The application of electron microscopic morphometry as helpful method in the diagnosis of focal segmental glomerulosclerosis (FSGS) early phase. I. Morphometric electron microscopic studies of renal glomeruli in cases of focal segmental glomerulosclerosis (FSGS), minimal change disease (MCD) and mesangioproliferative glomerulonephritis (GNMES) in children.

Electron microscopy morphometric studies were carried out on material obtained from children with minimal change disease (MCD), mesangioproliferative glomerulonephritis (GNMES) and focal segmental glomerulosclerosis (FSGS). The results indicated that an increase in the volume of the matrix in mesangioproliferative glomerulonephritis was due to an increase in the number of cells. The amount of produced matrix in mesangioproliferative glomerulonephritis was proportional to the number of cells in mesangium (so there is no overproduction of matrix). The ratios of mesangial matrix volume to cell volume and matrix volume to the volume of the entire mesangial region in MCD and GNMES were similar and differed significantly from the ratios found in FSGS. The present findings indicate that morphometric studies may be useful in the early diagnosis of glomerular sclerosis. This is particularly significant in cases where light microscopic examination fails to reveal changes indicative of glomerular sclerosis.

The application of electron microscopic morphometry as a helpful method in the diagnosis of focal segmental glomerulosclerosis (FSGS) early phase. II. Clinical usefulness of electron microscopic morphometric studies in cases of minimal change disease (MCD) and mesangioproliferative glomerulonephritis (GNMES) with suspicion of progression into focal segmental glomerulosclerosis (FSGS).

Clinical and morphological analysis (including morphometric studies of electron microscopic material) was made in 15 children with MCD and 15 children with GNMES. In both groups, an early phase of FSGS was suspected on the basis of electron microscopic studies. Moreover, analysis included the results obtained in 13 children with the diagnosis of FSGS and in whom repeated biopsies were performed. In most of them, MCD or GNMES was diagnosed from the first biopsy. In most children in whom electron microscopic studies revealed an increase in matrix area in some mesangial regions, thereby suggesting an early stage of glomerular sclerosis, the results of morphometric studies resembled or were identical to the results obtained from a control group with the established diagnosis of FSGS. These findings indicate that morphometric studies of electron microscopic material are significant. The results, when compared with the clinical data, confirm the usefulness of such a diagnostic procedure.

Th1/Th2 balance and CD45-positive T cell subsets in primary nephrotic syndrome.

T cells are involved in the pathogenesis of nephrotic syndrome (NS). The aim of the study was to determine whether the activity of T-helper-1 (Th1) and T-helper-2 (Th2) cells and the distribution of the lymphocyte subsets, namely CD45RA+CD4+ ("naive" helper T cells, suppressor-inducer), CD45RA+CD8+ ("naive" suppressor T cells, suppressor-effector), CD45RO+CD4+ ("memory" helper T cells), are predictive for steroid sensitivity in children with primary NS. These parameters were assessed at the onset of disease, before initiation of steroid therapy. Two groups of NS children were retrospectively formed according to steroid sensitivity (SS) or resistance (SR). The activity of Th1 and Th2 cells was defined by the production of interleukin-2 (IL-2), interferon-gamma, IL-4, and IL-10 in the supernatants of CD4+ T cell cultures activated with autologous monocytes presenting tetanus toxoid (TT). Peripheral lymphocyte subsets were determined using double- or triple-color flow cytometry. In SS children with NS we found a decreased proliferative response of CD4+ T cells to TT stimulation, cytokine synthesis indicating the predominance of Th2 activity, and an increased percentage of activated suppressor-inducer (CD45RA+ CD4+CD25+, 5.18+/-0.8, P<0.001) and suppressor-effector (CD45RA+CD8+CD25+, 2.05+/-0.6, P<0.01) cells, with the concomitant reduction of activated memory cells (CD45RO+CD4+CD25+, 0.2+/-0.1, P<0.001). In children with SRNS we found an increased proliferative response of CD4+ T cells to TT, a rise in activated memory (CD45RO+CD4+CD25+, 3.82+/-0.7, P<0.01) and suppressor-inducer peripheral T cells (CD45RA+ CD4+CD25+, 3.85+/-0.6, P<0.01), but a low percentage of activated suppressor-effector (CD45RA+CD8+ CD25+, 0.5+/-0.2, P<0.05) T cells. We conclude that prior to treatment the distribution of lymphocyte subpopulations in peripheral blood together with Th1 and Th2 cell activity provides a useful tool for evaluating the likelihood of steroid sensitivity in patients with primary NS.

[Does the changed Th1/Th2 activity in children with the assessment of body water in children with nephrotic syndrome: initial results]. / Czy zmieniona aktywnosc limfocytów Th1/Th2 u dzieci z zespolem nerczycowym moze byc wskaznikiem reaktywnosci na leczenie?

T cells are involved in the pathogenesis of nephrotic syndrome (NS). The aim of the study was to determine whether the activity of T-helper-1 (Th1) and T-helper-2 (Th2) cells are predictive for steroid sensitivity in children with primary NS. These parameters were assessed at the onset of disease, before initiation of steroid therapy. Two groups of NS children were retrospectively formed according to steroid sensitivity(SS) or resistance(SR). Activity of Th1 and Th2 cells was defined by the production of IL-2, IFN-gamma and IL-4, IL-10 (ELISA), respectively, in the supernatants of the culture of CD4+ T cell cultures activated with autologous monocytes presenting tetanus toxoid (TT). Peripheral lymphocyte subsets were determined using double or triple colour flow cytometry. In SS children with NS we found the cytokine synthesis indicating the predominance of Th2 activity. We conclude that prior to treatment the Th1 and Th2 cell activity provides a useful tool to evaluate the probability of steroid sensitivity in patients with primary NS.

Clinical and morphological (including morphometric) aspects of minimal change disease and mesangial glomerulonephritis with unfavourable course in children.

Clinical and morphological analysis was made to assess 9 cases of minimal change disease (MCD) and 30 cases of mesangial glomerulonephritis (GNMES) recognized by light microscopy with unfavourable course. Case selection was based exclusively on the clinical course suggesting a possibility of early sclerosis (long-term steroid resistance, frequent recurrences, rare short-lasting remissions, hypertension, renal failure). It was found that the unfavourable clinical course was clearly more frequently associated with electron microscopic than light microscopic changes. Marked increase of the matrix was observed also in those glomeruli in which light microscopy did not reveal any changes or only the signs of immaturity. It was also noticed that in those cases in which the assessment of mesangial matrix increase (which means the onset of sclerosis) is not certain, it is useful to make a morphometric analysis of electron microscopic material.

Is vacuolization of podocytes and glomerular endothelial cells of prognostic value with respect to FSGS?

Focal segmental glomerulosclerosis (FSGS) poses a major problem both from the clinical and pathomorphological viewpoint. The diagnosis of FSGS in its early stage is vital mainly because of rapidly developing therapeutic modalities. In the literature various changes are discussed which may be of prognostic value (may predict the development of FSGS). One the these changes in vacuolization, mainly of podocytes and less frequently of endothelial cells. The purpose of the present study was to analyse biopsy specimens to find out to what extent vacuolization of podocytes and endothelial cells is associated with FSGS. We compared vacuolization in minimal change disease (MCD), mesangial glomerulonephritis (GNMES) and FSGS. A similar analysis was made also with respect to those cases of MCD and GNMES, in which electron microscopy suggested an early stage of FSGS. In each group electron micrographs obtained from 15 children were analysed. Electron micrographs (12-15 on average) were obtained most frequently from 3 glomeruli. Each case electron micrographs contained 90-100 podocytes. Based upon the same electron micrographs we counted capillary lumina and defined the percentage of those which contained vacuolized endothelia (we counted the capillary lumina, and not the cells, because it is most frequently impossible to identify the border of vacuolized endothelial cells). The number of capillary cross-sections was 60 on average. The results of the analysis were compared with the clinical data. This comparison did not confirm the hypothesis of other investigators that vacuolization is of a prognostic value. Additionally we evaluated the character of vacuoles. Within podocytes the vacuoles were varying in shape. Surrounded by a single membranous layer most frequently they contained material corresponding to proteins or proteoglycans, rarely to lipids. Sometimes the vacuoles were autophagosomal, occasionally they consisted of the dilated rough endoplasmic reticulum. Vacuole-like changes within the capillary lumina were related to the swelling of endothelial cytoplasm or mesangial processes. The reasons for a discrepancy between our results and those reported by other investigators necessitate further studies.

[Thrombo-embolic disease as a complication of nephrotic syndrome in children]. / Choroba zakrzepowo-zatorowa jako powiklanie zespolu nerczycowego u dzieci.

Eight children with thrombo-embolic disease in the course of nephrotic syndrome were treated at II Clinic of Children's Diseases (Institute of Pediatrics, Poznan) between 1991 and 1993. The diagnosis was established on the basis of clinical examination and noninvasive imaging techniques. Two patients had an atypical localisation of the thrombus in the left ventricle and right atrium. In laboratory tests of the coagulation system, all of the children had decreased levels of antithrombin III (AT III). All children were treated with heparin and 4 with fibrinolytic agents. AT III concentrate was administered to 3 children. Total resolution of thrombo-embolic disease was obtained in 5 patients, 3 died during treatment. Thrombo-embolic disease should be taken into account in the differential diagnosis of complications of nephrotic syndrome.

[One center's experience with fibrinolytic treatment in children]. / Leczenie fibrynolityczne u dzieci: doswiadczenia wlasne.

Fifteen children treated with fibrinolytic agents are presented. The most frequent indication was thromboembolic disease (TED). Eleven patients received streptokinase, 5-urokinase and 3-tissue plasminogen activator. Concomitant heparin was administered to 9 patients with TED. Total resolution was achieved in 9 children, partial improvement in 5; 1 child died during treatment without any improvement. Bleeding complications were observed in 6 patients, 1 of them died due to haemorrhagic stroke. According to the literature and our own experience, we recommend fibrinolytic agents as the treatment of choice for severe TED also in children.

Morphological and clinical aspects of membrano-proliferative glomerulonephritis in children.

Clinical and morphological studies were carried out in 34 children with the diagnosis of primary membrano-proliferative glomerulonephritis. The studies were prompted by an increasing incidence of this type of glomerulonephritis in Poland in the light of its regular decrease in the world. We found: (a) a number of discrepancies in the clinical manifestations and course of the disease in our children as compared with those in the literature; (b) difficulties in morphological diagnosis; (c) a frequent lack of correlation between the severity of morphological changes and the clinical course. It is of note that our series includes a large group of children below 6 years of age, which is a rare phenomenon.

Mesangial glomerulonephritis (GNMes) in children. Diagnostic problems, usefulness of repeated biopsy.

We analysed the results of clinical and morphological examinations in 256 children with mesangial glomerulonephritis. In the majority of children the onset of the disease was associated with the nephrotic syndrome, less frequently with erythrocyturia, proteinuria plus erythrocyturia or proteinuria. The course of the disease was markedly worse in those with proteinuria. The patients in this group were most frequently submitted for repeated biopsy. Renal specimens were studied in light, electron and immunofluorescence microscopy. Certain relationships between the initial symptoms and composition of deposits were found. There was, however no relation between the presence or absence of the deposits or their composition and the course of the disease. In 30 children the results of first biopsy (mainly electron microscopy examinations) suggested a possibility of focal segmental glomerulosclerosis (FSG). In 11 out of these children biopsy was repeated confirming the results of the first one. Repeated biopsy was performed in a total of 22 children. Progression of changes (signs of FSG) was found in 19 children, in 2 children changes in repeated biopsy did not differ from those in first biopsy, and in one child regression was observed.

Slightly dilated acute obstructive failure of congenital solitary kidney.

We present a case of a 10-year-old boy with slightly dilated obstructive acute failure of congenital solitary kidney. Obstruction of the ureter by stone was suggested as a cause of renal failure. The dilatation of the urinary tract above the obstruction was very small.

Morphometric analysis in the diagnosis and differentiation of certain glomerulopathies (MCD, GNMes, FSG)

Morphometric analysis was used to evaluate mesangial components in MCD (minimal changes disease), GNMes (mesangial glomerulonephritis), FSG (focal segmental glomerulosclerosis). In GNMes the increase of matrix was found to be generally proportional to the amount of mesangial cells. There are clear statistically significant differences in the ratio of matrix volume to cell component volume and of matrix volume to the whole mesangial area in MCD and GNMes as compared with FSG. In the case of GNMes where morphometric results resemble those in FSG cautious prognosis is recommended as there is a possibility of FSG. This has been confirmed both by the course of the disease and the results of repeated biopsy.

The clinicomorphological correlations in Schoenlein-Henoch nephropathy in children.

Clinicomorphological analysis has been performed in Schoenlein-Henoch nephropathy. Various clinical symptoms are accompanied by morphological changes of variable type and severity. Electron microscopy is a major tool for evaluating these changes. It relatively frequently modifies the diagnosis made by light microscopy. It mainly concerns class I and VI changes (according to a grading system of the International Study Group of Kidney Diseases in Childhood). It was shown that late prognosis was largely determined by the type and severity of morphological changes. Varying severity of changes in individual glomeruli in the same specimen requires in each case a comparison of results obtained by electron microscopy with those obtained by light microscopy in semithin sections. In three children biopsy was repeated. Progression of morphological changes was found in one child. He developed renal failure. In one child morphological changes on first biopsy did not differ from those on second biopsy. Repeated biopsy was performed due to the presence of hypertension. In one child with persistent proteinuria repeated biopsy showed marked attenuation of morphological changes.

Thin basement membranes syndrome: a rare cause of erythrocyturia.

The results of the studies in five children with the syndrome of thin basement membranes have been discussed. A comparison of clinical data with the morphological ones shows that recognition of erythrocyturia or hematuria necessitates familial examinations and long-term follow-up. Final diagnosis of this syndrome may be made only by means of electron microscopy.

Focal segmental glomerulosclerosis in children.

Clinical and morphological examinations in 25 children with the diagnosis of focal segmental glomerulosclerosis (FSG) show that: 1. electron microscopy permits a detection of FSG in its early stage when light microscopy does not reveal any changes, and immunomorphological studies do not show deposits 2. in this stage small focal interstitial changes may be visible 3. ultrastructural studies reveal changes in case of nonspecific light microscopy i.e. suggesting mesangial glomerulonephritis 4. in doubtful cases it is useful to repeat biopsy.