Mark Dominik Alscher

Fibrogenic Growth Factors in Encapsulating Peritoneal Sclerosis

Background: Increased local levels of fibrogenic growth hormones contribute substantially to the process of encapsulating peritoneal sclerosis (EPS) in animal models. Methods: We analyzed probes from patients with normal kidney function (n = 10), with normal kidney function and inflammation (n = 10), on PD without (n = 10) and with EPS (n = 9). We investigated the degree of fibrosis and the number of vessels and vasculopathy. Additionally, we investigated the expression of NFκB, TGFβ1, TGFβ1 receptor, TGFβ2, TGFβ2 receptor, FGF-BP, CTGF and VEGF by immunohistochemistry. Results: In EPS, we found an exclusive upregulation of VEGF (normal 0, appendicitis 1.0 ± 1.2, PD 1.7 ± 1.8 and EPS 5.7 ± 4.4; p < 0.0001), whereas in PD, CTGF was significantly increased (normal 6.0 ± 2.8, appendicitis 7.3 ± 2.5, PD 10.0 ± 1.8 and EPS 7.3 ± 2.1; p = 0.0059). The results for the TGFβ system and NFκB were not uniform, in EPS no increases were demonstrable. Vasculopathy was significantly more pronounced in EPS (normal 0.4 ± 0.5, appendicitis 0.2 ± 0.3, PD 1.0 ± 0.7 and EPS 1.6 ± 1.2; p < 0.0001) than in PD or inflammation (normal 30 ± 16, appendicitis 82 ± 48, PD 1,936 ± 952 and EPS 2,613 ± 1,209; p < 0.0001), whereas the density of vessels were decreased (normal 125 ± 114, appendicitis 817 ± 347, PD 81 ± 57 and EPS 36 ± 33; p < 0.0001). Conclusions: The process of EPS was associated with increased VEGF in the peritoneum. The reduced density of vessels compared with marked fibrosis could point to hypoxia as an inducer.

Association of Renal Stress/Damage and Filtration Biomarkers with Subsequent AKI during Hospitalization among Patients Presenting to the Emergency Department

BACKGROUND AND OBJECTIVESnEmergency departments (EDs) have a growing role in hospital admissions, but few studies address AKI biomarkers in the ED.nnnDESIGN, SETTING, PARTICIPANTS, & MEASUREMENTSnPatients admitted to the internal medicine service were enrolled during initial workup in the ED at Robert-Bosch-Hospital, Stuttgart, Germany. Daily serum creatinine (sCr) and urine output (UO) were recorded for AKI classification by Kidney Disease Improving Global Outcomes (KDIGO) criteria. Cystatin C, kidney injury molecule-1, liver-type fatty acid-binding protein, and neutrophil gelatinase-associated lipocalin were measured in blood and urine, and IL-18, insulin-like growth factor-binding protein 7 (IGFBP7), tissue inhibitor of metalloproteinases-2 (TIMP-2) and [TIMP-2]⋅[IGFBP7] were measured in urine collected at enrollment, after 6 hours, and the following morning. Association between these biomarkers and the end point of moderate-severe AKI (KDIGO stage 2-3) occurring within 12 hours of each sample collection was examined using generalized estimating equation logistic regression. Performance for prediction of the AKI end point using two previously validated [TIMP-2]-[IGFBP7] cutoffs was also tested.nnnRESULTSnOf 400 enrolled patients, 298 had sufficient sCr and UO data for classification by KDIGO AKI criteria: AKI stage 2 developed in 37 patients and AKI stage 3 in nine patients. All urinary biomarkers, sCr, and plasma cystatin C had statistically significant (P<0.05) odds ratios (ORs) for the AKI end point. In a multivariable model of the urine biomarkers and sCr, only [TIMP-2]⋅[IGFBP7] and sCr had statistically significant ORs. Compared with [TIMP-2]⋅[IGFBP7]<0.3 (ng/ml)(2)/1000, values between 0.3 and 2.0 (ng/ml)(2)/1000 indicated 2.5 (95% confidence interval [95% CI], 1.1 to 5.2) times the odds for the AKI end point and values >2.0 (ng/ml)(2)/1000 indicated 11.0 (95% CI, 4.4 to 26.9) times the odds. Addition of [TIMP-2]⋅[IGFBP7] to a clinical model significantly improved area under the receiver-operating characteristic curve from 0.67 (95% CI, 0.61 to 0.78) to 0.77 (95% CI, 0.72 to 0.86) (P<0.001); however, including both markers in the model was not significantly different from including either marker alone.nnnCONCLUSIONSnUrinary [TIMP-2]⋅[IGFBP7] with pre-established cutoffs provides valuable information about risk for imminent AKI in the ED that is complementary to sCr and clinical risk factors.

Severe thrombocytopenia in hantavirus-induced nephropathia epidemica

Nephropathia epidemica is a milder form of hemorrhagic fever with renal syndrome, caused by Puumala virus. The clinical picture is characterized by a rapid loss of renal function (acute kidney injury) and thrombocytopenia. The purpose of the current analysis was to compare the clinical course of patients presenting with or without severe thrombocytopenia. In 47 out of 456 patients with acute nephropathia epidemica, the nadir count of thrombocytes was available for the acute course of the disease. The clinical course of these patients was further analyzed. No major bleeding (e.g., intracranial bleeding or gastrointestinal bleeding) occurred in either group. Creatinine peak levels were higher and proteinuria was more frequently present in the severely thrombocytopenic group. In conclusion, severe thrombocytopenia is common in nephropathia epidemica and is associated with a more severe course of the disease; however, bleeding complications are rare.

Risk factors predicting the successful function and use of autogenous arteriovenous fistulae for hemodialysis.

BACKGROUNDnFor patients with end-stage renal failure hemodialysis with an autogenous arteriovenous fistula (AVF) has proven to be the ideal vascular access.nnnOBJECTIVEnThe aim of this study is to discover potential predictors of a well-functioning hemodialysis fistula.nnnMETHODSnFrom December 2009 to March 2011, 80 patients undergoing first time AVF creation were enrolled in our retrospective study. We analyzed pre- and postoperative vessel diameters and flow characteristics gained by duplex ultrasonography (DUS) and intraoperative ultrasound transit-time flow measurements regarding intraoperative blood flow and pulsatility index (PI). Follow-up was defined until the end of the first month with regular hemodialysis, 10 weeks after AVF creation. We performed statistical analyses by employing Spearman correlation, t test, analysis of variance, χ2 test, and receiver operating characteristics (ROC).nnnRESULTSnAt the end of the follow-up, 62 patients (78%) featured functioning AVFs and 18 patients (22%) featured nonfunctioning AVFs. Factors influencing AVF function were radial artery diameter (χ2 = 5.23, p = 0.02), intraoperative flow (χ2 = 7.09, p = 0.01), intraoperative PI (χ2 = 6.5, p = 0.01), and postoperative flow (χ2 = 16.29, p = 0.01). According to the ROC analyses, we could develop cut-off values for predicting an ideal AVF function: radial artery diameter more than 2.3 mm, cephalic vein diameter more than 2.7 mm, intraoperative mean flow more than 113 mL/min, PI less than 1.4, and postoperative mean flow more than 160 mL/min.nnnCONCLUSIONnIntraoperative ultrasound transit-time flow measurements gained at surgery and postoperative follow-up with DUS can help identify AVFs that are unlikely to function and therefore need early intervention.

TKTL-1 expression in lung cancer.

Study of the physiological changes associated with the development of malignancy demonstrates a metabolic signature for the different stages of tumorigenesis. Increased glucose uptake and lactate production have been detected during malignant transformation. Based on energy production, malignancies can be divided into two subclasses: (a) tumor cells which use the mitochondrial machinery for ATP synthesis, and (b) tumor cells which generate ATP by glucose fermentation and lactate production even in the presence of oxygen (aerobic glycolysis). Recently, transketolase-like protein 1 (TKTL1) gene expression has been shown to contribute to carcinogenesis through increased aerobic glycolysis and hypoxia-inducible factor alpha stabilization. In the present study, 197 patients suffering from lung cancer were investigated by immunohistochemistry for the presence of TKTL1 protein expression. We detected: (1) moderate to strong TKTL1 expression (immune reactive score>100) in 39.1% of the investigated lung cancer patients; (2) a complete lack of TKTL1 by immunohistochemistry in 12.7% of lung cancer cases, with small cell lung cancer (SCLC) being most frequent in this subgroup; (3) no correlation of TKTL1 with overall survival, disease-free survival, any of the established variables of the TNM system, grading, stage, smoking status, or gender. Based on this data, we conclude that TKTL1 could be a target protein for improved therapeutic strategies in some cases of lung cancer.

Urinary [TIMP-2] × [IGFBP7] for risk prediction of acute kidney injury in decompensated heart failure

In acute decompensated heart failure (ADHF) the risk of acute kidney injury (AKI) is high. Early detection of patients at risk for AKI is important. We tested urinary [TIMP‐2]u2009×u2009[IGFBP7], a new US Food and Drug Administration–cleared test to assess AKI risk, in a cohort of hospitalized ADHF patients.

Hantavirus and acute appendicitis—The diagnosis behind the diagnosis?

A 33-year-old man with a history of acute lower abdominal pain was admitted to the emergency room. After laparoscopic appendectomy and pathological confirmed acute appendicitis the patient developed thrombocytopenia and acute renal failure. Serological testing for hantaviruses revealed a positive result for PUUV IgG and IgM. Immunohistochemical work-up detected PUUV antigen in endothelial cells of capillaries and larger vessels. The high percentage of patients with hantavirus infection and severe abdominal pain is remarkable and, up to now, unexplained. To our knowledge this is the first report demonstrating PUUV antigen in the human intestine. Further studies are warranted whether hantaviruses are setting the stage for a secondary bacterial infection or cause an inflammation itself.

Renal effects of metallothionein induction by zinc in vitro and in vivo

AbstractBackgroundMetallothionein (MTT) is an endogenous antioxidant that can be induced by both zinc (Zn) and ischemia. In kidneys, increased MTT expression exerts a putative protective role in diabetes and hypoxia. Our goal was to further investigate the behavior of MTT under the influence of Zn and hypoxia in vitro and in vivo.MethodsMTT expression was measured in vitro in cell cultures of proximal tubular cells (LCC-PK1) by immune-histochemistry and real-time PCR after incubation with increasing concentrations of Zn under hypoxic and non-hypoxic conditions. In addition, in vivo studies were carried out in 54 patients to study MTT induction through Zn. This is a sub-study of a prospective, randomized, double-blind trial on prevention of contrast-media-induced nephropathy using Placebo, Zn and N-Acetylcysteine. Blood samples were obtained before and after 2xa0days p.o. treatment with or without Zn (60xa0mg). ELISA-based MTT level measurements were done to evaluate the effects of Zn administration. For in vivo analysis, we considered the ratio of MTT to baseline MTT (MTT1/MTT0) and the ratio of eGFR (eGFR1/eGFR0), correspondingly.ResultsIn vitro quantitative immuno-histochemical analysis (IHC) and real-time PCR showed that at increasing levels of Zn (5, 10, and 15xa0μg/ml) led to a progressive increase of MTTs: Median (IQR) expression of IHC also increased progressively from 0.10 (0.09–0.12), 0.15 (0.12–0.18), 0.25 (0.25–0.27), 0.59 (0.48–0.70) (pu2009<u20090.0001). Median (IQR) expression of PCR: 0.59 (0.51–1.72), 1.62 (1.38–4.70), 3.58 (3.06–10.42) and 10.81 (9.24–31.47) (pu2009<u20090.0001). In contrast, hypoxia did not change MTT-levels in vitro (pu2009>u20090.05).n In vivo no significant differences (pu2009=u20090.96) occurred in MTT-levels after 2xa0days of Zn administration compared with no Zn intake. Nevertheless, there was a significant correlation between MTT (MTT1/MTT0) and eGFR (eGFR1/eGFR0) in case of Zn administration (rhou2009=u2009−0.49; 95%-CI: −0.78 to −0.03; pu2009=u20090.04).ConclusionsWe found that Zn did induce MTTs in vitro, whereas hypoxia had no significant impact. In contrast, no significant increase of MTTs was detected after in vivo administration of Zn. However, there was a significant negative correlation between MTT and eGFR in vivo in case of Zn administration, this could indicate a protective role of MTTs in a setting of reduced kidney function, which is possibly influenced by Zn.Trial registrationClinicalTrials.gov Identifier: NCT00399256. Retrospectively registered 11/13/2006.

Remote Patient Management for Home Dialysis Patients

Remote patient management (RPM) offers renal health care providers and patients with end-stage kidney disease opportunities to embrace home dialysis therapies with greater confidence and the potential to obtain better clinical outcomes. Barriers and evidence required to increase adoption of RPM by the nephrology community need to be clearly defined. Ten health care providers from specialties including nephrology, cardiology, pediatrics, epidemiology, nursing, and health informatics with experience in home dialysis and the use of RPM systems gathered in Vienna, Austria to discuss opportunities for, barriers to, and system requirements of RPM as it applies to the home dialysis patient. Although improved outcomes and cost-effectiveness of RPM have been demonstrated in patients with diabetes mellitus and heart disease, only observational data on RPM have been gathered in patients on dialysis. The current review focused on RPM systems currently in use, on how RPM should be integrated into future care, and on the evidence needed for optimized implementation to improve clinical and economic outcomes. Randomized controlled trials and/or large observational studies could inform the most effective and economical use of RPM in home dialysis. These studies are needed to establish the value of existing and/or future RPM models among patients, policy makers, and health care providers.

Ethylene glycol poisoning: a rare but life-threatening cause of metabolic acidosis—a single-centre experience

Background. Intoxication with ethylene glycol happen all around the world and without rapid recognition and early treatment, mortality from this is high. Methods. In our study, we retrospectively analysed six cases of ethylene glycol intoxication in our department. We measured ethylene glycol or glycolate levels, lactate levels and calculated the osmolal and anion gap. Results. Data from six patients admitted to the nephrology department between 1999 and 2011 with ethylene glycol poisoning are reported. All patients were men. The mean pH on admission was 7.15 ± 0.20 and the anion and osmolal gap were elevated in five of six patients. Four patients had an acute kidney injury and one patient had an acute-on-chronic kidney injury. All patients survived and after being discharged, two patients required chronic intermittent haemodialysis. Interestingly, at the time of admission, all patients had elevated lactate levels but there was no linear regression between toxic levels and lactate levels and no linear correlation was found between initial lactate levels and anion gap and osmolal gap. Conclusions. The initial diagnosis of ethylene glycol poisoning is difficult and poisoning with ethylene glycol is rare but life threatening and needs rapid recognition and early treatment. Therefore, intoxication with ethylene glycol should not be misdiagnosed as lactic acidosis in patients with metabolic acidosis and elevated lactate levels.