Oxidative stress markers in predicting response to treatment with ferric carboxymaltose in nondialysis chronic kidney disease patients.

BACKGROUND: Nearly half of all non-dialysis chronic kidney disease (CKD) patients respond to iron therapy. Factors affecting anemia response to iron therapy are not well characterized. Oxidative stress (OS) is a recognized factor for anemia in CKD and promotes erythropoiesis stimulating agent (ESA) resistance; however, the influence in predicting response to intravenous (IV) iron has not been evaluated. METHODS: Patients (n = 47) with non-dialysis CKD stages 3 - 5 (mean eGFR: 26 ± 10.4 mL/min/1.73 m2) and iron-deficiency anemia (hemoglobin < 11 g/dL, transferrin saturation (TSAT) index < 20%, and/or ferritin < 100 ng/mL) received a single injection of 1,000 mg of ferric carboxymaltose (FCM) and were observed for 12 weeks. Based on erythropoietic response (defined as ≥ 1 g/dL increase in hemoglobin level), patients were classified as responders or non-responders. Baseline conventional markers of iron status (TSAT and ferritin), inflammatory markers (C-reactive protein and IL-6), OS markers (oxidized LDL, protein carbonyl groups, erythrocyte superoxide dismutase, and glutathione peroxidase (GPx)), and catalase activity were measured. RESULTS: FCM resulted in a significant increase in hemoglobin, TSAT, and ferritin (10 ± 0.7 vs. 11.4 ± 1.3 g/dL, p < 0.0001; 14.6 ± 6.4% vs. 28.9 ± 10%, p < 0.0001; 67.8 ± 61.7 vs. 502.5 ± 263.3 ng/dL, p < 0.0001, respectively). Responders and non-responders were 34 (72%) and 13 (28%), respectively. Age, baseline hemoglobin, estimated glomerular filtration rate, parathyroid hormone, and use of ESA or angiotensin-modulating agents were similar in both groups. Responders showed a tendency towards lower TSAT than non-responders (13.6 ± 6.5% vs. 17.2 ± 5.6%, p = 0.06) but similar ferritin levels. Inflammatory markers were similar in both groups. eGPx activity was lower in non-responders compared to responders (103.1 ± 50.9 vs. 144.9 ± 63.1 U/g Hb, p = 0.01, respectively), although the other proteins, lipid oxidation markers, and enzymatic antioxidants did not differ between the two groups. In the multivariate adjusted model, odds (95% CI) for achieving erythropoietic response to FCM were 10.53 (1.25 - 88.16) in the third tertile of eGPX activity and 3.20 (0.56 - 18.0) in the second tertile compared to those in the lowest tertiles (p = 0.02). CONCLUSIONS: Decreased eGPx activity has adverse influences on response to FCM, suggesting that impaired erythrocyte antioxidant defense may be involved in the response to iron therapy in CKD patients.

Effect of ferric carboxymaltose on serum phosphate and C-terminal FGF23 levels in non-dialysis chronic kidney disease patients: post-hoc analysis of a prospective study.

BACKGROUND: Some parenteral iron therapies have been found to be associated with hypophosphatemia. The mechanism of the decrease in serum phosphate is unknown. The aim of this study is to examine the effect of IV ferric carboxymaltose(FCM) on phosphate metabolism and FGF23 levels in patients with chronic kidney disease(CKD). METHODS: This is a post-hoc analysis of a prospective study carried out in 47 non-dialysis CKD patients with iron-deficiency anaemia who received a single 1000 mg injection of FCM. Markers of mineral metabolism (calcium, phosphate, 1,25-dihydroxyvitamin D, PTH and FGF23[c-terminal]) were measured prior to FCM administration and at week 3 and week 12 after FCM administration. Based on the measured levels of serum phosphate at week 3, patiens were classified as hypophosphatemic or non-hypophosphatemic. RESULTS: Serum phosphate levels decreased significantly three weeks after FCM administration and remained at lower levels at week 12 (4.24 ± 0.84 vs 3.69 ± 1.10 vs 3.83 ± 0.68 mg/dL, respectively, p < 0.0001. Serum calcium, PTH and 1,25-dihydroxyvitamin D did not change over the course of the study. Serum FGF23 decreased significantly from 442(44.9-4079.2) at baseline to 340(68.5-2603.3) at week 3 and 191.6(51.3-2465.9) RU/mL at week 12, p < 0.0001. Twelve patients were non-hypophosphatemic and 35 hypophosphatemic. FGF23 levels decreased in both groups, whereas no changes were documented in any of the other mineral parameters. CONCLUSIONS: In non-dialysis CKD patients, FCM induces reduction in serum phosphate levels that persists for three months. FCM causes a significant decrease in FGF23 levels without changes to other bone metabolism parameters.

Acute and sub-acute effect of ferric carboxymaltose on inflammation and adhesion molecules in patients with predialysis chronic renal failure.

BACKGROUND: Treatment with parenteral iron causes oxidative stress, inflammation and endothelial dysfunction. Ferric carboxymaltose (FCM) is a new preparation of non-dextran iron which, due to its pharmacokinetics and stability, may induce less toxicity than other iron molecules. The aim of this study was to analyse the effect of FCM on inflammation and adhesion molecules in chronic kidney disease (CKD). METHODS: Forty-seven patients with predialysis CKD and iron-deficiency anaemia received a single dose of FCM (15 mg/kg, maximum dose 1 gram). At baseline and after 60 minutes (acute effect) and after 3 weeks and 3 months (sub-acute effect), we determined inflammatory markers: C-reactive protein (CRP), interleukin-6 (IL-6) and endothelial dysfunction: intercellular adhesion molecule (ICAM) and vascular adhesion molecule (VCAM). RESULTS: Treatment with FCM was associated with a significant increase in haemoglobin levels: 10 (0.7) vs. 11.4 (1.3)g/dl, p<.0001. CRP, IL-6, ICAM and VCAM levels did not correlate with baseline haemoglobin or ferritin levels and there was no relationship between changes in these markers and those of haemoglobin after administration of FCM. No significant, acute or sub-acute changes occurred in any of the inflammatory or endothelial markers studied. Statin therapy was associated with lower VCAM concentrations. CONCLUSIONS: Treatment with high doses of FCM in patients with predialysis CKD has no proinflammatory effect and does not alter levels of adhesion molecules ICAM and VCAM in this population.

Post intrastromal corneal ring segments insertion complicated by Candida parapsilosis keratitis.

This case report describes the clinical and histopathologic features, including molecular confirmation, of fungal keratitis after intrastromal corneal ring segments placement for keratoconus. A 52-year-old woman underwent insertion of Intacs(®) corneal implants for treatment of keratoconus. Extrusion of the implants was noted 5 months post insertion and replaced. Three months later, monocular infiltrates and an epithelial defect were observed. The Intacs were removed and the infiltrates were treated with ofloxacin and prednisolone acetate. Microbial cultures and stains were negative. The patient demonstrated flares and exacerbation one month later. Mycoplasma and/or fungus were suspected and treated without improvement. Therapeutic keratoplasty was performed 10 months following initial placement of the corneal ring implants. The keratectomy specimen was analyzed by light microscopy and a panfungal polymerase chain reaction assay. A histopathologic diagnosis of Candida parapsilosis keratitis was made and confirmed by polymerase chain reaction. One year postoperatively, a systemic workup of the patient was done with no signs of recurrence. This rare report of fungal keratitis following Intacs insertion is the first reported case of C. parapsilosis complicating Intacs implantation.

Molecular detection of Bartonella henselae for the diagnosis of cat scratch disease and bacillary angiomatosis of the conjunctiva.

PURPOSE: The purpose of this study was to evaluate clinical cases of cat scratch disease (CSD) and bacillary angiomatosis involving the conjunctiva by special stains and transmission electron microscopy (TEM) and to compare these findings with the results from species-specific polymerase chain reaction (PCR) analysis of the same specimens. METHODS: Six potential cases of CSD and 2 possible cases of bacillary angiomatosis of the conjunctiva were analyzed by light microscopy, the Warthin-Starry technique, TEM, and PCR. DNA isolated from cultured Bartonella henselae, B. bacilliformis, B. quintana, and B. elizabethae were used as control templates for establishment of the PCR sensitivity and specificity. Cultured DNA was also used as appropriate positive controls during analysis of the clinical specimens. RESULTS: The histological studies, electron microscopy, and the PCR analysis confirmed the identification of the bacilli within the involved tissues. Furthermore, molecular diagnosis by PCR allowed for speciation of the infecting Bartonella organisms in 6 of the 8 cases and correlated with the histological findings. CONCLUSIONS: The PCR-based identification of Bartonella correlated well with the results of light microscopy and TEM and provided a simple and rapid method of diagnosis to the species level. The molecular analysis may prove to be beneficial in enhancing the current diagnostic techniques for CSD and bacillary angiomatosis.

Cat-scratch uveitis confirmed by histological, serological, and molecular diagnoses.

PURPOSE: To report a case of a cat-scratch uveitis caused by Bartonella henselae, which was confirmed by histology, serology, and polymerase chain reaction (PCR) methodology. METHODS: An iris nodule was biopsied from a 4-year-old child who was scratched by a kitten on the side of his face and developed redness of the eye associated with cervical lymphadenopathy. Sections of the iridectomy specimen were stained with hematoxylin-eosin, periodic acid-Schiff, and Warthin-Starry technique for histopathologic evaluation. Additionally, serologic tests and molecular diagnosis using B. henselae-specific PCR were performed. RESULTS: Histopathologically, sections of the iridectomy specimen showed a zonal granulomatous inflammation with a central iris necrotic abscess surrounded by a mantle of epithelioid histiocytes and more peripherally by lymphocytes and plasma cells. The Warthin-Starry stain disclosed scattered short bacilli within the necrotic abscess morphologically compatible with B. henselae. Report of serologic tests for B. henselae disclosed a negative immunoglobulin G antibody (negative: less than 12) and a positive immunoglobulin M antibody of 18 (positive: greater than 15). Other serologic studies including Toxocara, histoplasmin, blastomycin, coccidioidin, aspergillin, and Chlamydia were all negative. PCR was positive for B. henselae DNA. CONCLUSIONS: Our case showed a unilateral chronic granulomatous iritis with the histopathologic features compatible with CSD caused by B. henselae bacillus as demonstrated in the iris biopsy and confirmed by serology and PCR technique. This case is an example of a relatively rare uveal manifestation of CSD.

Cystatin C and cardiac hypertrophy in primary hypertension.

INTRODUCTION: Cystatin C is a marker of kidney function and a predictor of cardiovascular morbidity and mortality. It is unknown whether this protein may be related to the cardiac involvement that is common among patients with essential hypertension. PATIENTS AND METHODS: We evaluated the relationship between serum cystatin C, serum creatinine, estimated glomerular filtration rate and cardiac structure assessed by echocardiography, in a group of 49 non-diabetic patients with primary hypertension and normal serum creatinine. RESULTS: Mean cystatin C levels were 0.74 +/- 0.15 mg/l. Age, body mass index, triglycerides and creatinine, estimated glomerular filtration rate and left ventricular mass index were independently associated with cystatin C levels. Seventy three per cent of patients had cardiac hypertrophy. The prevalence of left ventricular hypertrophy was higher in patients who had cystatin C levels above the 70th percentile (0.79 mg/dl) than patients below this percentile (93.3% vs 66.7%, respectively, p = 0.04). Serum cystatin C (beta = 0.48, p = 0.009), but not serum creatinine nor estimated glomerular filtration rate, was independently related to left ventricular mass index in a logistic regression analysis. CONCLUSION: Cystatin C is closely related to left ventricular mass in hypertensive patients, and could be a marker for cardiac hypertrophy in these patients.

Ultrastructural features of posterior crocodile shagreen of the cornea.

Three elderly patients with a clinical diagnosis of posterior crocodile shagreen of the cornea underwent penetrating keratoplasty. Each of the patients had the characteristic symmetrical, polygonal opacities with indistinct edges and intervening clear spaces in the central posterior corneal stroma. Electron microscopic examination of the keratoplasty specimens disclosed the presence of vacuoles throughout the corneal stroma, many of which contained electron-dense material. The vacuoles were observed with increasing density posteriorly and were most concentrated adjacent to the anterior banded portion of Descemet's membrane. A sawtooth-like configuration of the stromal collagenous lamellae was noted in the posterior cornea in one case. We reviewed the three cases of central corneal clouding reported with histopathological findings as well as the clinical descriptions of this entity. Although a sawtooth-like lamellar configuration of the stromal collagen may be seen by electron microscopy, characteristic vacuoles appear to be the only consistent finding. We believe that posterior crocodile shagreen is most likely a degenerative disorder and that it should be distinguished from central cloudy dystrophy of François by its non-familial pattern of occurrence.

Mesenchymal chondrosarcoma of the orbit: a unique radiologic-pathologic correlation.

PURPOSE: To report a unique radiologic-histopathologic correlation of mesenchymal chondrosarcoma of the orbit in a 24-year-old Asian woman. METHODS: Clinicopathologic case review. RESULTS: The patient was examined for left-sided proptosis of several months' duration. CT showed a left orbital mass depicting a central radiolucent, nonenhancing component, and a denser peripheral enhancing portion. Histopathologic examination of the orbital mass showed a biphasic pattern of a mesenchymal chondrosarcoma exhibiting features of a high-grade sarcoma with hemangiopericytoma pattern that corresponds to the radiopaque portion of the mass and areas of chondrosarcoma that correlated with the radiolucent component of the tumor. The patient underwent exenteration of the left orbit followed by radiotherapy and chemotherapy. The last follow-up (8 years, 1 month) disclosed no evidence of recurrence or metastatic disease. CONCLUSIONS: In this case, a unique CT-histopathologic correlation of the mass was established. The authors believe that recognizing the different radiologic features of the orbital tumor can help clinicians in establishing the correct preoperative diagnosis of this potentially lethal neoplasm. To the best of the authors' knowledge, this diagnostic correlation has not been previously reported.

Primary adenoid cystic carcinoma of the conjunctiva arising from the accessory lacrimal glands: a clinicopathologic study of three cases.

PURPOSE: To report 3 cases of primary adenoid cystic carcinoma originating from the accessory and/or ectopic lacrimal glands of the conjunctiva. METHODS: We examined 3 conjunctival tumors histopathologically. The specimens were fixed in 10% formalin. Sections were cut at 5 microm, and the slides were stained with hematoxylin-eosin, periodic acid-Schiff, alcian blue, and colloidal iron methods. RESULTS: We report 3 conjunctival tumors that histopathologically proved to be adenoid cystic carcinomas that had arisen from the accessory lacrimal glands of the conjunctiva (cases 1 and 2) and from ectopic lacrimal gland tissue (case 3). The age of the patients ranged between 53 and 68 years. In 2 of the cases, the tumor involved the tarsal conjunctiva. The third patient had a mass involving the limbal conjunctiva and two thirds of the cornea inferiorly. Histopathologically, acini of accessory lacrimal glands of the conjunctiva were found near the neoplastic lobules in 2 of the tumors. Foci of perineural invasion were observed in 1 of the tumors (case 1). Follow-up examination showed no evidence of recurrence or metastatic disease in cases 1 and 2 (10 and 8 years, respectively). In case 3, the patient was alive and without any evidence of recurrence 1 year after surgical excision of the mass. CONCLUSIONS: Adenoid cystic carcinoma arising from the accessory lacrimal glands of the conjunctiva is a rare occurrence. Only 2 previously reported cases have appeared in the literature, and to our knowledge, there are no reports of this tumor arising from ectopic lacrimal gland tissue in the conjunctiva. Follow-up studies are mandatory to evaluate the biologic behavior of the tumor.

A novel mutation of the Keratin 12 gene responsible for a severe phenotype of Meesmann's corneal dystrophy.

PURPOSE: To determine if a mutation within the coding region of the keratin 12 gene (KRT12) is responsible for a severe form of Meesmann's corneal dystrophy. METHODS: A family with clinically identified Meesmann's corneal dystrophy was recruited and studied. Electron microscopy was performed on scrapings of corneal epithelial cells from the proband. Mutations in the KRT12 gene were sought using direct genomic sequencing of leukocyte DNA from two affected and two unaffected family members. Subsequently, the observed mutation was screened in all available family members using polymerase chain reaction and direct sequencing. RESULTS: A heterozygous missense mutation (Arg430Pro) was found in exon 6 of KRT12 in all 14 affected individuals studied. Unaffected family members and 100 normal controls were negative for this mutation. CONCLUSIONS: We have identified a novel mutation in the KRT12 gene that is associated with a symptomatic phenotype of Meesmann's corneal dystrophy. This mutation results in a substitution of proline for arginine in the helix termination motif that may disrupt the normal helix, leading to a dramatic structural change of the keratin 12 protein.

Cutaneous malignant melanoma metastatic to the vitreous.

We describe a patient with dysplastic nevus syndrome and cutaneous melanoma in whom vitreous involvement was the first sign of metastatic disease. Cytologic examination of vitreous aspirate can usually confirm the diagnosis. Enucleation may be a treatment option if the vitreous is the sole metastatic site.

Histological parameters helpful in recognising steroid-treated temporal arteritis: an analysis of 35 cases.

AIM: To establish the histological and immunohistochemical parameters that are helpful in recognising temporal arteritis in patients who have been treated with steroids before biopsy, and to analyse the clinical features and correlate them with the histological findings. METHODS: A retrospective review of charts of 35 patients treated with steroids before obtaining temporal artery biopsy specimens, spanning a 11-year period from 1995 to 2005. The study was conducted at the Ophthalmic Pathology Laboratory, Cullen Eye Institute, Houston, Texas, USA. The clinical features were evaluated and correlated with the histopathological findings. Each case was evaluated with respect to age, sex, race, clinical findings, erythrocyte sedimentation rate, corticosteroid dosage (oral versus intravenous) and the duration of treatment. The time interval between obtaining the biopsy specimen and the onset of steroid treatment was carefully recorded for each patient. In selected cases, histiocytic markers (CD-68 and HAM-56) were used to identify the presence of epithelioid histiocytes, which characterises a granulomatous inflammation. Other immunohistochemical studies (CD3, CD20, CD4, CD8, CD45RO, CD45RA and S-100 protein) were performed in selected cases to characterise the inflammatory cells. RESULTS: The three most reliable histopathological parameters of corticosteroid-treated temporal arteritis are the following: (1) complete or incomplete mantle of lymphocytes and epithelioid histiocytes located between the outer muscular layer and the adventitia; (2) large circumferential defects in the elastic lamina (best seen with the Movat's pentachrome); and (3) absent or few small multinucleated giant cells. In some cases the main artery appears normal, whereas the primary branches show evidence of a healing arteritis. The histological findings vary according to the duration of treatment before obtaining the biopsy specimen. CONCLUSION: Striking histological differences can be recognised objectively between patients with active (untreated) giant cell arteritis and patients who have been treated with corticosteroids. The earliest histopathological changes were detected by the end of the first week after steroid treatment (usually after day 4 to the end of the first week). The histological findings were more difficult to recognise at 2-3 months after steroid treatment. Ophthalmic and general pathologists should be able to recognise this entity on the basis of the histological findings including the special stains and results of immunohistochemical studies (CD-68 and HAM-56).

IgG-kappa immunoglobulin deposits involving the predescemetic region in a patient with multiple myeloma.

PURPOSE: To report the clinico-pathologic features of corneal deposits in a patient with multiple myeloma with surgical intervention and follow-up. DESIGN: Interventional case report. METHODS: We reviewed the patient's chart and the relevant literature on immunoglobulin corneal deposits and its prognosis. RESULTS: A 52-year-old man with a history of multiple myeloma underwent penetrating keratoplasty sequentially for decreased vision in both eyes secondary to abnormal corneal deposits. Pathologic examination of the keratectomy specimens, including immunohistochemistry and transmission electron microscopy, revealed IgG-kappa immunoglobulin deposits in the predescemetic region in both corneas. After keratoplasty, he regained excellent vision in both eyes, which was maintained at the end of 18 months of follow-up in both eyes despite early signs of recurrence in the right eye. His systemic condition was well controlled during the period of follow-up. CONCLUSION: Corneal deposits in multiple myeloma are well described in the literature, but there are few reports regarding the prognosis and visual function after penetrating keratoplasty. Our report shows that when the systemic condition is well controlled, penetrating keratoplasty has an excellent prognosis in these patients.

Primary squamous cell carcinoma arising from an epithelium-lined cyst of the lacrimal gland.

A 66-year-old man presented with a slowly enlarging, nontender left orbital mass of 2 months' duration. CT and MRI showed a left lacrimal gland mass with enhancement and internal irregularity of cystic structures. Histopathologic analysis of the biopsy specimen revealed a squamous cell carcinoma arising from an epithelium-lined cyst. The patient underwent left orbital exenteration followed by radiation treatment. No evidence of tumor recurrence was observed after a follow-up of 30 months. We believe this primary squamous cell carcinoma may have arisen either from preexisting lacrimal duct cyst (dacryops) with areas of squamous metaplasia or, less likely, from a choristomatous epithelium-lined cyst of the lacrimal gland. Although rare, this entity should be included in the differential diagnosis of cystic lesions of the lacrimal gland.