Association between CTLA-4 polymorphisms and the susceptibility to systemic lupus erythematosus and Graves’disease in Thai population.

Background: Cytotoxic T-lymphocyte antigen-4 (CTLA-4) is a cell surface molecule involved in the regulation of T cells. Single nucleotide polymorphisms (SNPs) of CTLA-4 gene are known to be associated with susceptibility to several autoimmune diseases, including systemic lupus erythematosus (SLE) and Graves’ disease (GD). Objective: The aim of this study was to determine whether the common SNPs +49A/G on exon1 and CT60A/G in 3’UTR of the CTLA-4 gene are associated with susceptibility to SLE and GD in Thai population. Methods: Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was used to analyze these two SNPs in 151 patients with SLE, 132 patients with GD and 153 healthy controls. Results: Our study showed that there were no statistically significant differences in the allele and genotype frequencies of +49A/G and CT60A/G SNPs between patients with SLE and healthy controls as well as patients with GD vs. healthy controls (P >0.05). However, the GG genotypes of +49A/G and CT60A/G were likely to be risk factors (OR >1) for GD but not in SLE. The effect of the +49G allele was similar to that of an autosomal recessive gene in the presence of the GG genotype, when compared to AA and AG, with an OR of 1.58 (95% CI =0.95-2.61, p =0.061) in GD. We also observed a dose response effect of the CT60G allele on GD susceptibility with an OR of 1.43 for GG homozygous and 1.17 for AG heterozygous subjects, when compared to the AA genotype, although these were not statistically significant (P >0.05). Conclusion: We found no association between two functional polymorphisms (+49A/G and CT60A/G) of the CTLA-4 gene and susceptibility to SLE and GD. However, the association study utilizing a larger sample size should be performed to confirm this.

Alleviation of renal and pulmonary injury by immunomodulation in leptospirosis: hamster model.

OBJECTIVE: Severe leptospirosis manifestations include acute renal failure, caused by acute interstitial nephritis and pulmonary hemorrohage. Spirochete invasion and toxicity of outer membrane cause robust inflammatory host responses. These responses lead to the generation of cytokines, chemokines, and inflammatory cell infiltrations which result in severe organ dysfunctions. The immunomodulation by the modulation of host immune response may alleviate the renal and pulmonary injury. The authors determined whether the current immunosuppressive agents could alleviate the inflammation and minimize the organ injury in hamster model. MATERIAL AND METHOD: The animal experiments were conducted with the approval of The Ethical Research Committee of Chulalongkorn University Hospital. The leptospira interrogan serovar pyrogenese was isolated from a wild rat. The spirochete was grown in Fletcher's semisolid media and after subcultures were transferred to the Fletcher's liquid media. An amount of 0.5 ml of the spirochete culture media containing 1 x 10(8) leptospires/ml was intraperitoneally injected to golden Syrian hamsters (Mesocrietus auratus), age 4-6 weeks, weighing 60-80 grams. The hamsters were randomed into 5 groups (n = 4 in each group) namely, 1) Normal group (Control group), 2) Leptospira group, 3) CsA group (leptospira with cyclosporine feeding, 100 mg/kg/ day), 4) Rapa group (leptospira with rapamicin feeding, 0.6 mg/kg/day), and 5) Irra group (leptospira with irradiation). Cyclosporine and rapamicin were started at day 0 after the spirochete injection. Gamma ray dose 200 cGy was irradiated to the hamster 3 days before the spirochete inoculation. The animals were autopsied or euthanized if expired or at day 5 post inoculation. The blood samples for BUN, and creatinine were drawn before the inoculation and at autopsy or euthanasia. RESULTS: The inoculation of L Interrogan 0.5 ml (1 x 10(8) leptospires/ml) without immunomodulation cause mortality of all animals at day 4 or day 5 post inoculation. The blood chemistry showed acute severe azotemia. The autopsy findings revealed severe interstitial nephritis and severe pulmonary hemorrhage. The hamsters in the Rapa group had only minimal pulmonary hemorrhage and minimal focal interstitial inflammation of kidney. There were cytoadherance of inflammatory cells to the endothelial cells in lungs and kidneys without the intrusion into the interstitium. The blood chemistry in Rapa group showed mild elevation of BUN and Cr. The immunomodulation by cyclosporine and irradiation did not alleviate the disease. On the contrary, cyclosporine and irradiation caused more severe histopathology. CONCLUSION: The immunomodulation by rapamicin in leptospirosis in hamsters could alleviate the kidney and pulmonary injuries. The up-regulation of IL-2 in peripheral blood lymphocytes did not result in the kidney and pulmonary injuries.

High prevalence of indinavir-associated renal complications in Thai HIV-infected patients.

BACKGROUND: Indinavir (IDV) is the protease inhibitor (PI) used most often in resource-limited countries. The present study aimed to determine the prevalence of IDV-associated renal complications as well as their clinical characteristics. MATERIAL AND METHOD: The authors reviewed all patients participating in cohorts of indinavir-containing regimens at the HIV-NAT research center during the period of indinavir treatment. Patients who had pre-existing renal diseases were excluded. Renal toxicities included presence of urologic symptoms, nephrolithiasis, abnormal urine sediments, crystalluria and loss of renal function. Radiological studies of KUB system were reviewed as well. RESULTS: Two-hundred and four patients treated with IDV were included. Median (IQR) follow up period was 216 (150-312) weeks. One hundred and eighty patients were treated with ritonavir-boosted regimens at some point, and 24 patients were treated only with unboosted regimens. Leukocyturia (51.9%) was the most common finding of IDV-associated renal complications. Thirty-five percent of patients had urologic symptoms such as flank pain or dysuria. Almost half of the patients had significant loss of renal function that was associated with prolonged use of IDV The most common radiological finding was nephrolithiasis. Less common, but of greater clinical importance, are nephrocalcinosis or renal atrophy. CONCLUSION: A high prevalence of IRC was found in Thai HIV-infected patients. As long as no other cost-effective boosted PI regimens are available, strategies to prevent irreversible loss of renal function are warranted.

Study of cyclosporine level at 2 hours after administration in preoperative kidney transplant recipients for prediction of postoperative optimal cyclosporine dose.

OBJECTIVE: Absorption profiling of cyclosporine is a current concept of drug monitoring. A single blood concentration measurement 2 hours after cyclosporine administration (C2) has been shown to be a good predictor of drug exposure and clinical outcome. The recommendation states that achieving the recommended target level of 1700 +/- 340 ng/ml within 3-5 days after renal transplantation is associated with a lower rate of acute rejection and nephrotoxicity. The high variation of pharmacokinetic profile and short limited time during early post-transplantation period make it hard to adjust the cyclosporine dose that can reach that target level on time. The present study was designed to be a method to predict the optimal pre-transplant CsA dose. MATERIAL AND METHOD: Eleven living-related kidney transplant recipients were recruited to receive cyclosporine and were monitored for C2 concentration during the 2 weeks before operation by the designed method. The pre-transplant empirical dose of 3.5 mg/kg/dose every 12 hours were assigned to all patients. The first predicted dose was estimated by using C2 concentration of 1,700 ng/mL. The first predicted dose was prescribed to the patients. The second predicted dose was estimated by using C2 concentration of the first predicted dose. All patients received the average of the first and the second predicted doses of cyclosporine within 12-24 hrs before transplantation and until the 3rd day after transplantation. RESULTS: Nine out of 11 patients (81.81%) reached the target C2 level on the 3rd day after transplantation without any serious side effect and complications. The most common side effect was nausea and a flushing sensation that usually abated with a later dose after transplantation. CONCLUSION: The early postoperative optimal cyclosporine dose can be effectively predicted by pre-transplant C2 measurement as conducted in the present study.

The clinicopathology and outcome of post-infectious glomerulonephritis: experience in 36 adults.

Post-infectious glomerulonephritis is one of the most common causes of acute glomerulonephritis. A retrospective study of post-infectious glomerulonephritis at King Chulalongkorn Memorial Hospital, Thailand was performed from January 1999 to December 2005. Among thirty six patients, eight cases were post-streptococcal glomerulonephritis and twenty eight cases were post non-streptococcal Glomerulo Nephritis (GN). Most cases present with edema, hypertension, gross hematuria and nephrotic-range proteinuria. C3 and CH50 commonly were low. Post-streptococcal glomerulonephritis had more aggressive pathology compared to the others. However the long term outcome was excellent. In the present study the authors found ESRD in only 14.3% (4 out of 28 cases) that reflects the excellent prognosis of post-infectious glomerulonephritis. Of interest, all of the ESRD patients were caused by post non-Streptococcal GN. Even though, no statistic was achieved; it might reflect the aggressiveness of non-Streptococcal pathogen.

A rare case of chylous ascites and chyluria in an adult nephrotic syndrome with focal segmental glomerulosclerosis.

The authors report the first case of chylous ascites and chyluria in a 65-year-old Thai women with nephrotic syndrome due to focal segmental glomerulosclerosis (FSGS), tip variant. She presented with generalized edema and abdominal discomfort. Abdominal paracentesis revealed milky white fluid. Chylous ascites was confirmed. Abdominal and thoracic computed tomography did not show any cause of chylous ascites and chyluruia. Lymphoscintigraphy could not demonstrate lymph flow obstruction and connection between lymphatic pathway and KUB system. Those could have explained the chylous ascites or chyluria. Hypoalbuminemia-induced bowel edema may predispose to change the permeability of mucosal or serosal lymphatics. This could result in chylous ascites but the cause of chyluria could not be determined in this case.

Etiologies of glomerular diseases in Thailand: a renal biopsy study of 506 cases.

BACKGROUND: The nationwide renal registry has not yet been organized in Thailand, and the literature contains no registry of renal pathologic finding across the Southeast Asian (SEA) countries in the modern era when electron microscopy (EM) is routinely available. OBJECTIVE: The aim of the present study was to examine the prevalence of renal pathology in Thai population. MATERIAL AND METHOD: The authors reviewed the case file and renal biopsy specimens of King Chulalongkorn University Hospital to identify all adult native renal biopsy specimens received from January 2001 to December 2004, investigating prevalence and clinical and histological data. Biopsy of renal graft and in cases of trauma and tumors the authors excluded. Most of the biopsy specimens obtained The authorsre analyzed using light microscopy (LM), immunofluorescense (IF), and EM. Final diagnosis was made for each patient based on clinicopathologic correlations. RESULTS: A total of 506 native renal biopsies were processed during this period, 69.8% were female and 30.2% were male. Their age average was 37 +/- 14.2 (13-80) years. The most common indications for renal biopsy were nephrotic syndrome and SLE (36.8%, 34.5%, respectively), followed by asymptomatic hematuria/proteinuria in 10.9% of patients. Secondary glomerular diseases were dominant against primary diseases in all but elderly age group (>50 years), particularly LN. Among primary glomerular diseases, the prevalence of IgAN, focal segmental glomerulosclerosis, and membranous nephropathy were 31.0%, 24.9%, and 13.1%, respectively. The provisional clinical diagnosis was correct in three fourths (73.2%) of the SLE cases. Postbiopsy complications occurred in 3.3% (17/506). Gross hematuria was seen in 2.3% (12/506), and perinephric hemptoma in 0.79%. Three of them required blood transfusion but none of them died and required an invasive procedure for resolution. The major complications were 2 folds less than regular prevalence (0.6% compared to 1.3%). CONCLUSION: Although the data was collected from single center where EM is routinely performed, the authors believe that IgAN is the commonest primary GN in SEA countries. The authors are looking forward to seeing the nationwide registry data in Thailand and other SEA countries.

Pharmacokinetics of sirolimus in Thai healthy volunteers.

Sirolimus, a novel immunosuppressive drug, has been used in kidney transplant recipients to minimize calcineurine inhibitor (CNI) and steroid toxicities. Likewise CNI, Sirolimus's pharmacokinetics have both inter and intra-individual pharmacokinetic variations. Due to ethnic differences, the recommended oral loading dose of 6 mg and oral maintenance dose of 2 mg per day for Caucasian patients and oral loading dose of 10 mg and oral maintenance dose of 5 mg per day for African-American patients may not be appropriate for Asian recipients. We, therefore conducted the pharmacokinetic study of sirolimus in Thai population, aimed to delineate the appropriate sirolimus dose for further clinical use. The study was performed in 12 healthy Thai volunteers. After an over night fasting, a single oral dose of 6 mg sirolimus was given. The complete pharmacokinetic study was done by UVhigh performance liquid chromatography (HPLC-UV) to measure the whole blood sirolimus level at 0.5 hour after the dose (C0.5) and then C1, C1.5, C2, C2.5, C3, C4, C6, C8, C12, and C24 hours. A complete area under the concentration time curve from 0-24 hours (AUC(0-24 hr)) was calculated by using the trapezoidal rule. The mean (+/- SD) time to maximal concentration (Tmax) was 1.45 +/- 0.5 hr (range 1-3 hrs). The maximal (Cm) and minimal plasma concentration (Ctroug) for sirolimus were 25.3 +/- 6.1 ng/ml (range 18.10 - 40 ng/ml) and 4.47 +/- 0.57 ng/ml (range 2.90 - 7.20) ng/ml respectively. The AUC(0-24 hr) were 187.9 +/- 48.2 ng * hr/ml (range 151.3 - 294.8 ng * hr/ml). Sirolimus level at 4 hr post-dose had the best of correlation with AUC(0-24 hr) (Pearson correlation = 0.76, p < 0.007). One volunteer had a very high sirolimus level. This subject's pharmacokinetic data showed AUC(0-24 hr) of 256 ng * hr/ml and Cmax of 40 ng/ml. In conclusion, the oral loading dose of 6 mg of sirolimus in Thai volunteers did not achieve the recommended therapeutic level (5-10 ng/ml) in most subjects. There are differences in pharmacokinetics of sirolimus between Thais and Caucasians.

The prevalence and risk factors of osteoporosis in Thai renal-transplant patients.

OBJECTIVES: To determine the prevalence and risk factors of osteoporosis after renal transplantation in Thai patients. MATERIAL AND METHOD: A single-center cross-sectional study of bone mineral density was conducted in 102 Thai renal allograft recipients. Correlations were made between the clinical parameters and the occurrences of osteoporosis. RESULTS: The prevalence of osteoporosis was 24.5%, 9.8% and 26.4% at lumbar vertebrae, hip region, and any sites, respectively. Binary logistic regression analysis revealed that cumulative dosage of steroids was significantly correlated with osteoporosis of the lumbar spine (p = 0.023, adjusted OR = 1.005), while body mass index (p = 0.005, adjusted OR = 0.738) and age (p = 0.052, adjusted OR = 1.077) were correlated with osteoporosis of the hip region. CONCLUSION: Osteoporosis is common in Thai renal allograft recipients, particularly of the lumbar vertebrae. Cumulative dosage of steroids is the most important risk factor of low BMD of the lumbar vertebrae.

The efficacy of combined low dose of Allopurinol and benzbromarone compared to standard dose of Allopurinol in hyperuricemia.

OBJECTIVE: To compare the efficacy of combined low dose of hypouricemic drugs (Allopurinol 100 mg and benzbromarone 20 mg; Allomaron) and standard dose 300 mg of allopurinol in hyperuricemia. MATERIAL AND METHOD: A prospective, open study of 94 hyperuricemic patients was done at King Chulalongkorn Memorial Hospital. Each group of 47 patients was given a combined low dose of hypouricemic drugs (Allopurinol 100 mg and benzbromarone 20 mg; Allomaron) and a standard dose 300 mg of allopurinol. Serum uric acid was measured before and 4 weeks after receiving the drugs. The efficacy was measured from the difference of the level of serum uric acid before and after receiving the drugs. RESULTS: The patients receiving the combined low dose of hypouricemic drugs and standard dose of allopurinol showed a mean reduction of serum uric acid of 2.5+/-3.4 mg/dl and 4.1+/-2.7 mg/dl consecutively. There was a statistically significant difference between the 2 groups (P = 0.010). CONCLUSION: This study demonstrates that the efficacy of standard dose 300 mg of allopurinol is superior to a combined low dose of allopurinol and benzbromarone in lowering the level of serum uric acid level.

Clinical manifestations of patients with hyperuricemia.

OBJECTIVE: To study the clinical manifestations of patients with hyperuricemia in King Chulalongkorn Memorial Hospital. METHOD: A cross sectional study of 188 hyperuricemic patients was done at King Chulalongkorn Memorial Hospital. History, physical examination, and blood samples were drawn to assess complete blood count (CBC), blood urea nitrogen (BUN), creatinine (Cr), liver function test (LFT), and serum uric acid in all patients. RESULTS: Most of the patients (92%) were male, more than 50 years old (69%), the mean age of the patients was 56.7 +/- 12.1 years old. All of the female patients were more than 50 years old. Symptomatic hyperuricemia was found in 93%, the mean duration of symptoms was 63.2 +/- 66.3 months. The mean of the serum uric acid level was 10.0 +/- 2.9 mg/dl. Associated diseases were found in 46% of the patients, and 30% of these patients had more than one disease. Hypertension was the most common followed infrequency by dyslipidemia, diabetes mellitus, ischemic heart disease, and chronic obstructive pulmonary disease consecutively. Renal impairment was detected in about one-third of the patients. CONCLUSION: This study shows that hyperuricemia is common in elderly, male patients. Associated diseases and renal impairment can befoundfrequently, and the patients should be monitored.