Gisela Schieren

High-dose cholecalciferol to correct vitamin D deficiency in haemodialysis patients

BACKGROUND Vitamin D has emerged as an important survival factor in patients with chronic kidney disease. Non-activated vitamin D may also have beneficial effects on bone, cardiovascular and immune functions. Cholecalciferol is the prevalent non-activated vitamin D in Europe, but there is no valid prospective data available about its use in haemodialysis patients. Thus, we initiated a prospective study to evaluate dosing, safety and tolerability of cholecalciferol supplementation in haemodialysis patients. METHODS The prospective study included 64 haemodialysis patients. During replenishment phase patients received 20 000 IU cholecalciferol/week for 9 months. In the open maintenance phase (15 months), patients were randomized to a treated group (20 000 IU cholecalciferol/month) and an untreated group, which did not receive cholecalciferol. RESULTS Calcidiol [25(OH)D] deficiency (<37.5 nmol/l; <15 microg/l) was detected in 61/64 patients (95%). During the replenishment phase, calcidiol increased significantly from 16.65 +/- 9.6 to 79.48 +/- 27.15 nmol/l (6.66 +/- 3.84 microug/l to 31.79 +/- 10.86 microg/l) (P < 0.001). Recommended levels (>75 nmol/l; >30 microg/l; K/DOQI) were achieved in 57% of patients. Calcium increased from 2.28 +/- 0.17 to 2.37 +/- 0.19 mmol/l (9.1 +/- 0.69 mg/dl to 9.49 +/- 0.75 mg/dl) (P<0.01). Phosphorus, calcium-phosphorus product and parathyroid hormone showed no significant changes. Fifty-nine patients progressed to the maintenance phase. Analysis per protocol showed a significant drop of calcidiol in the treated [83.98 +/- 31.73 versus 78.5 +/- 38.75 nmol/l (33.59 +/- 12.69 versus 31.4 +/- 15.5 microg/l) (P < 0.001)] and untreated groups [86.35 +/- 40.75 versus 53.4 +/- 26.2 nmol/l (34.54 +/- 16.3 versus 21.36 +/- 10.48 microg/l) (P < 0.001)]. The comparison of the treated and the untreated groups showed no significant differences at the beginning of the maintenance phase: 83.98 +/- 31.73 versus 86.35 +/- 40.75 nmol/l (33.59 +/- 12.69 versus 34.54 +/- 16.3 microg/l). At the end they differed significantly: 78.5 +/- 38.75 versus 53.4 +/- 26.2 nmol/l (31.4 +/- 15.5 versus 21.36 +/- 10.48 microg/l) (P < 0.001). CONCLUSION Vitamin D deficiency is present in a majority of haemodialysis patients. Supplementation with cholecalciferol is safe, well tolerated and reasonable to replenish vitamin D stores in haemodialysis patients. However, only 57% of patients achieved recommended calcidiol levels, thus favouring additional dose-finding studies.

Methylated APC and GSTP1 genes in serum DNA correlate with the presence of circulating blood tumor cells and are associated with a more aggressive and advanced breast cancer disease.

BackgroundTumor-related methylated DNA and circulating tumor cells (CTC) in the peripheral blood might be of prognostic importance in breast cancer. Thus, the aim of our study was to examine free methylated DNA and CTC in the blood from breast cancer patients and to correlate it with clinicopathological features known to influence prognosis.Materials and methodsWe prospectively obtained serum samples from 85 patients with breast cancer and 22 healthy volunteers. Sera were analysed by methylation specific PCR (MethyLight PCR) for five genes: adenomatous polyposis coli (APC), ras association domain family protein 1A (RASSF1A), estrogen receptor 1 (ESR1), CDKN2A (p16) and glutathione s-transferase pi 1 (GSTP1). Beta actin (ACTB) served as control. In parallel matched peripheral blood of 63 patients was used to assay for circulating tumor cells in the peripheral blood by a modified immunomagnetic AdnaTest BreastCancerSelect with PCR detection for EPCAM, MUC1, MGB1 and SPDEF.ResultsWe found a hypermethylation in the APC gene in 29% (25/85), in RASSF1A in 26% (22/85), in GSTP1 in 18% (14/76) and in ESR1 in 38% (32/85) of all breast cancer patients. No hypermethylation of CDKN2A was found (0/25). Blood samples of patients were defined CTC positive by detecting the EPCAM 13% (8/63), MUC1 16% (10/63), MGB 9% (5/55), SPDEF 12% (7/58) and in 27% detecting one or more genes (15/55). A significant difference was seen in methylated APC DNA between cancer patients and healthy volunteers. Moreover, methylated APC, RASSF1 and CTC were significantly different in metastatic versus non-metastatic disease. In addition, the presence of methylated APC, RASSF1A and CTC correlated significantly with AJCC-staging (p = 0.001, p = 0.031 and 0.002, respectively). High incidences of methylations were found for the genes RASSF1 and ESR1 in healthy individuals (both 23% 5/22). Methylated GSTP1 was predominantly found in the serum of patients with large primaries (p = 0.023) and was highly significantly correlated with positive Her2/neu status (p = 0.003). Elevated serum CA15.3 was strongly correlated with methylated APC and CTC detection (both p = 0.000). Methylated ESR1 failed to exhibit significant correlations with any of the above mentioned parameters. The presence of CTC in peripheral blood was significantly associated with methylated APC (p = 0.012) and methylated GSTP1 (p = 0.001).ConclusionThe detection of methylated APC and GSTP1 DNA in serum correlated with the presence of CTC in the blood of breast cancer patients. Both methylated DNA and CTC correlated with a more aggressive tumor biology and advanced disease.

Nephrogenic systemic fibrosis--a rapidly progressive disabling disease with limited therapeutic options.

BACKGROUND Nephrogenic systemic fibrosis (NSF) affects some patients on dialysis after gadolinium contrast agent-enhanced magnetic resonance imaging. It is characterized by progressive skin fibrosis of the extremities, sometimes including the trunk and internal organs. METHODS The clinical course of 10 patients with biopsy-proven NSF was analyzed retrospectively with regard to gadolinium exposition, disease onset, and progression of NSF with special emphasis on physical mobility and impact of different therapeutic approaches. RESULTS Despite physiotherapy and different additional therapeutic approaches (eg, immunosuppression, ultraviolet A-1 phototherapy, or extracorporal photopheresis) all patients developed progressive skin fibrosis of the lower extremities, sometimes including the trunk and arms. Kidney transplantation led to a slow improvement of skin lesions in one patient. Nine patients developed progressive joint contractures, and 8 patients became wheelchair bound within 12 months after disease onset and became dependent on the support of family members or a nursing service. LIMITATIONS Retrospective analysis in a relatively small number of patients is a limitation. CONCLUSION NSF appears to be a rapidly progressive disabling disease with limited therapeutic options.

Cystatin C - a fast and reliable biomarker for glomerular filtration rate in head and neck cancer patients.

Purpose:Determination of renal function is a prerequisite for planning therapy in cancer patients. Limitations of creatinine as marker for the glomerular filtration rate (GFR) led to the proposal of cystatin C as a more accurate biomarker especially in mild renal insufficiency or in patients with low muscle mass. We compared the accuracy of cystatin C- and creatinine-based equations to estimate GFR in head and neck cancer (HNC) patients receiving platinum-based radiochemotherapy.Patients and Methods:The study population consisted of 52 HNC patients (GFR range, 37–105 mL/min/1.73 m2 complemented by 17 patients with known renal insufficiency (GFR range, 10–60 mL/min/1.73 m2). Intraclass correlation coefficients were calculated between the reference method (51)Cr-EDTA clearance and estimated GFR by creatinine clearance and equations based on creatinine (Cockroft-Gault, modification of diet in renal disease (MDRD), Wright) or cystatin C (Larsson, Dade-Behring, Hoek). In addition, sensitivity and specificity to discriminate GFR > 60 mL/min/1.73 m2 were evaluated by receiver operating characteristic curve (ROC).Results:The highest correlation coefficients were found for the cystatin C-based estimates in comparison with creatinine-based estimates or creatinine clearance, even though Bland-Altman plots revealed GFR overestimation for all equations tested. The cystatin C-based Hoek formula exhibited the highest overall precision and accuracy. GFR of < 60 mL/min/1.73 m2 was assumed as a cut-off for chemotherapy. ROC analyses revealed the highest AUC to predict a GFR > 60 mL/min/1.73 m2 for the creatinine-based Wright formula, closely followed by the MDRD formula and cystatin C-based equations of Larsson, Dade-Behring, and Hoek.Conclusion:Cystatin C-based GFR estimates showed the overall strongest correlation to the reference method. Thus, we recommend cystatin C for GFR estimation in HNC patients as an alternative method to the estimated creatinine clearance in clinical practice.ZusammenfassungZielsetzung:Bei Tumorpatienten ist die exakte Bestimmung der Nierenfunktion eine wichtige Voraussetzung für die individuelle Therapieplanung. Die Aussagefähigkeit des Serumkreatinins als Marker der glomerulären Filtrationsrate (GFR) ist jedoch limitiert aufgrund seiner Abhängigkeit von der Muskelmasse sowie fehlendem Anstieg der Serumkonzentration bei einer GFR > 60 ml/ min/1,73 m2. Cystatin C wird als sensitiverer Parameter für das Vorliegen einer Niereninsuffizienz in den Frühstadien sowie bei Muskelschwachen Patienten diskutiert. In der vorliegenden Studie wurde die Präzision von Cystatin-C-basierten sowie Kreatinin-basierten Formeln zur Berechung der GFR in Kopf-Hals-Tumorpatienten verglichen.Patienten und Methodik:Die Studienkohorte bestand aus 52 Kopf-Hals-Tumorpatienten (GFR 37–105 mL/min/1,73 m2) sowie 17 Patienten mit bekannter Niereninsuffizienz Stadium 3–5 (GFR 10–60 mL/min/1,73 m2). Es wurde der Intra-Class-Correlation factor berechnet zwischen der Referenzmethode (51)Cr-EDTA-Clearance und der Kreatinin-Clearance, den Kreatinin-basierten Formeln (Cockroft-Gault, Modified Diet in Renal Disease, Wright) und den Cystatin-C-basierten Formeln (Larsson, Dade-Behring, Hoek) zur GFR-Berechnung. Zusätzlich ermittelten wir Sensitivität und Spezifität der verschiedenen Clearance-Bestimmungen zur Erkennung einer GFR > 60 ml/min/1,73 m2 mittels Receiver Operating Characteristic Curve (ROC).Ergebnisse:Die beste Korrelation zur Referenzmethode wurde für die Cystatin-C-basierten Formeln zur GFR-Bestimmung im Vergleich zu Kreatinin-basierten Formeln oder der Kreatinin-Clearance ermittelt. Jedoch zeigte der Bland-Altman-Plot, dass im Vergleich zur Referenzmethode alle Formeln – sowohl Cystatin-C- als auch Kreatinin-basiert – die Nierenfunktion überschätzen. Die höchste Genauigkeit und Präzision wurde bei der Hoek-Formel beobachtet. Da eine GFR < 60 ml/min/1,73 m2 häufig als Grenze angesehen wird zur Durchführung einer Chemotherapie, ermittelten wir die Präzision, mit der die verschiedenen GFR-Bestimmungen dies für den Einzelnen voraussagen konnten. Bei der ROC-Analyse zeigte die Kreatinin-basierte Formel nach Wright die höchste Area Under the Curve, dicht gefolgt von der Modified-Diet-in-Renal-Disease-Formel und den Cystatin-C-basierten Formeln nach Larsson, Dade-Behring und Hoek.Schlussfolgerung:Die Cystatin-C-basierten Formeln zur GFR-Berechnung zeigten insgesamt die beste Präzision und Korrelation zur Referenzmethode in Kopf-Hals-Tumorpatienten. Daher empfehlen wir Cystatin-C-basierte Formeln zur GFR-Berechnung im klinischen Alltag bei diesen Patienten.

C-Reactive Protein Levels and Clinical Symptoms Following Gadolinium Administration in Hemodialysis Patients

BACKGROUND Until recently, gadolinium (Gd)-enhanced magnetic resonance imaging (MRI) has increasingly replaced iodinated contrast agent examinations in dialysis patients, although only limited data existed about the clinical safety of Gd contrast agents in these patients. Specific clinical adverse events (AEs), including nephrogenic systemic fibrosis, were linked to Gd exposure in dialysis patients. An inflammatory reaction or transmetallation may be involved. STUDY DESIGN Secondary analysis of a 5-day observational study in a parent cardiovascular study with repetitive cardiac MRI (32 patients) and patients undergoing Gd-enhanced MRI for clinical indications (6 patients). Clinical information and samples were obtained according to parent protocol. SETTING & PARTICIPANTS Dialysis patients at a university-based dialysis unit. PREDICTOR Gd-chelate complex. 37 of 38 patients underwent 64 MRI studies with Gd-diethylenetriamine penta-acetic acid (Gd-DTPA). 25 of these patients underwent additional MRI studies with gadobutrol (n = 10), 0.9% saline (n = 7), or both (n = 8), and 1 patient received gadobutrol only. OUTCOMES Clinical adverse events; C-reactive protein (CRP) levels on days 1, 3, and 5 after MRI; Gd levels in blood and urine after MRI. RESULTS CRP levels increased 10-fold on day 3 after MRI in 87% of MRI studies with Gd-DTPA (+59.3 +/- 57.9 mg/L [P < 0.001] versus -0.9 +/- 3.7 mg/L with gadobutrol versus -0.9 +/- 8.5 mg/L with 0.9% saline). 77 mild to moderate and 3 serious AEs were observed in 24 patients. CRP levels and adverse events did not correlate with Gd blood concentrations. CRP level increase or AEs were not observed after MRI with gadobutrol or 0.9% saline. LIMITATIONS Observational study without randomization, risk of bias because of multiple MRI studies in a limited patient cohort. CONCLUSION Gd-DTPA, but not gadobutrol, induces an acute-phase reaction and clinical AEs in dialysis patients. Additional investigations have to analyze the underlying pathomechanism.

Decorin is significantly overexpressed in nephrogenic systemic fibrosis.

The role of the proteoglycans in the pathogenesis of nephrogenic systemic fibrosis (NSF) is unclear. We assessed expression of decorin, versican, and transforming growth factor beta1 (TGF-beta1) in skin specimens of 10 patients with biopsy-proven NSF and different control groups. Real-time reverse transcription-polymerase chain reaction studies and immunohistochemical analysis were performed on full-thickness skin specimens. The messenger RNA (mRNA) and protein levels of decorin were significantly higher in the skin lesions of patients with NSF than in skin lesions of patients with systemic sclerosis, patients undergoing hemodialysis, and healthy subjects. The versican mRNA levels in NSF lesions differed significantly only from the levels in healthy subjects. TGF-beta1 mRNA expression was significantly overexpressed in NSF lesions compared with control skin specimens investigated. In NSF specimens, the mRNA expression of TGF-beta1 and decorin were highly correlated (r = 0.92). Our results suggest that decorin and TGF-beta1 may have a fundamental role in the pathogenesis of NSF. Conversely, versican seems less likely to be of pathogenetic significance in NSF.

Balance of Profibrotic and Antifibroting Signaling in Nephrogenic Systemic Fibrosis Skin Lesions

BACKGROUND Nephrogenic systemic fibrosis (NSF) is an uncommon fibrotic disorder occurring after administration of linear gadolinium contrast agents in patients with severely decreased kidney function. The underlying pathogenetic mechanism of fibrosis remains to be elucidated. Transforming growth factor beta (TGF-beta), a key player in the pathogenesis of fibrotic disorders, has been found to be overexpressed in NSF skin lesions. The aim of this study is to analyze the TGF-beta-SMAD-connective tissue growth factor (CTGF) axis in NSF skin lesions compared with skin specimens from patients with systemic sclerosis, hemodialysis patients without NSF, and healthy controls. Additionally, expression of tissue inhibitor of metalloproteinase 1 (TIMP-1) and antifibrotic tumor necrosis factor alpha (TNF-alpha) were examined. STUDY DESIGN Observational study. SETTING & PARTICIPANTS Full-thickness skin biopsy specimens from fibrotic lesions or healthy skin were obtained from 10 patients with NSF, 16 patients with systemic sclerosis, 8 non-NSF hemodialysis patients, and 17 healthy participants. PREDICTOR Patient diagnosis of NSF, systemic sclerosis, non-NSF hemodialysis patients, and healthy participants, as defined using skin biopsy. OUTCOME & MEASUREMENTS Dermal messenger RNA and protein expression of profibrotic TGF-beta, SMAD2, SMAD3, SMAD4, SMAD7, CTGF, TIMP-1, antifibrotic SMAD7, and TNF-alpha were analyzed using real-time reverse transcription-polymerase chain reaction and immunohistologic examination on formalin-embedded tissue. RESULTS Dermal expression of nearly all parameters differed in hemodialysis patients compared with healthy controls. In comparison to hemodialysis patients and healthy participants, we found increased messenger RNA levels for TGF-beta, the profibrotic receptor-activated SMAD2 and SMAD3, CTGF, and TIMP-1 in NSF and systemic sclerosis lesions. Few differences between NSF and non-NSF hemodialysis patients were observed for common SMAD4, inhibitory SMAD7, and TNF-alpha. LIMITATIONS Small patient cohort. CONCLUSION Our results suggest a profibrotic imbalance in the TGF-beta-SMAD-CTGF axis in NSF skin lesions. Significantly increased dermal expression of TGF-beta and TIMP-1 in non-NSF hemodialysis patients in comparison to healthy participants emphasizes the need for a hemodialysis control group for future investigations and suggests a pre-existing profibrotic situation in the skin of hemodialysis patients.

Severe everolimus-induced steatohepatis: a case report

The mammalian target of rapamycin inhibitors are normally favored as immunosuppressant agents for solid organ transplantation such as kidney, liver or heart. Only in recent years have they been increasingly administered for the treatment of neuroendocrine tumors. Even though mammalian target of rapamycin inhibitors are known to exhibit specific side effects, everolimus-related severe hepatic steatosis has not as yet been described in the literature. We report the case of a 76-year-old man who developed severe hepatic steatosis within four weeks of treatment with everolimus as concomitant tumor therapy for a progressively growing neuroendocrine carcinoma of the ileum. A diagnosis of hepatic steatosis was established using computer tomography and fibroscan©. Other underlying causes for steatosis hepatis could be excluded. Further studies are warranted to explain the underlying mechanisms.

Detection of clonal T cells in the circulation of patients with nephrogenic systemic fibrosis.

BACKGROUND Nephrogenic systemic fibrosis is a sclerodermalike disease in patients with acute or chronic renal insuffiency related to administration of gadolinium-containing contrast agents. Previous studies have demonstrated clonal T-cell populations in the blood of patients with systemic sclerosis, suggesting that these cells may be involved in the pathogenesis of the disease. Facing the clinical similarities of both diseases, we hypothesized that clonal expansion of T cells could be present in nephrogenic systemic fibrosis as well. OBSERVATIONS Findings from polymerase chain reaction and high-resolution capillary electrophoresis for T-cell receptor gamma gene rearrangement analysis showed that all 6 prospectively evaluated patients (100%) with nephrogenic systemic fibrosis had detectable clonal T cells in their peripheral blood. In contrast, only 4 of the 15 control patients (27%) with chronic renal failure and none of the 12 healthy individuals analyzed in this study had evidence for T-cell clonality using the same type of examination. Clonal T-cell-positive patients with systemic sclerosis have previously been reported to better respond to extracorporeal photopheresis. However, this was not the case in 2 of our patients with nephrogenic systemic fibrosis. Conclusion As in systemic sclerosis, clonally expanded T-cell populations could play a critical role in the pathogenesis of nephrogenic systemic fibrosis, probably as an in vivo-activated inflammatory response to gadolinium exposure.

Fulminant staphylococcus lugdunensis septicaemia following a pelvic varicella-zoster virus infection in an immune-deficient patient: a case report.

IntroductionThe deadly threat of systemic infections with coagulase negative Staphylococcus lugdunensis despite an appropriate antibiotic therapy has only recently been recognized. The predominant infectious focus observed so far is left-sided native heart valve endocarditis, but bone and soft tissue infections, septicaemia and vascular catheter-related bloodstream infections have also been reported. We present a patient with a fatal Staphylococcus lugdunensis septicaemia following zoster bacterial superinfection of the pelvic region.Case presentationA 71-year old male diagnosed with IgG kappa plasmocytoma presented with a conspicuous weight loss, a hypercalcaemic crisis and acute renal failure. After initiation of haemodialysis treatment his condition improved rapidly. However, he developed a varicella-zoster virus infection of the twelfth thoracic dermatome requiring intravenous acyclovir treatment. Four days later the patient presented with a fulminant septicaemia. Despite an early intravenous antibiotic therapy with ciprofloxacin, piperacillin/combactam and vancomycin the patient died within 48 hours, shortly before the infective isolate was identified as Staphylococcus lugdunensis by polymerase chain reaction.ConclusionDespite S. lugdunensis belonging to the family of coagulase-negative staphylococci with an usually low virulence, infections with S. lugdunensis may be associated with an aggressive course and high mortality. This is the first report on a Staphylococcus lugdunensis septicaemia following a zoster bacterial superinfection of the pelvic region.