Can tonsillectomy modify the innate and adaptive immunity pathways involved in IgA nephropathy?

The benefits of tonsillectomy in IgA nephropathy (IgAN) are still debated. Tonsillectomy may remove pathogen sources and reduce the mucosal associated lymphoid tissue (MALT), limiting degalactosylated IgA1 (deGal-IgA1) production, which is considered to be the initiating pathogenetic event leading to IgA glomerular deposition. In the European network VALIGA, 62/1147 IgAN patients underwent tonsillectomy (TxIgAN). In a cross-sectional study 15 of these patients were tested and compared to 45 non-tonsillectomized IgAN (no-TxIgAN) and healthy controls (HC) regarding levels of deGal-IgA1, and markers of innate immunity and oxidative stress, including toll-like receptors (TLR)2, 3, 4 and 9 mRNAs, proteasome (PS) and immunoproteasome (iPS) mRNAs in peripheral blood mononuclear cells (PBMC), and advanced oxidation protein products (AOPP). Levels of deGal-IgA1 were lower in TxIgAN than in no-TxIgAN (p = 0.015), but higher than in HC (p = 0.003). TLR mRNAs were more expressed in TxIgAN than in HC (TLR4, p = 0.021; TLR9, p = 0.027), and higher in TxIgAN than in no-TxIgAN (p ≤ 0.001 for TLR2, 4, 9). A switch from PS to iPS was detected in PBMC of TxIgAN in comparison to HC and it was higher than in no-TxIgAN [large multifunctional peptidase (LMP)2/ß1, p = 0.039; LPM7/ß5, p < 0.0001]. The levels of AOPP were significantly higher in TxIgAN than HC (p < 0.001) and no-TxIgAN (p = 0.033). In conclusion, the activation of innate immunity via TLRs and ubiquitin-proteasome pathways and the pro-oxidative milieu were not affected by tonsillectomy, even though the levels of aberrantly galactosylated IgA1 were lower in patients with IgAN who had tonsillectomy. The residual hyperactivation of innate immunity in tonsillectomized patients may result from extra-tonsillar MALT.

[Indications from the first audit on peritoneal dialysis in Piedmont and Aosta valley]. / Indicazioni dal primo audit sulla dialisi peritoneale in Piemonte e in Valle D'Aosta.

In March 2009 a clinical audit was held in Turin on peritoneal dialysis in order to analyze the problems that still hinder the effective deployment of the technique in Piedmont-Aosta Valley. Various data about epidemiological and clinical management were collected by means of a questionnaire that all 26 nephrology centers of the two regions responded to. The two major critical issues highlighted were the role of the outpatient facility dedicated to uremic patients and why the peritoneal technique was not chosen for new dialysis patients. With regard to the first issue, the presence of a well structured outpatient facility dedicated to chronic renal failure seems to direct more uremic patients to peritoneal dialysis, at the same time decreasing the rate of late referrals. Regarding the second issue, patient choice was the leading cause followed by problems related to the partner, while traditional clinical contraindications interfered to a lesser extent with the choice of dialysis technique. We therefore believe that it will be possible to increase the use of peritoneal dialysis by improving organizational aspects of the dialysis center and trying to remedy the lack of social support. Accurate information and early care of uremic patients by dedicated outpatient facilities are in fact able to lead more patients to choose peritoneal dialysis. The implementation of measures of support, such as financial incentives to dialysis patients following a recent decision of the Piedmont region, could help to overcome problems related to the lack or unhelpfulness of a partner.

Personal dialysis capacity (PDC(TM)) test: a multicentre clinical study.

BACKGROUND: The assessment of the peritoneal membrane capacity and physiology of the individual patient is becoming increasingly important. It allows the prescription of an individualized peritoneal dialysis (PD)-regimen, and the monitoring of peritoneal membrane function over time. The PDC(TM) program offers the possibility to evaluate the peritoneal membrane characteristics and to predict solute and water removal by simulation of different treatment regimens. METHODS: This study evaluates the relevance of the PDC(TM) program when routinely used. The PDC(TM) data of 336 patients from nine different centres in Europe were evaluated. RESULTS: The area parameter was 20 985+/-7578 cm/1.73 m(2) (mean+/-SD). The reabsorption of fluid after dissipation of glucose, Jv(AR), was 1.97+/-1.00 ml/min/1.73 m(2). The large pore fluid flux, Jv(L), was 0.11+/-0.07 ml/min/1.73 m(2). A multivariate model for prediction of serum albumin included dialysate protein loss, Jv(L), Jv(AR), nPCR, A(0)/deltaX, BMI and gender (R(2)=0.81, P<0.001). Total clearance fell with increasing PD duration (P<0.001). A negative relation between A(0)/deltaX and ultrafiltration (rho=-0.26, P<0.05), a positive relation between A(0)/deltaX and peritoneal creatinine clearance (rho=0.52, P<0.05) and urea clearance (rho=0.36, P<0.05), and a positive relation between measured peritoneal creatinine and urea clearance (rho=0.64, P<0.01) was observed. CONCLUSIONS: In summary, the present study shows that the PDC(TM) program is a robust, accurate method to describe the peritoneal membrane transport characteristics. Analysis of PDC(TM) data of large groups of patients, especially if followed up over time, can give interesting information on the physiology of the peritoneal membrane and the impact of different parameters on it.