[Intramedullary nail removal in the upper and lower limbs. Should we recommend this operation?]. / Entfernung von Verriegelungsnägeln an der oberen und unteren Extremität. Soll diese Operation generell empfohlen werden?

BACKGROUND: Absolute indications for removing intramedullary locking nails (ILN) are undisputed, but there are also relative indications when implant removal might be discussed. The aim of our study was to evaluate complications of ILN removal in the upper and lower extremities. METHODS: Four hundred sixty (460) patients who underwent interlocking nail removal were reviewed regarding complications after removal of implants in the humerus, femur, or tibia. RESULTS: The most common complications were delayed wound healing and wound infections. For the humerus, the complication rate of implant removals due to absolute indication was 29%, and the rate for removals due to relative indication was 12%. In the forearm, no complications were seen. Patients who underwent ILN removal in the femur or tibia for absolute indication had a 21% complication rate; the complication rate in patients with relative indication was 10%. CONCLUSION: The complication rate of interlocking nail removal is too high to justify such a procedure without clear indication.

Laceration of gastric mucosa associated with dialysis-related amyloidosis.

We report a 72-year-old female on long-term hemodialysis, who was admitted to the hospital because of hematemesis. On emergency laparotomy, pylorogastrectomy was performed. The resected specimen showed a giant hematoma and traversing fissure along the lesser curvature of the body of the stomach. Histologically, the specimen showed wide hematoma formation and amyloid deposits in the submucosal layer, especially in the wall of blood vessels. These deposits reacted positively to antihuman beta2-microglobulin antibody. The post-operative course was favorable, and the patient was discharged on the 35th hospital day. In this case, the laceration site on the gastric mucosa was almost intact and did not demonstrate ischemic change, suggesting that the giant hematoma was caused by submucosal vessel rupture, which led to the gastric mucosa laceration. To our knowledge, this is the first case of gastric mucosa laceration associated with dialysis-related amyloidosis.

Younger onset myeloperoxidase-specific antineutrophil cytoplasmic antibody- (MPO-ANCA) related glomerulonephritis accompanied with nephrotic syndrome.

It is known that nephrotic syndrome rarely accompanies myeloperoxidase-specific antineutrophil cytoplasmic antibody- (MPO-ANCA) related glomerulonephritis. We present a case of younger onset MPO-ANCA-related glomerulonephritis accompanied with nephrotic syndrome in a female patient. It was diagnosed through the renal biopsy and the detection of a high titer of MPO-ANCA and steroid therapy (intravenous steroid pulse therapy and oral administration), anticoagulant therapy and antiplatelet therapy were initiated. Since her nephrotic syndrome persisted in spite of the decrease of MPO-ANCA, we conducted a second renal biopsy. We found active necrotizing crescentic glomerulonephritis with a small deposition of immunoglobulin and fibrinogen on the glomeruli. To suppress her disease activity, we administered second steroid-pulse therapy and MPO-ANCA titer disappeared. However, as her nephrotic syndrome, which was accompanied by severe hyperlipidemia, persisted, we tried to treat her using low-density lipoprotein (LDL) apheresis. It was effective temporarily, but she finally fell into end-stage renal failure. We discuss here the possibility of double nephropathy by considering her clinical and renal pathologic features.

Initiation of enzyme replacement therapy for an adult patient with asymptomatic type 1 Gaucher's disease.

A 27-year-old woman was admitted for further examination of thrombocytopenia. Symptoms were absent, but physical examination demonstrated hepatosplenomegaly without neurological abnormalities. Bone marrow examination revealed many Gaucher cells, and glucocerebrosidase activity from cultured skin fibroblasts was markedly reduced. A 1448C (L444P) mutation was detected on one allele of the glucocerebrosidase gene. Because magnetic resonance imaging (MRI) of the femora indicated severe infiltration of Gaucher cells into bone marrow, enzyme replacement therapy was initiated despite the absence of skeletal symptoms. Hematologic abnormalities, visceral and bone involvement have been improving. In cases of thrombocytopenia or hepatosplenomegaly, Gaucher's disease should be suspected.

Glomerular expression of alpha-smooth muscle actin reflects disease activity of IgA nephropathy.

To elucidate the relationship between histological disease states and clinicopathological features in immunoglobulin A nephropathy (IgAN), 90 needle-biopsy specimens diagnosed as IgAN were analyzed. The specimens were divided into four groups according to histological grade and stage index. Immunohistochemical features of alpha-smooth muscle actin (alpha-SMA), macrophages positive for myeloid/histiocyte antigen (MAC387), and expression of type I, III and IV collagens were all examined. Glomerular expression scores of alpha-SMA and the degree of intraglomerular macrophage infiltration were highest in the active and non-sclerotic groups. Type I and IV collagens were significantly more abundant in the sclerotic groups than in the active groups. Type III collagen was strongly expressed in both the active and sclerotic groups. Double immunolabeling of alpha-SMA and intercellular adhesion molecule (ICAM)-1 revealed that ICAM-1 was expressed around the alpha-SMA-positive mesangial area. In multivariate analysis, the glomerular expression score of alpha-SMA was mostly correlated with histological grading in the 10 clinicopathological parameters. Type IV collagen score was mostly correlated with histological staging. These results suggest that glomerular alpha-SMA expression reflects the histological activity of IgAN. Immunohistological staining of alpha-SMA is valuable to estimate the degree of disease activity in IgAN.

The role of hepatitis C virus infection in glomerulopathy.

The characteristics and prevalence of hepatitis C virus (HCV)-associated glomerulopathy remain to be determined. To analyze the relationship between HCV infection and glomerulopathy, we enrolled three groups of individuals or patients. The first group consisted of 7776 individuals who were seen for routine checkups. The second group consisted of 86 patients with chronic hepatitis C, 40 patients with chronic hepatitis B, and 51 patients with non-viral liver diseases. The third group consisted of nine patients with HCV association glomerulopathy who underwent renal biopsy. Of the 7776 individuals undergoing medical checkups, 142 (1.8%) were positive for HCV antibody. The positive rate of proteinuria was significantly higher (P<0.030) in individuals with HCV antibody (2.1%) than in those without the antibody (0.6%). Abnormal levels of serum creatinine (5.8 vs. 0%, P=0.025) and complications of cryoglobulinemia (45 vs. 5%, P<0.001) were significantly more common in the 86 patients with chronic hepatitis C (5.8%) than in the 91 patients with other liver diseases. All patients with abnormal levels of serum creatinine had concomitant cryoglobulinemia. Of the nine patients with histologically proven HCV-associated glomerulopathy, four had cryoglobulinemia (all were type II). Elevations of serum creatinine level (4/4 vs. 0/5, P=0.048) and a glomerular legion of membranoproliferative glomerulonephritis (3/4 vs. 0/5, P=0.048), a severe type of glomerulonephritis, were more common in the four patients with cryoglobulinemia than in the remaining five patients. In conclusion, HCV infection was found to be significantly associated with glomerulopathy. In addition, the presence of cryoglobulinemia, which usually accompanies membranoproliferative glomerulonephritis, was found to be an indicator of renal insufficiency in patients with HCV-associated glomerulopathy.

Transmission of and liver injury by TT virus in patients on maintenance hemodialysis.

To study the prevalence and clinical significance of TT virus (TTV) infection in hemodialysis patients, we tested for TTV DNA in serum, using the nested polymerase chain reaction. The prevalence of TTV DNA in 352 hemodialysis patients was 32%, significantly higher than that in 50 healthy blood donors (12%). The prevalence increased with age (P = 0.0098): it was 20% (22/110) in patients aged less than 49 years, 37% (69/188) in those aged 50-69 years, and 41% (22/ 54) in those aged over 70 years. Other clinical features and the prevalence of other hepatitis viral markers tested did not differ between patients with TTV DNA and those without it. The detection rate of hepatitis C virus (HCV) and hepatitis G virus (HGV) viremias increased with duration of hemodialysis and with the number of blood transfusion units, but the prevalence of TTV viremia did not. Twenty-nine of 91 patients followed for 5 years were initially positive for TTV DNA. Of these 29 patients, 17 (59%) carried this viremia for at least 5 years. Fourteen of the 62 patients (23%) who were initially negative for TTV DNA acquired TTV viremia. Serum alanine aminotransferase (ALT) levels were elevated in patients with HCV viremia but not in patients with HGV or TTV viremia. However, the mean ALT level in patients with all three viremias (HCV, HGV, and TTV) was significantly higher than that in patients with one or two of the viremias. More than 30% of the hemodialysis patients had TTV viremia and the carrier state was maintained for years. The hemodialysis procedures, including blood transfusion, did not seem to be crucial for the transmission of TTV. The pathogenic effects of TTV on hepatitis appear to be limited.

A case of mitochondrial cytopathy with a typical point mutation for MELAS, presenting with severe focal-segmental glomerulosclerosis as main clinical manifestation.

A 27-year-old female with short stature and mild hearing loss was diagnosed as having focal-segmental glomerulosclerosis by renal biopsy at our hospital. One year later she developed progressive renal dysfunction and cardiac failure and was admitted again to our hospital for evaluation. Though her only neurological disorder was mild hearing loss, her short stature and elevated lactate and pyruvate values in cerebrospinal fluid suggested mitochondrial cytopathy. A muscle biopsy specimen of the left biceps brachii, using modified Gomori trichrome stain, showed a typical image of ragged-red fibers, and an increased number of giant mitochondria with paracrystalline inclusions were visible by electron microscopy. Mitochondrial DNA from the skeletal muscle showed an A-to-G transition at 3243 of transfer RNALeu(UUR), the common point mutation for mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes. These data confirmed the diagnosis of atypical mitochondrial cytopathy with renal and heart involvement. Mitochondrial cytopathies are often associated with hypertrophic cardiomyopathy but rarely with renal disease. Among the few reported cases with associated renal disease, most included renal tubular disorders; few cases with focal glomerular sclerosis are known. The present case of atypical mitochondrial cytopathy was characterized by a unique clinical course and rare complications with focal-segmental glomerulosclerosis.

Prospective follow-up study of hepatitis C virus infection in patients undergoing maintenance haemodialysis: comparison among haemodialysis units.

A prospective follow-up study on hepatitis C virus (HCV) infection was conducted in seven haemodialysis units from April 1990 to March 1995. A total of 634 patients were undergoing maintenance haemodialysis in the seven units. Of those, 302 patients participated in the follow-up study; 179 were initially HCV antibody negative and 123 were initially positive. Nine of the 179 initially negative patients became positive for HCV antibody during the follow-up period. In accordance with the appearance of HCV antibody, indicating new infection of HCV, all nine of these patients were diagnosed with HCV viraemia. As no other routes were apparent, HCV infection in all nine patients was likely due to nosocomial transmission. Prevalence of HCV antibody at the start of follow up was significantly higher (P < 0.001) in haemodialysis units A-C (37.9%) than in haemodialysis units D-G (17.0%). Incidence of new HCV infection was significantly higher (P = 0.005) in the former units (2.2% per year) than in the latter (0.2% per year). Ten of the 123 patients who were initially positive for the HCV antibody exhibited a loss of reactivity during the follow-up period; of these 10 patients, nine were negative for HCV-RNA from the start of the study. In conclusion, the incidence of new HCV infection seen in patients undergoing haemodialysis suggests that their risk of acquiring HCV infection is directly related to the prevalence of HCV antibody positive patients being treated in the units.

Clinical significance of hepatitis G virus infection in patients on long-term haemodialysis.

Infection with the newly discovered hepatitis G virus (HGV) was analysed in 163 patients on long-term haemodialysis to clarify its prevalence and clinical significance. Hepatitis G virus RNA in serum was measured by polymerase chain reaction with primers corresponding to the putative non-structural 5' region. Of the 163 patients, three (1.8%) were positive for hepatitis B surface antigen, 40 (24.5%) were positive for hepatitis C virus (HCV)-RNA and 16 (9.8%) were positive for HGV-RNA. Five of the 16 patients with HGV-RNA were also positive for HCV-RNA. Patients with HCV and HGV coinfection had undergone a longer duration of haemodialysis (P = 0.001) and had higher units of transfusion (P = 0.031) compared with those without hepatitis virus infection. Transfusion history was significantly higher (P = 0.039) in patients with only HGV infection than in those without hepatitis virus infection. Hepatitis C virus RNA concentration was higher (P = 0.032) in patients with HCV and HGV coinfection than in those with HCV infection only, but alanine aminotransferase (ALT) levels were similar between these two groups. In conclusion, about 10% of patients on haemodialysis were infected with HGV and the infection was closely associated with transfusion history.

Increased expression of monocyte chemoattractant protein-1 in anti-thymocyte antibody-induced glomerulonephritis.

The infiltration of monocytes-macrophages in the glomerulus is one of the hallmarks of glomerulonephritis and may play an important pathogenetic role. Monocyte chemoattractant protein-1 (MCP-1) and colony stimulating factor-1 (CSF-1) are monocyte-specific cytokines with chemoattractant and activating activities for monocytes. MCP-1 and CSF-1 can be generated by several cell types, including glomerular mesangial cells, and can be stimulated by cytokines and immune complexes. To study the expression of CSF-1 and MCP-1 in a model of proliferative glomerulonephritis we used Northern blot analysis and immuno-histochemistry. The glomerular lesion was induced in rats by the i.v. injection of a heterologous anti-thymocyte antiserum (ATS), directed against an antigen which is localized on glomerular mesangial cells. Northern blot analysis revealed comparable amounts of CSF-1 in glomeruli isolated from control untreated rats, and from rats after 30 minutes to three weeks of injection of ATS antibody. In control glomeruli no mRNA levels for MCP-1 were detectable, but increased markedly 30 minutes after the induction of the nephritis, were then reduced at 24 hours and increased again at 5 and 21 days after induction of the disease. The increase in mRNA levels for MCP-1 30 minutes or 24 hours after ATS injection was markedly attenuated if rats were complement depleted by cobra venom injection. These time points following antibody injection were associated with mesangial immune complex formation (30 min), mesangiolysis (24 hr) and proliferative glomerulonephritis (5 and 21 days). By immunohistology the presence of MCP-1 was demonstrated in glomeruli with a predominant mesangial distribution. The mesangial immunofluorescence for MCP-1 followed a pattern similar to that of the mRNA for MCP-1 after induction of the disease process, that is, it increased after 30 minutes, decreased after 24 hours and was increased again at three weeks. Within 30 minutes of the antibody injection an increased infiltration of monocytes-macrophages was observed in the glomeruli, which was maintained up to three weeks of induction of the glomerulonephritis. When the rats were decomplemented with cobra venom factor prior to the i.v. injection of ATS, the expression of MCP-1 in glomeruli remained low and the influx of monocytes/macrophages did not appear. We conclude that MCP-1 is increased early on in glomeruli of rats with immune-mediated mesangial proliferative glomerulonephritis. This increase is mediated by complement activation secondary to the in situ immune complex formation at the glomerular mesangium.(ABSTRACT TRUNCATED AT 400 WORDS)

Preliminary report on use of a p(HEMA)-collagen composite in maxillo-facial surgery.

After being thoroughly tested on animals, a composite polymer material based on poly(2-hydroxyethyl methacrylate) and calf skin collagen has been allowed in a limited clinical trial in the Czech Republic. Up to now, the medical use of the biomaterial comprises implants for maxillo-facial surgery, i.e. augmentation of soft tissues (seven cases); reparation of fractured eye sockets (12 cases) and in special indications (two cases). The clinical results obtained so far are presented here as case reports. These preliminary results are very encouraging for a broader utilization of this type of biomaterial in the surgical fields of human medicine.

Oxygen radicals as second messengers for expression of the monocyte chemoattractant protein, JE/MCP-1, and the monocyte colony-stimulating factor, CSF-1, in response to tumor necrosis factor-alpha and immunoglobulin G. Evidence for involvement of reduced nicotinamide adenine dinucleotide phosphate (NADPH)-dependent oxidase.

The potential involvement of reactive oxygen species in the expression of genes involved in immune response was examined in mesangial cells. Tumor necrosis factor (TNF-alpha) and aggregated (aggr.) IgG increased mRNA levels for the monocyte chemoattractant protein, JE/MCP-1, and the colony-stimulating factor, CSF-1. Scavengers for free radicals such as di- and tetra-methylthiourea (DMTU and TMTU) attenuated the increase in mRNA levels in response to TNF-alpha and aggr. IgG. Generation of superoxide anion by xanthine oxidase and hypoxanthine increased mRNA levels of these genes, but exogenous H2O2 did not. Addition of NADPH to activate a membrane-bound NADPH-oxidase generated superoxide and caused a dose-dependent increase in mRNA levels and further enhanced the stimulation by TNF-alpha or aggr. IgG. An inhibitor of NADPH-dependent oxidase 4'-hydroxy-3'-methoxy-acetophenone attenuated the rise in mRNA levels in response to TNF-alpha and aggr. IgG. By nuclear run-on experiments TNF-alpha, aggr. IgG and NADPH increased the transcription rates for JE/MCP-1 and CSF-1, effects inhibited by TMTU. We conclude that generation of reactive oxygen species, possibly by NADPH-dependent oxidase, are involved in the induction of the JE/MCP-1 and CSF-1 genes by TNF-alpha and IgG complexes. The concerted expression of leukocyte-directed cytokines represents a general response to tissue injury.

Pharmacokinetics of temocapril and enalapril in patients with various degrees of renal insufficiency.

Temocapril is a novel ACE inhibitor that is cleared via dual excretion routes in humans. Borderline or mildly hypertensive patients with normal renal function [group 1, creatinine clearance (CLCR) > 70 ml/min (4.2 L/h), n = 12], moderate renal impairment [group 2, CLCR 30 to 70 ml/min (1.8 to 4.2 L/h), n = 12] or severe renal impairment [group 3, CLCR < 30 ml/min (1.8 L/h), n = 12] received a single oral dose of either temocapril 1 mg (n = 6, each group) or enalapril 5mg (n = 6, each group). These 2 drugs gave similar values for the area under the plasma concentration-time curve (AUC) of the active diacids. The maximum plasma concentration of enalapril diacid was increased 2- and 6-fold in moderate and severe renal impairment, respectively, whereas that of temocapril diacid was not altered. The AUC of enalapril diacid increased 13-fold at CLCR values < 30 ml/min, but that of temocapril diacid increased only 2-fold. The duration of plasma ACE inhibition due to enalapril was greatly prolonged by the impairment of renal function, whereas that due to temocapril was affected very little. Urinary recovery of temocapril diacid was decreased markedly in patients with severe renal dysfunction, most probably because the diacid was excreted through the biliary route. On the other hand, urinary recovery of enalapril diacid remained fairly high even in patients with severe renal impairment, because of extremely high plasma diacid concentrations resulting from the lack of biliary excretion. These observations suggest that temocapril is beneficial in the treatment of hypertension in patients with severely impaired renal function.

Regulation of monocyte chemoattractant protein-1 and macrophage colony-stimulating factor-1 by IFN-gamma, tumor necrosis factor-alpha, IgG aggregates, and cAMP in mouse mesangial cells.

The interaction of mesangial cells and monocyte-macrophages plays an important role in renal glomerular immune injury. We have, therefore, examined the regulation of two monocyte-specific cytokines, i.e., macrophage CSF-1 and monocyte chemoattractant protein (MCP-1), the product of the mouse JE gene, in mouse mesangial cells. TNF-alpha, IFN-gamma, and aggregates of IgG increased the synthesis of CSF-1 (determined by RIA) and of MCP-1 (determined by biolabeling and immunoprecipitation). Stimulation of cAMP generation by forskolin or PGE2 decreased basal CSF-1 synthesis and attenuated the responses to TNF-alpha, IFN-gamma, and IgG. Forskolin and PGE2 also decreased biolabeled MCP-1 generation after stimulation with IFN-gamma, TNF-alpha, or IgG. By Northern blot analysis steady state levels of mRNA for CSF-1 and JE/MCP-1 were increased after incubation with IFN-gamma, TNF-alpha, or IgG, and these effects were attenuated by forskolin. By using nuclear run-on assays the decrease in CSF-1 and JE/MCP-1 mRNA levels induced by stimulation of cAMP generation with forskolin was attributed to decreased transcription of these genes. Thus, agents stimulating cAMP generation, including PGE2, counterbalance the generation of CSF-1 and JE/MCP-1 in response to IFN-gamma, TNF-alpha, and IgG complexes. The locally produced CSF-1 and MCP-1 may in turn influence the interaction between mesangial cells and monocyte-macrophages in glomerular injury.

Hepatitis virus infection (HBV and HCV) in eleven Japanese hemodialysis units.

To evaluate hepatitis C virus (HCV) and hepatitis B virus (HBV) infection in hemodialysis (HD) units, serum samples from 607 HD patients and 150 staff members at 11 HD units in Japan were collected, and were compared with those from 704 ordinary blood donors as a control. Serum samples subjected to a first generation ELISA for antibody to HCV (anti-C100-3) and were tested by ELISA for HB surface antigen (HBs-Ag), antibody to HBs-Ag, and antibody to HB core antigen (anti-HBc) as HBV markers. We also tested for HCV infection with a second generation ELISA (for antibodies to C22-3, C33c, and C100-3) in 120 HD patients and 30 staff members at 2 selected HD units. Of 607 HD patients, 104 (17%) were positive for anti-C100-3 and 221 (36%) for HBV markers, indicating a much higher prevalence of HCV and HBV infection among HD patients than among ordinary blood donors (0.9% and 18%, respectively). Of 159 patients without a history of blood transfusion, 17 (11%) were positive for anti-C100-3, showing that HCV infection can be acquired without transfusion. The incidence of anti-C100-3 varied from 0% to 53% at different HD units, and HBV markers varied from 17% to 50%. Our study detected a high prevalence of co-infection with HBV and HCV, suggesting that HCV infection may contribute to chronic liver dysfunction in HD patients. Out of 150 staff members, 3 (2%) were positive for anti-C100-3, whereas 25 (17%) were positive for anti-HBc (indicating prior HBV infection).(ABSTRACT TRUNCATED AT 250 WORDS)