Antonio Amoroso

Biological and Clinical Significance of Endotoxemia in the Course of Hepatitis C Virus Infection

Endotoxins or lipopolysaccharides (LPS), major components of the cell wall of Gram-negative bacteria, once released from the bacterial outer membrane bind to specific receptors and, in particular, to a membrane-bound receptor, the CD14 (mCD14) and the toll-like receptor 4 present on monocytes/ macrophages. In turn, LPS-activated monocytes/ macrophages release in the host tissue an array of so-called proinflammatory cytokines and, among them, Tumor Necrosis Factor (TNF)-alpha, interleukin (IL)-1beta, IL-6, IL-8 and IL-12 are the major mediators. Before therapy (To) and at the end of 6-month interferon (IFN)-alpha/Ribavirin (RIB) treatment (T6), circulating endotoxin levels were measured in responder and non responder HCV+ patients. At T0, 57% of the non responders were endotoxin-positive and had, on average, 54 pg/ml of plasma LPS while in 50% of the responder patients endotoxin were found with an average of 29 pg/ml. At T6, in responders LPS were no longer detectable, while in 42% of the non responders LPS were found (average levels 45 pg/ml). In terms of serum cytokine concentration, at T6 IFN-gamma levels when compared to those detected at T0 were increased in both endotoxin-positive and endotoxin-negative patients. However, at T6 IL-10 concentration was significantly increased only in the group of endotoxin-negative subjects (responder patients), in comparison to T0 values. The origin of endotoxemia in HCV+ patients seems to be multifactorial, likely depending on impaired phagocytic functions and reduced T-cell mediated antibacterial activity. In these patients, however, one cannot exclude the passage of LPS from the gut flora to the blood stream, owing a condition of altered intestinal permeability. At the same time, a less efficient detoxification of enteric bacterial antigens at the hepatic level should be taken into consideration. Finally, novel therapeutic attempts aimed to neutralize LPS in the host are discussed.

Modifications of the Immune Responsiveness in Patients with Hepatitis C Virus Infection following Treatment with IFN-α / Ribavirin

The balance between T helper (h)1 and Th2 responsiveness seems to represent a key event in the evolution of hepatitis C virus (HCV) infection. In particular, Th1 cytokines [interleukin (IL-2) and interferon (IFN-gamma)] have been demonstrated to mediate the antiviral immune response. Serum levels of Th1 cytokines (IL-2 and IFN-gamma) as well as of Th2 products (IL-4 and IL-10) were determined in a group of HCV-positive patients before and after treatment with IFN-alpha and Ribavirin (RIB). Results indicate that responder patients exhibited increased levels of IFN-gamma and IL-10, while this enhancement was not observed in non-responder patients. In this respect, the major effect exerted by the combined therapy with IFN-alpha/RIB could be represented by the attainment of a re-equilibrium between inflammatory (Th1) and antiinflammatory (Th2) mechanisms. In this framework, according to current literature, novel therapeutical approaches to treat HCV infection are represented by administration of recombinant IL-2 and IL-10.

Evaluation of Chronic Kidney Disease Epidemiology Collaboration equation to estimate glomerular filtration rate in scleroderma patients

OBJECTIVEnRenal involvement in SSc is often subclinical and chronic kidney disease (CKD) develops, with slow worsening of glomerular filtration rate (GFR). The present investigation was undertaken in order to study how well the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) correlates with measured GFR (mGFR) in a group of SSc patients with serum creatinine (sCr) in the normal range.nnnMETHODSnForty-one scleroderma patients (37 females and 4 males) with a median age of 46 years were enrolled. GFR was measured using technetium-99u2009m DTPA (Tc-99u2009m DTPA). The modified Cockroft-Gault formula, 4- and 7-variable Modification of Diet in Renal Disease (MDRD) and CKD-EPI equations were used for estimated GFR (eGFR).nnnRESULTSnmGFR showed a median value of 84u2009ml/min (range 32.8-121.2u2009ml/min). Seven patients had reduced GFR (<60u2009ml/min), 19 had GFR within 60-90 ml/min and 15 had GFR >90u2009ml/min. The results showed mild correlation between the BSA-modified Cockroft-Gault and mGFR (Pu2009>u20090.05), mild statistically significant correlation with 4-variable MDRD (Pu2009<u20090.05), high statistically significant correlation with 7-variable MDRD (Pu2009=u20090.01), but the greatest correlation was obtained using CKD-EPI (Pu2009=u20090.002). No correlation with age, disease duration or subset of disease was found.nnnCONCLUSIONSnIn scleroderma patients with normal sCr value, CKD-EPI is a useful formula to assess GFR.

Autonomic dysfunction in patients with systemic sclerosis: Correlation with intrarenal arterial stiffness

Systemic sclerosis (SSc) is a systemic disease of connective tissue,characterized by endothelial dysfunction and fibrosis of the skin andvisceral organs [1]. Autonomic dysfunction (AD) is a feature of SSc,starting early in the disease and possibly preceding the developmentof fibrosis [2].Several manifestations of renal involvement occur in SSc and wehave recently demonstrated that renal resistive index (RI) correlateswith glomerular filtration rate (GFR), digital microvascular damage [3]and in monitoring scleroderma renal crisis [4].Accordingly, the aim of the study is to assess intrarenal arterialstiffness by Doppler ultrasound and examine the correlation with ADusing heart rate variability (HRV) analysis.The protocol is in accordance with the Declaration of Helsinki andwas approved by the Ethics Committee at our Institution. NineteenCaucasian subjects fulfilling the American Rheumatism Association(ARA) criteria for classification and diagnosis of SSc [5] and nineteenhealthysubjectswereexaminedbeforeinclusioninthestudy.Allexam-ined patients underwent clinical evaluation, 24-h Holter monitoring,electrocardiography (ECG) and transthoracic echocardiogram.Scleroderma patients with coronary artery disease, congestiveheartfailure, left ventricular dysfunction, significant valvular abnormalitiesand arrhythmias were not included in the study.Patients with pulmonary function abnormalities were not includedeither. Patients with diabetes mellitus, renal failure, hepatic or thyroiddysfunction and anaemia were excluded.Patients were not taking β-blockers, antiarrhythmic drugs, ACE-inhibitors or angiotensin receptor antagonists. GFR was calculatedwith CKD-EPI equation [6].Autonomic nervous activity was evaluated by heart rate variability(HRV) analysis during 24-hour ECG recording. Autonomic nervousactivity was analyzed following the recommendations of the TaskForce of the European Society of Cardiology and the North AmericanSociety of Pacing and Electrophysiology [7]. Total power in the fre-quency range (0–0.40 Hz) was divided into low frequency (LF:0.04–0.15 Hz, modulated mainly by sympathetic system) and highfrequency (HF: 0.15–0.40 Hz, modulated by parasympathetic system).The power of LF and HF components was considered in normalizedunits (nu). LF/HF rate is sympathovagal balance. Artificial data andarrhythmic were excluded. Data analyses were performed with soft-ware Del Mar Avionics Accuplus 363, Irvine California, USA.Renal Doppler ultrasound was performed using a Toshiba AplioUltrasound System SSA-790 (Tokyo, Japan) equipped with convex 3.5-MHz probe. RI was calculated as (peak systolic frequency shift −minimum diastolic frequency shift) / peak systolic frequency shift.All the ultrasound examinations were performed by same blindedphysician in order to reduce variability in the assessment managementof the study.Thedatawereexpressedasmedianandrange.Multivariateanalysiswas applied for the estimation of relationship of HRV variables withrenal Doppler indices or disease variables. The Mann–Whitney U-testor Kruskal–Wallis was used to test differences between two individualstudy groups. Spearmans rank order correlation coefficient (r) wasused to test for an association between numerical variables. p-Valuesb0,05 were considered significant. Commercially software (SPSSversion 20.0) was used for statistical analysis.Nineteen scleroderma patients were enrolled in the current study.Median age of 45 years (range 23–58) and a median SSc duration of6,5 years (range 2–25) were investigated in the Clinical ImmunologyUnit-Scleroderma Center. Six patients had limited cutaneous SSc and

D-Lactic acidosis 25 years after bariatric surgery due to Salmonella enteritidis

D-Lactic acidosis is a rare complication that occurs in patients with short bowel syndrome due to surgical intestine resection for treatment of obesity. The clinical presentation is characterized by neurologic symptoms and high anion gap metabolic acidosis. The incidence of this syndrome is unknown, probably because of misdiagnosis and sometimes symptoms may be incorrectly attributed to other causes. Therapy is based on low carbohydrate diet, sodium bicarbonate intravenous, rehydratation, antiobiotics, and probiotics that only produce L-lactate. In the case we describe, D-lactic acidosis encephalopathy occurred 25 y after bypass jejunoileal, due to Salmonella enteriditis infection.

Diabetic Nephropathy: Focus on Current and Future Therapeutic Strategies.

BACKGROUNDnDiabetic nephropathy (DN) is currently the most common cause of end-stage renal disease (ESRD). Although nowadays much is known about its classification, pathogenesis, clinical manifestations and evolution, to date we are not yet able to stop the natural progression of nephropathy in diabetic patients.nnnMETHODSnTreatment options are: lifestyle change with close blood pressure monitoring and tight glycemic control. The most common therapies adopted for this condition are Angiotensing Converting Enzyme-inhibitors (ACEi). However these drugs are able to block the progression of renal damage only in a small proportion of patients. In the remaining, DN progresses and may evolve into ESRD.nnnCONCLUSIONnThe purpose of this review is to summarize the state of art of current novel therapeutic strategies to stem this debilitating kidney disease.

Clinical and histological outcome predictors in renal limited pauci-immune crescentic glomerulonephritis: A single centre experience

Renal-limited vasculitis is a pauci-immune crescentic glomerulonephritis with no signs of systemic involvement, representing one of the most common causes of rapidly progressive glomerulonephritis. The study aims to examine clinical and histological features in twenty-four patients with RLV diagnosed by the Nephrology Department of Sapienza University of Rome, Italy, evaluating the role of these parameters in predicting renal survival. Patients details, clinical and histological features and outcomes were recorded at the time of renal biopsy and over a mean follow-up period of 36±6 months. In our study, serum creatinine at presentation was significantly higher in patients who had a poor outcome than in those who survived with independent renal function (6.3±2.47 mg/dl vs 2.84±2.01 mg/dl, P= 0.002). The presence of C3c was found in the area of glomerular fibrinoid necrosis and in small arteries and arterioles with fibrinoid necrosis in 17 patients (P= 0.018). In conclusion, serum creatinine at presentation and focal C3c depositions in areas of glomerular and arteriolar fibrinoid necrosis were the best determinants of poor renal outcome, maybe underlining the pathogenic role of alternative pathway activation of complement system but also demonstrating the focal distribution of necrotizing lesions.

Correlation between intrarenal arterial stiffness and exercise tolerance in systemic sclerosis patients without renal and cardiopulmonary impairment: The role of the microvascular damage

Correlation between intrarenal arterial stiffness and exercise tolerance in systemic sclerosis patients without renal and cardiopulmonary impairment: The role of the microvascular damage Antonietta Gigante ⁎, Antonella Romaniello , Damiano Magri , Matteo Bonini , Biagio Barbano , Liborio Sardo , Silvia Quarta , Maria Anna Digiulio , Marcello Di Paolo , Rosario Cianci , Paolo Palange , Antonio Amoroso , Edoardo Rosato a

Evaluation of estimated glomerular filtration rate and clinical variables in systemic sclerosis patients.

OBJECTIVESnThe most important renal complication of systemic sclerosis (SSc) is scleroderma renal crisis (SRC). Many patients demonstrate less severe renal complications, most likely associated with reduced renal blood flow and a consequent reduction in glomerular filtration rate (GFR). The mechanism of this slowly progressive form of chronic renal disease is unclear. The aim of this study was to evaluate GFR by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and the 7-variable Modification of Diet and Renal Disease (MDRD) equations in SSc patients and to correlate estimated GFR (eGFR) with clinical variables of the disease.nnnMETHODSn105 unselected and consecutive patients with SSc were enrolled. Serum creatinine was measured in all patients and GFR was estimated by 7-variable MDRD and CKD-EPI equations. Nailfold videocapillaroscopy was performed in all patients.nnnRESULTSnThe mean value of eGFR evaluated by both 7-variable MDRD and CKD-EPI was significantly different (p < 0.0001) in the three capillaroscopic groups and correlated negatively with the severity of capillaroscopic damage (early: 95 ± 16 mL/min and 101 ± 12 mL/min, active: 86 ± 25 mL/min and 95 ± 17 mL/min, late: 76 ± 21 mL/min and 82 ± 21 mL/min). The mean value of eGFR evaluated by 7-variable MDRD (97 ± 23 mL/min vs. 74 ± 15 mL/min, p < 0.0001) and CKD-EPI< (0.83 ± 0.20 mL/min vs. 0.68 ± 0.10 mL/min, p < 0.0001) was significantly higher in SSc patients without history of digital ulcers than in those with.nnnCONCLUSIONnWe can conclude that in SSc patients without renal involvement, eGFR decreases with the progression of digital vascular damage.

Exome sequencing in children of women with skewed X-inactivation identifies atypical cases and complex phenotypes

BACKGROUNDnMore than 100 X-linked intellectual disability (X-LID) genes have been identified to be involved in 10-15% of intellectual disability (ID).nnnMETHODnTo identify novel possible candidates, we selected 18 families with a male proband affected by isolated or syndromic ID. Pedigree and/or clinical presentation suggested an X-LID disorder. After exclusion of known genetic diseases, we identified seven cases whose mother showed a skewed X-inactivation (>80%) that underwent whole exome sequencing (WES, 50X average depth).nnnRESULTSnWES allowed to solve the genetic basis in four cases, two of which (Coffin-Lowry syndrome, RPS6K3 gene; ATRX syndrome, ATRX gene) had been missed by previous clinical/genetics tests. One further ATRX case showed a complex phenotype including pontocerebellar atrophy (PCA), possibly associated to an unidentified PCA gene mutation. In a case with suspected Lujan-Fryns syndrome, a c.649C>T (p.Pro217Ser) MECP2 missense change was identified, likely explaining the neurological impairment, but not the marfanoid features, which were possibly associated to the p.Thr1020Ala variant in fibrillin 1. Finally, a c.707T>G variant (p.Phe236Cys) in the DMD gene was identified in a patient retrospectively recognized to be affected by Becker muscular dystrophy (BMD, OMIM 300376).nnnCONCLUSIONnOverall, our data show that WES may give hints to solve complex ID phenotypes with a likely X-linked transmission, and that a significant proportion of these orphan conditions might result from concomitant mutations affecting different clinically associated genes.