Disparities in treatment rates of paediatric end-stage renal disease across Europe: insights from the ESPN/ERA-EDTA registry.

BACKGROUND Considerable disparities exist in the provision of paediatric renal replacement therapy (RRT) across Europe. This study aims to determine whether these disparities arise from geographical differences in the occurrence of renal disease, or whether country-level access-to-care factors may be responsible. METHODS Incidence was defined as the number of new patients aged 0-14 years starting RRT per year, between 2007 and 2011, per million children (pmc), and was extracted from the ESPN/ERA-EDTA registry database for 35 European countries. Country-level indicators on macroeconomics, perinatal care and physical access to treatment were collected through an online survey and from the World Bank database. The estimated effect is presented per 1SD increase for each indicator. RESULTS The incidence of paediatric RRT in Europe was 5.4 cases pmc. Incidence decreased from Western to Eastern Europe (-1.91 pmc/1321 km, P < 0.0001), and increased from Southern to Northern Europe (0.93 pmc/838 km, P = 0.002). Regional differences in the occurrence of specific renal diseases were marginal. Higher RRT treatment rates were found in wealthier countries (2.47 pmc/€10 378 GDP per capita, P < 0.0001), among those that tend to spend more on healthcare (1.45 pmc/1.7% public health expenditure, P < 0.0001), and among countries where patients pay less out-of-pocket for healthcare (-1.29 pmc/11.7% out-of-pocket health expenditure, P < 0.0001). Country neonatal mortality was inversely related with incidence in the youngest patients (ages 0-4, -1.1 pmc/2.1 deaths per 1000 births, P = 0.10). Countries with a higher incidence had a lower average age at RRT start, which was fully explained by country GDP per capita. CONCLUSIONS Inequalities exist in the provision of paediatric RRT throughout Europe, most of which are explained by differences in country macroeconomics, which limit the provision of treatment particularly in the youngest patients. This poses a challenge for healthcare policy makers in their aim to ensure universal and equal access to high-quality healthcare services across Europe.

Tissue transglutaminase and the progression of human renal scarring

ABSTRACT. Experimental renal scarring indicates that tissue transglutaminase (tTg) may be associated with the accumulation of extracellular matrix (ECM), both indirectly via TGF-β1 activation and directly by the formation of ε(γ-glutamyl) lysine dipeptide bonds within the ECM. The latter potentially accelerates deposition and confers the ECM with resistance to proteolytic digestion. Studied were 136 human renal biopsy samples from a range of chronic renal diseases (CRD) to determine changes in tTg and ε(γ-glutamyl) lysine crosslinking. Immunofluorescence for insoluble tTg showed a 14-fold increase in the kidneys of CRD patients (5.3 ± 0.5 versus 76 ± 54 mV/cm2), which was shown to be active by a similar 11-fold increase in the ε(γ-glutamyl) lysine crosslink (1.8 ± 0.2 versus 19.3 ± 14.2 mV/cm2). Correlations were obtained with renal function for tTg and crosslink. In situ hybridization for tTg mRNA showed that tubular epithelial cells were the major source of tTg; however, both mesangial and interstitial cells also contributed to elevated levels in CRD. This mRNA pattern was consistent with immunohistochemistry for soluble tTg. Changes in renal tTg and its product, the ε(γ-glutamyl) lysine crosslink, occur in progressive renal scarring in humans independently of the original etiology and in a similar manner to experimental models. tTg may therefore play a role in the pathogenesis of renal scarring and fibrosis in patients with CRD and can therefore be considered a potential therapeutic target. E-mail: T.Johnson@sheffield.ac.uk

The impact of heatwaves on mortality and emergency hospital admissions from non-external causes in Brisbane, Australia

Objectives Heatwaves can have significant health consequences resulting in increased mortality and morbidity. However, their impact on people living in tropical/subtropical regions remains largely unknown. This study assessed the impact of heatwaves on mortality and emergency hospital admissions (EHAs) from non-external causes (NEC) in Brisbane, a subtropical city in Australia. Methods We acquired daily data on weather, air pollution and EHAs for patients aged 15 years and over in Brisbane between January 1996 and December 2005, and on mortality between January 1996 and November 2004. A locally derived definition of heatwave (daily maximum ≥37°C for 2 or more consecutive days) was adopted. Case–crossover analyses were used to assess the impact of heatwaves on cause-specific mortality and EHAs. Results During heatwaves, there was a statistically significant increase in NEC mortality (OR 1.46; 95% CI 1.21 to 1.77), cardiovascular mortality (OR 1.89; 95% CI 1.44 to 2.48), diabetes mortality in those aged 75+ (OR 9.96; 95% CI 1.02 to 96.85), NEC EHAs (OR 1.15; 95% CI 1.07 to 1.23) and EHAs from renal diseases (OR 1.41; 95% CI 1.09 to 1.83). The elderly were found to be particularly vulnerable to heatwaves (eg, for NEC EHAs, OR 1.24 for 65–74-year-olds and 1.39 for those aged 75+). Conclusions Significant increases in NEC mortality and EHAs were observed during heatwaves in Brisbane where people are well accustomed to hot summer weather. The most vulnerable were the elderly and people with cardiovascular, renal or diabetic disease.

Gremlin1 preferentially binds to Bone Morphogenetic Protein-2 (BMP-2) and BMP-4 over BMP-7

Gremlin (Grem1) is a member of the DAN family of secreted bone morphogenetic protein (BMP) antagonists. Bone morphogenetic protein-7 (BMP-7) mediates protective effects during renal fibrosis-associated with diabetes and other renal diseases. The pathogenic mechanism of Grem1 during DN has been suggested to be binding and inhibition of BMP-7. However, the precise interactions between Grem1, BMP-7 and other BMPs have not been accurately defined. Here we show the affinity of Grem1 for BMP-7 is lower than that of BMP-2 and BMP-4, using a combination of surface plasmon resonance and cell culture techniques. Using kidney proximal tubule cells and HEK-293 cell Smad1/5/8 phosphorylation and BMP-dependent gene expression as readout, Grem1 consistently demonstrated a higher affinity for BMP-2>4>7. Cell-associated Grem1 did not inhibit BMP-2 or BMP-4 mediated signalling, suggesting that Grem1-BMP-2 binding occurred in solution, preventing BMP receptor activation. These data suggest that Grem1 preferentially binds to BMP-2 and this may be the dominant complex in a disease situation where levels of Grem1 and BMPs are elevated.

The evaluation of a predialysis class on client knowledge and attitude toward compliant behaviours

In this quasi-experimental study, the theory of reasoned action was used as a conceptual framework to assess the outcome effect of a predialysis class. A pretest, posttest design was used to determine changes in client knowledge about their condition and its treatment, and their intention, attitudes and social norm towards compliant behaviours. The related compliant behaviours were following a low-salt diet and taking medications as proscribed. Thirty-eight End Stage Renal Diseases (ESRD) clients were self-selected into the treatment or control groups. Both groups received the standard predialysis education from members of the multidisciplinary renal team. In addition, the treatment group also attended the predialysis class. Subjects' health locus of control, anxiety and demographic variables were measured as possible extraneous variables. Study subjects from both groups demonstrated a high internal and powerful others health locus of control and a normal range of anxiety. Although not statistically significant ill = .64), the experimental group demonstrated higher knowledge level and greater intention to follow a low salt diet UL= .73). They developed more significantly positive attitudes towards following a low salt diet and increased subjective norm influence after attending the predialysis class. Attending the predialysis class did not have an effect on subjects' intentions, attitudes or subjective norm towards taking medications as prescribed. Conclusion: The predialysis class was only marginally effective in increasing client knowledge, but influenced clients' attitudes towards following a low-salt diet. Based on the results, recommendations for improvements to the class have been suggested.

Efficacité de deux méthodes d'enseignement d'hygiène orale chez les patients atteints de maladies rénales

La maladie rénale peut se manifester avec différents types de pathologies buccales pouvant augmenter les risques de bactériémie. Bien que l’endocardite infectieuse soit une condition rare chez les patients atteints de maladie rénale, elle peut toutefois être retrouvée suite à des infections nosocomiales. Dans le passé, une antibiothérapie prophylactique était prescrite aux patients hémodialysés pour les protéger de l’endocardite infectieuse et de l’infection de l’accès d’hémodialyse. Aujourd’hui, cette recommandation est révolue. Afin de contrer les risques de bactériémie transitoire, une attention particulière doit être apportée aux soins d’hygiène orale à la maison. Le but de l’étude est d’évaluer l’efficacité de deux méthodes d’enseignement d’hygiène orale chez les patients atteints de maladie rénale. Objectifs de recherche Les trois objectifs de recherche sont a) d’évaluer les connaissances des parents de patients atteints de maladies rénales sur l’endocardite infectieuse et le lien avec la santé buccodentaire; b) d’évaluer la perception des parents par rapport à la santé buccodentaire de leur enfant et leurs habitudes d’hygiène orale; et c) de comparer l’influence de deux méthodes d’hygiène orale sur l’indice de plaque chez les enfants atteints de maladies rénales. Hypothèses Les deux hypothèses de recherche sont que a) les parents d’enfants atteints de maladies rénales connaissent et adhèrent aux recommandations émises par l’American Heart Association; et que b) l’amélioration de l’indice de plaque chez les patients atteints de maladies rénales est plus grande pour le groupe recevant des instructions par le matériel audiovisuel par rapport à ceux qui les reçoivent par le néphrologue. Méthodologie Suite à l’obtention d’un certificat d’éthique à la recherche du Centre Hospitalier Universitaire Sainte-Justine, 37 des 38 sujets recrutés âgés entre 6 et 16 ans (19 filles et 18 garçons) ont participé à cette étude transversale. Suite à la signature d’un consentement éclairé, les sujets sont assignés par randomisation à l’un des deux groupes d’instructions d’hygiène orale, soit celui sans instructions spécifiques (groupe 1) ou par matériel audiovisuel (groupe 2). Un questionnaire portant sur les connaissances des parents en rapport avec la santé buccodentaire est remis aux parents. Un indice de plaque initial est noté avant l’application des instructions d’hygiène orale reçues. Un indice de plaque final mis en évidence à l’aide de pastilles révélatrices est documenté avec des photographies intra-orales et mesuré par deux observateurs, testés pour la fiabilité intra et inter-observateurs. Résultats Les analyses statistiques ne démontrent aucune différence significative entre les deux groupes d’instructions d’hygiène orale. Les variables à l’étude (âge, sexe, suivi dentaire, fréquence des soins à la maison, connaissances et motivation) ne montrent aucune influence significative sur la qualité de l’hygiène orale des sujets. Seul l’indice de plaque initial est inversement relié à la perception des parents face à la santé buccodentaire de leur enfant : plus le relevé de plaque est bas, plus la santé buccodentaire est perçue comme bonne. Conclusion Selon les résultats de notre étude, il n’existe pas de différence statistiquement significative entre les deux méthodes d’instructions d’hygiène orale. Néanmoins, les deux techniques permettent de diminuer significativement l’indice de plaque chez les enfants atteints de maladies rénales et de conscientiser cette population à l’importance du maintien d’une bonne santé buccodentaire.

Inhibition of human mesangial cell proliferation by targeting T-Type calcium channels

Background: Aberrant glomerular mesangial cell (MC) proliferation is a common finding in renal diseases. T-type calcium channels (T-CaCN) play an important role in the proliferation of a number of cell types, including vascular smooth muscle cells. The hypothesis that T-CaCN may play a role in the proliferation of human MC was investigated. Methods: The presence of T-CaCN in primary cultures of human MC was examined using voltage clamping and by RT-PCR. The effect of calcium channel inhibitors, and of siRNA directed against the Cav3.2 T-CaCN isoform, on MC proliferation was assessed using the microculture tetrazolium assay and nuclear BrdU incorporation. Results: Human MC express only the Cav3.2 T-CaCN isoform. Co-incubation of MC with a T-CaCN inhibitor (mibefradil, TH1177 or Ni2+) results in a concentration-dependent attenuation of proliferation. This effect cannot be attributed to direct drug-induced cytotoxicity or apoptosis and is not seen with verapamil, an L-type channel blocker. Transfection of MC with siRNA results in knockdown of T-CaCN Cav3.2 mRNA and a clear attenuation of MC proliferation. Conclusions: These results demonstrate for the first time an important role for T-CaCN in human MC proliferation. This could potentially lead to a novel therapy in the treatment of proliferative renal diseases.

Micronutrient prenatal supplementation prevents the development of hypertension and vascular endothelial damage induced by intrauterine malnutrition

Aims: The premise that intrauterine malnutrition plays an important role in the development of cardiovascular and renal diseases implies that these disorders can be programmed during fetal life. Here, we analyzed the hypothesis that supplementation with mixed antioxidant vitamins and essential mineral in early life could prevent later elevation of blood pressure and vascular and renal dysfunction associated with intrauterine malnutrition. Main methods: For this, female Wistar rats were randomly divided into three groups on day 1 of pregnancy: control fed standard chow ad libitum; restricted group fed 50% of the ad libitum intake and a restricted plus micronutrient cocktail group treated daily with a combination of micronutrient (selenium, folate, vitamin C and vitamin E) by oral gavage. Key findings: In adult offspring, renal function and glomerular number were impaired by intrauterine malnutrition. and the prenatal micronutrient treatment did not prevent it. However, increased blood pressure and reduced endothelium-dependent vasodilation were prevented by the micronutrient prenatal treatment. Intrauterine malnutrition also led to reduced NO production associated with increased superoxide generation, and these parameters were fully normalized by this prenatal treatment. Significance: Our current findings indicate that programming alterations during fetal life can be prevented by interventions during the prenatal period, and that disturbance in availability of both antioxidant vitamins and mineral may play a crucial role in determining the occurrence of long-term cardiovascular injury. (C) 2009 Elsevier Inc. All rights reserved.

Aplicações clínicas da suplementação de L-carnitina

A carnitina, uma amina quaternária (3-hidroxi-4-N-trimetilamino-butirato), é sintetizada no organismo (fígado, rins e cérebro) a partir de dois aminoácidos essenciais: lisina e metionina, exigindo para sua síntese a presença de ferro, ácido ascórbico, niacina e vitamina B6. Tem função fundamental na geração de energia pela célula, pois age nas reações transferidoras de ácidos graxos livres do citosol para mitocôndrias, facilitando sua oxidação e geração de adenosina Trifosfato. A concentração orgânica de carnitina é resultado de processos metabólicos - como ingestão, biossíntese, transporte dentro e fora dos tecidos e excreção - que, quando alterados em função de diversas doenças, levam a um estado carencial de carnitina com prejuízos relacionados ao metabolismo de lipídeos. A suplementação de L-carnitina pode aumentar o fluxo sangüíneo aos músculos devido também ao seu efeito vasodilatador e antioxidante, reduzindo algumas complicações de doenças isquêmicas, como a doença arterial coronariana, e as conseqüências da neuropatia diabética. Por esse motivo, o objetivo do presente trabalho foi descrever possíveis benefícios da suplementação de carnitina nos indivíduos com necessidades especiais e susceptíveis a carências de carnitina, como os portadores de doenças renais, neuropatia diabética, síndrome da imunodefeciência adquirida e doenças cardiovasculares.

Efeito dos solutos urêmicos sobre espécies reativas de oxigênio em sistemas-modelo in vitro

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Biologia molecular como ferramenta para o diagnóstico de fungemias: padronização de protocolos e comparação com métodos convencionais

Pós-graduação em Microbiologia - IBILCE

Inquérito de saúde: condições de vida de hipertensos maiores de 60 anos no Estado de São Paulo

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Manifestações oculares na leishmaniose

The Canine Visceral Leishmaniasis is a chronic disease of endemic character, caused by Leishmania Chagasi in Americas. The inoculation of the promastigote form in the individual triggers a local and widespread immune reaction with formation of inflammatory infiltrates and deposition of immune complexes in tissues. Initial clinical symptoms of the disease are: weight reduction, hepatomegaly, splenomegaly and, according to the disease chronicity, signs such as alopecia, erythema, onychogryphosis, arthropathies, renal diseases, pyoderma, seborrheic dermatitis, muscle atrophy and Ocular diseases. Ocular diseases are often reported and are result of the direct parasitism or immune-mediated mechanisms caused by the disease. The Leishmania spp have greater affinity for the anterior segment, so that anterior uveitis is one of the most frequently diagnosed injuries. Blepharitis diffuse and Keratoconjunctivitis also appear as important ocular changes. In histological section, inflammatory infiltrates and macrophages with amastigote form are observed in all ocular tissues, with the exception of the retina and optical nerve. In the clinical analysis and disease diagnosis, should be considered the differential diagnosis, such as Ehrlichiosis and systemic hypertension, because these may cause some ocular manifestations similar to those observed in leishmaniasis

Matrix Metalloproteinase (MMP)-2 Genetic Variants Modify the Circulating MMP-2 Levels in End-Stage Kidney Disease

Background: Matrix metalloproteinases (MMPs) play important roles in the pathophysiology of renal diseases, and imbalanced MMP-2 and its endogenous inhibitor (the tissue inhibitor of metalloproteinases-2; TIMP-2) are implicated in the vascular alterations of end-stage kidney disease (ESKD) patients. We have examined whether MMP-2 gene polymorphisms and haplotypes modify MMP-2 and TIMP-2 levels in ESKD patients as well as the effects of hemodialysis on the concentrations of these biomarkers. Methods: We determined MMP-2 and TIMP-2 plasma levels by gelatin zymography and ELISA, respectively, in 98 ESKD patients and in 38 healthy controls. Genotypes for two relevant MMP-2 polymorphisms (C-T-1306 and C-T-735 in the promoter region) were determined by TaqMan (R) allele discrimination assay and real-time polymerase chain reaction. The software program PHASE 2.1 was used to estimate the haplotype frequencies. Results: We found increased plasma MMP-2 and TIMP-2 levels in ESKD patients compared to controls (p<0.05), and hemodialysis decreased MMP-2 (but not TIMP-2) levels (p<0.05). The T allele for the C-T-735 polymorphism and the C-T haplotype were associated with higher MMP-2 (but not TIMP-2) levels (p<0.05), whereas the C-T-1306 had no effects. Hemodialysis decreased MMP-2 (but not TIMP-2) levels independently of MMP-2 genotypes or haplotypes (p<0.05). Conclusions: MMP-2 genotypes or haplotypes modify MMP-2 levels in ESKD patients, and may help to identify patients with increased MMP-2 activity in plasma. Hemodialysis reduces MMP-2 levels independently of MMP-2 genetic variants. Copyright (C) 2012 S. Karger AG, Basel

La terapia combinata di cellule mesenchimali stromali e aceinibitori riduce la fibrosi renale in un modello animale di ostruzione ureterale unilaterale

Le cellule mesenchimali stromali (MSC) sono cellule multipotenti e numerosi studi hanno mostrato i loro effetti benefici nel danno renale acuto ma non sono ancora stati dimostrati potenziali effetti nella malattia renale cronica. L'ostruzione ureterale unilaterale (UUO) è un modello di fibrosi interstiziale nel quale l'attivazione di molecole vasoattive, citochine profibrotiche e infiammatorie gioca un ruolo patogenetico nello sviluppo dell'apoptosi e atrofia tubulare. Il sistema renina-angiotensina (RAS) gioca un ruolo chiave nello sviluppo della fibrosi renale e i farmaci che hanno come target l'angiotensina II, principale mediatore del RAS, sono attualmente la terapia più efficace nel ridurre la progressione della malattia renale cronica. E' noto che gli ACE-inibitori (ACEi) inducono un aumento compensatorio della renina plasmatica per la mancaza del feedback negativo sulla sua produzione. Tuttavia, la renina (R) promuove il danno renale non solo stimolando la produzione di ANGII, ma anche up-regolando geni profibrotici attraverso l'attivazione del recettore renina/prorenina. Lo scopo dello studio è stato indagare se l'infusione di MSC riduceva il danno renalein un modello animale di UUO e comparare gli eventuali effetti protettivi di ACEi e MSC in UUO. Abbiamo studiato 5 gruppi di ratti. A: sham operati. B: ratti sottoposti a UUO che ricevevano soluzione salina. C: ratti sottoposti a UUO che ricevavano MSC 3X106 nella vena della coda al giorno 0. D:ratti sottoposti a UUO che ricevevano lisinopril dal g 1 al g 21. E: ratti sottoposti a UUO che ricevevano MSC 3X106 nella vena della coda al giorno 0 e lisinopril dal g 1 al g 21. I ratti sono stati sacrificati al giorno 7 e 21. I risultati dello studio mostrano che MSC in UUO prevengono l'aumento della renina, riducono la generazione di ANGII e che in terapia combinata con ACEi riducono ulteriormente l'ANGII, determinando una sinergia nel miglioramento della fibrosi renale.