbaum et al the electrocardiograms were classified as type A in 35 patients and type B in 36. Sixteen type B patients exhibited abnormal RVAW motion, which was characterized by an early onset of the posterior movement before S1 andl also by a premature peak formation before S2. A small step or hump nearly coincident with S1 was observed in 10 of these 16 patients. These findings seem to suggest that both contraction and relaxation of RVAW begin earlier than normal due to anterior right ventricular pre-excitation. RVAW motion was normal in all of type A patients. Echocardiographic investigation of RVAW motion appears to be useful in non-invasive estimation of the site of pre-excitation, especially in type B WPW patients.