Carbamazepine removal from low-strength municipal wastewater using a combined UASB-MBR treatment system.

An Upflow Anaerobic Sludge Blanket reactor combined with a two-stage membrane bioreactor were operated for 193 days in order to evaluate the biological removal of carbamazepine (CBZ) from low-strength municipal wastewater. The system worked in three different organic load stages (0.7 ± 0.1 kg COD·m-3·d-1, 0.4 ± 0.1 kg COD·m-3·d-1 and 0.1 ± 0.0 kg COD·m-3·d-1) to assess the impact of the influent OLR on operational parameters such as anaerobic and aerobic sludge retention time (SRT), acidity, volatile fatty acids (VFAs), biomass activity or biogas production. The highest carbamazepine removals were achieved during the anaerobic stage (UASB reactor), reaching averages of 48.9%, 48.0% and 38.2% operating at high, medium and low OLR, respectively. The aerobic treatment (MBR) served as post-treatment, improving the removals, and the global UASB-MBR system reached averages of 70.0%, 59.6% and 49.8% when the influent was at medium and low OLR, respectively. The results demonstrate the potential of combined biological systems on the removal of recalcitrant pharmaceuticals.

Acupuncture Points and Perforating Cutaneous Vessels Identified Using Infrared Thermography: A Cross-Sectional Pilot Study.

AIMS: To evaluate the presence of perforating cutaneous vessels (PCV) in different lower limb acupuncture points (AP) using thermography. MATERIAL AND METHODS: An analytical cross-sectional study was performed on the two lower limbs (n=6) of volunteer subjects. In total, 144 AP and 144 control points (CP) were analysed, one for each AP. First, the AP and CP were located on each individual. Subsequently, both the real and thermographic images were created. In the real images, the location of the AP and the established CP were highlighted with boxes. FLIR Tools Plus and Physio Thermal Imaging software were used to merge the real image with the AP and the CP and to merge the thermographic image with the PCV. By superimposing both images, we were able to verify the presence of PCV among the AP and CP. RESULTS: PCV were identified in 87.5% of the 144 AP examined and in 18.1% of the respective CP. All the AP had a higher percentage of PCV compared to their respective CP, with statistically significant differences in all points, except for ST33 and ST34. The probability of finding PCV in AP was 11 times higher than the probability of not finding it. DISCUSSION: Thermography may serve as a useful tool in the assessment and treatment of patients using acupuncture. The presence of PCV in the area of the acupuncture needle insertion could partially influence the effects generated by the acupuncture technique from the vascular autonomic point of view. CONCLUSIONS: There is a high proportion of PCV in the AP area located in the lower limb.

Cytomegalovirus infection in seronegative patients treated with prophylaxis: case-controlled study.

Primary cytomegalovirus (CMV) infection is common in infancy with approximately 90% to 95% of subjects developing antibodies against this virus. CMV seronegative renal allograft recipients generally receive this infection with a graft or with blood transfusions, showing a high morbidity and mortality. Prophylaxis in these patients has shown good results; however, the published studies have included a small number of patients. Our case-controlled study evaluated 163 kidney transplant recipients: 76 seronegatives for CMV and 87 seropositive for CMV as controls. The evaluated parameters were: CMV infection, CMV disease, renal function, and survival of the patient and graft. We studied our experience among CMV seronegative patients treated with various prophylaxis guidelines. Our conclusions were that CMV prophylaxis in seronegative patients was effective because it showed a risk of infection that was equal (or even less) than that in seropositive patients and revealed a delay in the onset of the disease. CMV seronegativity may be a positive prognostic factor for graft survival.

Histologic assessment of donor kidneys and graft outcome: multivariate analyses.

UNLABELLED: We performed a multivariate analysis to evaluate the importance of histologic parameters in donor kidney biopsies as predictors of graft outcome. METHODS: Wedge protocol biopsies from a single center were analyzed for glomerulosclerosis (GS), interstitial fibrosis (IF), tubular atrophy (TA), arteriosclerosis (AS), and arteriolar hyalinosis (AH). Alterations were quantified as percentage (GS, IF) or semiquantified according to Banff criteria (IF, TA, AS, AH). We calculated creatinine clearance (CrCl) at 1, 2, and 3 years posttransplant. Donor data included age, gender, and type: non-heart-beating donor or brain dead donors. Recipient data included age, gender, cold ischemia time, number of HLA mismatches, peak level of the panel reactive antibody (PRA), number of acute rejection episodes (ARE), and presence or absence of cytomegalovirus (CMV) disease. Univariate and multivariate analyses were performed. Follow-up range was 1 to 4.2 years. RESULTS: GS, IF, TA, and AH were associated with graft survival in the multivariate analysis. The histologic parameters were associated with CrCl at several posttransplant time intervals, but the significance of association was lost in the multivariate analysis. Donor age showed a better correlation with graft function. In the univariate analyses adjusting for donor age, only IF and AH were associated with graft function. CONCLUSIONS: Histologic parameters showed a modest association with graft function. In our study, donor age is the better predictor of graft function. IF and AH may be similar to or better than GS as predictors of graft outcome.

Varicella infection in adult renal allograft recipients: experience at one center.

Disseminated varicella-zoster virus (VZV) infection in adult renal allograft recipients is a rare but potentially fatal illness. We retrospectively collected the cases of VZV infection that occurred in 812 adult renal transplant recipients, performed between 1995 and 2004 at our institution. Eight patients developed varicella (1%), seven men and one woman. The overall median age was 38 years (range = 31 to 64). The median time from transplantation to infection was 32 months (range = 2 to 92). Four cases were primary infections and four disseminated VZV reactivations. Immunosuppression consisted of prednisone (PDN) + cyclosporine (CSA) + mycophenolate (MF; n = 4); PDN + CSA + azathioprine (n = 1); PDN + tacrolimus (FK) + MF (n = 1); FK + MF (n = 1); PDN + rapamycin + MF (n = 1). Seven patients (87%) required hospital admission for a median duration of 11 days (range = 3 to 21). Four patients were previously diagnosed with chronic hepatitis virus infection: two type B (HBV) and two type C (HCV). The last cohort required longer admission than the negative patients (11.5 +/- 3 vs 7.5 +/- 9 days; P = .1). The only clinical manifestation in four patients was general malaise, fever, and a disseminated vesicular rash; the other four patients also showed visceral involvement: two pneumonitis, one hepatitis, and thrombotic microangiopathy, and one developed multiorgan failure and died due to a delayed diagnosis in a patient positive for HBVs. The diagnosis was established according to the symptoms, IgG-IgM seroconversion and VZV polymerase chain reaction quantification in vesicle contents. Treatment consisted of reduced immunosuppression, antiviral drugs (acyclovir or gancyclovir), and in six patients, a varicella-zoster immunoglobulin dose. We concluded that varicella infection in adult renal allograft recipients is unusual but highly morbid. A vaccination program in seronegative pretransplant candidates should be attempted. Early diagnosis and treatment may improve the prognosis. Although further studies are required, chronic HBV or HCV infection seemed to be a risk factor for the disease.

Conversion to sirolimus in renal transplant patients with tumors.

BACKGROUND: Conversion from calcineurin inhibitors (CNI) to sirolimus (SRL) is an option for renal transplant patients who develop a tumor. This strategy, however, may be associated with an increased risk of rejection. AIM: We sought to evaluate a series of renal transplant patients who underwent conversion from CNI to SRL because they developed a tumor during the posttransplant period. METHODS: This prospective study of 29 patients included 2 patients with skin cancer (1 melanoma and 1 squamous cell carcinoma) and 27 patients who developed other tumors: lung (n = 6), prostate (n = 4), lymphoma (n = 2), colon adenocarcinoma (n = 2), kidney (n = 2), Kaposi sarcoma (n = 2), urothelium (n = 1), parotid (n = 1), larynx (n = 1), gastric (n = 1), breast (n = 1), tongue (n = 1), liver (n = 1), xanthoastrocytoma (n = 1), and aggressive angiomyxoma of the perineum (n = 1). RESULTS: CNI were withdrawn in 28 patients and reduced in the remaining patient. Renal function was better when CNI were rapidly or abruptly suspended, with maintenance of cyclosporine (CsA) + SRL for more than 3 months being especially detrimental. Proteinuria worsened in patients whose preconversion levels were >0.5 g/d, particularly those treated with CsA. There was no episode of rejection. CONCLUSIONS: SRL is a promising option for the management of posttransplant tumors. The switch in immunosuppression should be undertaken quickly, especially in patients under treatment with CsA.

Rechazo agudo refractario en el cuarto trasplante renal: cuando el arsenal terapéutico resulta insuficiente para una inmunosupresión adecuada / Refractary acute rejection in the fourth renal transplantation

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Removal of linear alkylbenzene sulfonates and their degradation intermediates at low temperatures during activated sludge treatment.

The degradation of linear alkylbenzene sulfonates and their degradation intermediates (sulfophenylcarboxylic acids) has been characterized at 9 degrees C in an activated sludge pilot plant. After an adequate adaptation period (20 days), LAS primary degradation exceeds 99% and takes place preferentially for long alkyl chain homologues and external isomers. LAS homologues in the reactor are preferentially sorbed onto particulate matter, while sulfophenylcarboxylic acids (SPCs) are present predominantly in solution, due to their lower hydrophobicity. During the adaptation period the most abundant LAS biodegradation intermediates were long chain sulfophenylcarboxylic acids (SPCs) (C(9)-C(13)SPC). However once this system is fully adapted, the microorganisms are capable of degrading SPCs efficiently. SPCs with 7-9 carbon atoms in the carboxylic chain predominate due to their degradation being slower than for the rest of the SPCs. The presence of C(13)SPC confirms that LAS degradation in wastewater starts with a omega-oxidation on the alkylic chain. A preferential degradation of SPC isomers of the types 2phiC(n)SPC to 6phiC(n)SPC was also detected, as shown by the relatively higher SPC concentrations of the remaining ones.

Effect of temperature and organic nutrients on the biodegradation of linear alkylbenzene sulfonate (LAS) during the composting of anaerobically digested sludge from a wastewater treatment plant.

Limits on the application of biosolids (anaerobically processed sludges from wastewater treatment plants) as fertilizers for the amendment of soil are becoming greater because of the accumulation of recalcitrant substances, making necessary the use of techniques that bring the concentration of xenobiotics to lower concentrations than those permitted. In general, the biosolids composting process is sufficient to reduce the usual concentration of linear alkylbenzene sulfonates (LAS) to low levels. In this work, an assessment is made on the effect of temperature in the capacity of enriched bacterial populations to biodegrade LAS, together with the influence that the available nutrients may have in the biodegradation of these compounds. The results show that the microbial metabolism of LAS was not observed in the thermophilic range. The optimum temperature for the biodegradation of LAS appears to be around 40 degrees C, this is, the lowest assayed here, and at this temperature the differences in the biodegradation of LAS among the nutritionally supplemented cultures are small.

Rechazo agudo refractario en el cuarto trasplante renal: cuando el arsenal terapéutico resulta insuficiente para una inmunosupresión adecuada / No disponible

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[Acalculous cholecystitis: an uncommon form of presentation of Q fever]. / Colecistitis alitiásica: una forma infrecuente de presentación de fiebre Q.

Acute acalculous cholecystitis is a very rare clinical presentation of Q fever. We report the case of a 38-year-old man who presented with fever associated with elevation of liver enzyme levels and thickening of the gallbladder wall on abdominal ultrasonography and who was initially diagnosed with acute acalculous cholecystitis. Due to the persistence of fever and transaminase elevation despite antibiotic treatment, a liver biopsy was performed. Characteristic "doughnut" epithelioid granulomas were observed, suggesting a diagnosis of granulomatous hepatitis caused by Q fever, which was confirmed by serological methods. Treatment with doxycycline was commenced and the patient subsequently showed rapid clinical improvement, with disappearance of fever and normalization of liver enzyme levels. We review 8 cases of acute cholecystitis associated with Q fever published in the literature and stress the importance of liver biopsy in the etiological diagnosis of patients with prolonged fever and abnormal liver function tests.

Colecistitis alitiásica: una forma infrecuente de presentación de fiebre Q / Acalculous cholecystitis: an uncommon form of presentation of Q fever

La colecistitis aguda alitiásica es una forma infrecuente depresentación de la fiebre Q. Se expone el caso clínico de unpaciente varón de 38 años con un síndrome febril asociado aalteraciones en las pruebas de función hepática y un engrosamientode la pared vesicular en la ecografía abdominal,que permitió establecer un diagnóstico inicial de colecistitisalitiásica. La falta de respuesta al tratamiento habitual, juntocon la persistencia de la fiebre e hipertransaminasemia,motivó la realización de una biopsia hepática que mostró lapresencia de granulomas de células epitelioides «en rosquilla» típicos de la hepatitis granulomatosa por fiebre Q. Eldiagnóstico se confirmó posteriormente mediante serología.El tratamiento con doxiciclina fue altamente efectivo, conrápida desaparición de la fiebre y normalización de laspruebas de función hepática.Además, se realiza una revisión de los 8 casos de colecistitisaguda asociada a fiebre Q descritos en la bibliografía y sesubraya el papel de la biopsia hepática en el diagnósticoetiológico de los cuadros de fiebre prolongada asociada a alteracionesen el perfil hepático

Acute acalculous cholecystitis is a very rare clinical presentationof Q fever. We report the case of a 38-year-old manwho presented with fever associated with elevation of liverenzyme levels and thickening of the gallbladder wall on abdominalultrasonography and who was initially diagnosedwith acute acalculous cholecystitis. Due to the persistence offever and transaminase elevation despite antibiotic treatment,a liver biopsy was performed. Characteristic «doughnut epithelioid granulomas were observed, suggesting adiagnosis of granulomatous hepatitis caused by Q fever,which was confirmed by serological methods. Treatmentwith doxycycline was commenced and the patient subsequentlyshowed rapid clinical improvement, with disappearanceof fever and normalization of liver enzyme levels.We review 8 cases of acute cholecystitis associated with Q feverpublished in the literature and stress the importance ofliver biopsy in the etiological diagnosis of patients with prolongedfever and abnormal liver function tests

Higher graft salvage rate in renal allograft rupture associated with acute tubular necrosis.

BACKGROUND: Renal allograft rupture is an early postoperative complication threatening graft and patient survival. We reviewed the etiology and prognostic factors for renal allograft rupture. MATERIAL AND METHODS: Among 657 renal transplants performed between 1990 and 2001, renal allograft rupture was diagnosed in 10 cases. Statistical analysis by Student t test, ANOVA, and chi-square was performed to assess donor and recipient characteristics. Multivariate logistic regression to predict renal allograft rupture used variables with P <.15 in the univariate analysis. RESULTS: Patients with renal allograft rupture were mainly men and young. Renal allograft rupture incidence was higher among allografts from non-heart-beating donors, kidneys with delayed graft function, or patients with a high antibody titer. Histopathological findings revealed that six renal allograft ruptures were secondary to acute rejection, three to acute tubular rejection and one to allograft infarction. Only one of six renal allograft ruptures (17.7%) secondary to rejection was resolved by surgery; two of the three patients (66.7%) with acute tubular necrosis were successfully operated and a nephrectomy was performed for the patient with allograft infarction. By multivariate logistic regression analysis, factors shown to be predictive for renal allograft rupture were: delayed graft function, age of recipient, peak panel-reactive antibody >25%, and initial immunosuppressive treatment without antithymocyte globulin. CONCLUSIONS: Higher graft salvage rates are possible in cases of graft rupture associated with acute tubular necrosis.

[BK virus in kidney allografts: a search for histologic evidence of the infection]. / Virus BK en injertos renales: evidencia histológica de la infección.

BACKGROUND: BK virus (BKV) associated interstitial nephritis is a complication in renal transplantation recipients. Its incidence is controversial. The aim of the present study is to determine the incidence of histopathologic evidence of BKV-infection in a single centre. MATERIALS AND METHODS: Renal allograft tissue samples (n = 838) from 526 patients undergoing renal transplant were evaluated by light microscopy. Polymerase chain reaction (PCR) assay for BKV DNA was performed in 41 microdissected cell populations from cases with viral inclusions, cases with other nuclear changes, and cases without nuclear changes. RESULTS: Polyomavirus-inclusions were identified in six cases (five with interstitial nephritis and other one with only urothelial infection). In one case with interstitial nephritis the DNA was degraded. PCR confirmed BKV infection in the other five and was negative in cases without inclusions. CONCLUSIONS: Five patterns of inclusions bodies are observed and they appear to be characteristic. PCR assay seemingly have a high specificity for BKV detection and it does not usually detect latent viral infection.

Early elimination of cyclosporine in kidney transplant recipients receiving sirolimus prevents progression of chronic pathologic allograft lesions.

Cyclosporine elimination in a regimen including sirolimus has been shown to be a safe and effective approach to improve graft function. Nevertheless, it is still unknown whether the functional benefit of CyA withdrawal coincides with a subsequent reduction in histologic lesions of chronic damage or development of chronic allograft nephropathy. This consideration would forecast a reduction in the rate of long-term graft loss. We analyzed 114 graft biopsies from a subgroup of 57 patients that had been included in a randomized study to eliminate CyA at 3 months posttransplant from a regimen including sirolimus either in group A CyA + SRL vs group B of SRL with CyA elimination at 3 months. Every patient had two biopsies, one at transplantation and another at 1 year. The biopsy reading was performed in a blinded manner by a central pathologist using the Banff 1997 and the CADI classifications. A significantly lower rate of progression of tubular and interstitial chronic lesions between basal and 1-year biopsies was observed for group B patients. In addition, the incidence of new cases of chronic allograft nephropathy during the first year was significantly lower in the group in which CyA had been eliminated at 3 months posttransplant. We conclude that early elimination of CyA in the first months posttransplant, when SRL is used as the main immunosuppressant, reduces the appearance or worsening of chronic histologic lesions, probably as a consequence of long-term CyA toxicity prevention.

Daclizumab induction as an immunosuppressive regimen for renal transplant recipients from non-heart-beating donors.

BACKGROUND: Recent reports have demonstrated the efficacy of interleukin-2-receptor blockers in lowering the incidence of early acute rejection. The present study aimed to test the hypothesis that the use of daclizumab induction (DAC) plus low-dose tacrolimus, mycophenolate mofetil, and steroid diminishes the incidence of delayed graft function (DGF) in renal transplants from non-heart-beating donors (NHBD). METHODS: We compared the incidence of DGF and rejection in 185 renal transplants from NHBD treated as follows: Group-I: quadruple sequential therapy with antithymocyte globulin, cyclosporine, azathioprine, and steroids (n=22); Group-II: cyclosporine (8 mg/kg/d) plus azathioprine plus steroid (n=26); Group-III: low-dose cyclosporine (5 mg/kg/d) plus mycophenolate mofetil plus steroid (n=68); Group-IV: low-dose tacrolimus (0.1 mg/kg/d) plus mycophenolate mofetil plus steroid (n=17); and Group-V: DAC plus low-dose tacrolimus plus mycophenolate mofetil plus steroid (n=43). RESULTS: The incidences of DGF were 72.7% in Group-I, 73.1% in Group-II, 69.1% in Group-III, 76.5% in Group-IV, and 44.2% in Group-V. Acute rejection was higher in Group-IV. CONCLUSIONS: The combination of DAC, low-dose tacrolimus, mycophenolate mofetil, and steroids is effective in lowering the incidence of DSF in NHBD kidney transplant recipients without any increase in acute rejection.

Does renal mass exert an independent effect on the determinants of antigen-dependent injury?

The aim of this retrospective study was to determine whether nephron mass may exert a direct, independent effect on immunological tolerance. To this end, data corresponding to patients transplanted with en block pediatric kidneys (EBPK) (n=48) were compared with those of renal transplants with a low risk of hyperfiltration (LRH) comprised of recipients of a kidney from young donors (age 5-40 years) (n=173), and transplants with a high risk of hyperfiltration (HRH) comprised of patients who had received a graft from an elderly donor (older than 55 years) (n=91). All the patients had been subjected to the same immunosuppressive treatment. The median follow-up period was 54 months (6-127 months). The EBPK group showed lowest serum creatinine and highest creatinine clearance levels at each follow-up time. The rate of proteinuria >500 mg/day was 5.7% in EBPK, 7.4% in LRH, and 27.3% in HRH (P=0.000). The incidence of acute corticoresistant rejection was minor in EBPK (7.0% in EBPK, 21.3% in LRH, and 23.3% in HRH; P=0.04). Logistic regression analysis showed that the type of transplant was predictive of acute corticoresistant rejection [RR 5.33 (95% confidence interval (CI) 1.15-24.62) for HRH and RR 4.75 (95%CI 1.06-21.27) for LRH, P=0.03]. Multivariate analyses for graft failure due to chronic rejection and for graft failure due to acute rejection according to Cox's regression analysis demonstrated that HRH transplant was a significant predictive variable of both types of failure [4.08 (95%CI 1.27-13.04) for graft loss due to chronic rejection and 8.69 (95%CI 1.69-44.67) for graft loss due to acute rejection]. The present stratification of data according to nephronal mass would appear to indicate that the greater the mass, the lower the incidence of both acute and chronic rejection. This finding lends support to the hypothesis that a large mass of transplanted tissue relative to recipient mass may dampen the immune response.