Association of drug metabolism gene polymorphisms with toxicities, graft-versus-host disease and survival after HLA-identical sibling hematopoietic stem cell transplantation for patients with leukemia

Individual differences in drug efficacy or toxicity can be influenced by genetic factors. We investigated whether polymorphisms of pharmacogenes that interfere with metabolism of drugs used in conditioning regimen and graft-versus-host disease (GvHD) prophylaxis could be associated with outcomes after HLA-identical hematopoietic stem cell transplantation (HSCT). Pharmacogenes and their polymorphisms were studied in 107 donors and patients with leukemia receiving HSCT. Candidate genes were: P450 cytochrome family (CYP2B6), glutathione-S-transferase family (GST), multidrug-resistance gene, methylenetetrahydrofolate reductase (MTHFR) and vitamin D receptor (VDR). The end points studied were oral mucositis (OM), hemorrhagic cystitis (HC), toxicity and venoocclusive disease of the liver (VOD), GvHD, transplantation-related mortality (TRM) and survival. Multivariate analyses, using death as a competing event, were performed adjusting for clinical factors. Among other clinical and genetic factors, polymorphisms of CYP2B6 genes that interfere with cyclophosphamide metabolism were associated with OM (recipient CYP2B6*4; P=0.0067), HC (recipient CYP2B6*2; P=0.03) and VOD (donor CYP2B6*6; P=0.03). Recipient MTHFR polymorphisms (C677T) were associated with acute GvHD (P=0.03), and recipient VDR TaqI with TRM and overall survival (P=0.006 and P=0.04, respectively). Genetic factors that interfere with drug metabolisms are associated with treatment-related toxicities, GvHD and survival after HLA-identical HSCT in patients with leukemia and should be investigated prospectively.

Long-term trends in sunshine duration and its association with schizophrenia birth rates and age at first registration - data from Australia and the Netherlands

Back ground. Based on the well-described excess of schizophrenia births in winter and spring, we hypothesised that individuals with schizophrenia (a) would be more likely to be born during periods of decreased perinatal sunshine, and (b) those born during periods of less sunshine would have an earlier age of first registration. Methods. We undertook an ecological analysis of long-term trends in perinatal sunshine duration and schizophrenia birth rates based on two mental health registers (Queensland. Australia n = 6630; The Netherlands n = 24, 474). For each of the 480 months between 1931 and 1970, the agreement between slopes of the trends in psychosis and long-term sunshine duration series were assessed. Age at first registration was assessed by quartiles of long-term trends in perinatal sunshine duration, Males and females were assessed separately. Results. Both the Dutch and Australian data showed a statistically significant association between falling long-term trends in sunshine duration around the time of birth and rising schizophrenia birth rates for males only. In both the Dutch and Australian data there were significant associations between earlier age of first registration and reduced long-term trends in sunshine duration around the time of birth for both males and females, Conclusions. A measure of long-term trends in perinatal sunshine duration was associated with two epidemiological features of schizophrenia in two separate data sets. Exposures related to sunshine duration warrant further consideration in schizophrenia research. (C) 2002 Elsevier Science B.V. All rights reserved.

Transcriptional regulation of the sodium-sulfate cotransporter NaSi-1 gene

Inorganic sulfate is one of the most abundant anions in mammalian plasma and is essential for proper cell growth and development, as well as detoxification and activation of many biological compounds. To date, little is understood how physiological levels of sulfate are maintained in the body. Our studies, and of others, have identified the NAS(i)-1 protein to be a functional sulfate transporter in the kidney and intestine, and due to this localization, constitutes a strong candidate gene for maintaining body sulfate homeostasis. Several factors, including hormones and metabolic conditions, have been shown to alter NAS(i)-1 mRNA and protein levels in vivo. In this study, we describe the transcriptional regulation of NaSi-1, with a focus on the mouse NaSi-1 gene (Nas1) that was recently cloned in our laboratory. Vitamin D (1,25-(OH)(2)D-3) and thyroid hormone (T-3) led to an increase in Nas1 promoter activity in OK cells. Mutational analysis of the Nas1 promoter resulted in identification of a direct repeat 6-type vitamin-D-responsive element (DR6 VDRE) at -525 to -508 and an imperfect inverted repeat 0-type T-3 responsive element (IRO T3RE) at -426 to -425 which conferred 1,25-(OH)(2)D-3 and T-3 responsiveness respectively. These findings suggest for vitamin D and thyroid hormone regulation of NaSi-1, may provide important clues to the physiological control of sulfate homeostasis.

Diagnosis and management of unusual dental abscesses in children

Although the majority of dental abscesses in children originate from dental caries or trauma, a few are associated with unusual conditions which challenge diagnosis and management. Recent research findings have shed light on these unusual entities and greatly improved understanding of their clinical implications. These conditions include developmental abnormalities such as dens invaginatus in which there is an invagination of dental tissues into the pulp chamber and dens evaginatus in which a tubercle containing pulp is found on the external surface of a tooth crown. In addition, inherited conditions which show abnormal dentine such as dentine dysplasia, dentinogenesis imperfecta, and osteogenesis imperfecta predispose the dentition to abscess formation. Furthermore, 'spontaneous' dental abscesses are frequently encountered in familial hypophosphataemia, also known as vitamin D-resistant rickets, in which there is hypomineralization of dentine and enlargement of the pulp. In addition to developmental conditions, there are also acquired conditions which may cause unusual dental abscesses,. These include pre-eruptive intracoronal resorption which was previously known as 'pre-eruptive caries' or the 'fluoride bomb'. In addition, some undiagnosed infections associated with developing teeth are now thought to be the mandibular infected buccal cysts which originate from infection of the developing dental follicles. In the present paper, these relatively unknown entities Which cause unusual abscesses in children are reviewed with the aim of updating the general practitioner in their diagnosis and management.

Risk factors for metabolic bone disease in Crohn's disease patients

Background: The aim was to evaluate the presence of metabolic bone disease (MBD) in patients with Crohn’s disease (CD) and to identify potential etiologic factors. Methods: The case–control study included 99 patients with CD and 56 controls with a similar age and gender distribution. Both groups had dual-energy x-ray absorptionmetry and a nutritional evaluation. Single nucleotide polymorphisms at the IL1, TNF-a, LTa, and IL-6 genes were analyzed in patients only. Statistical analysis was performed using SPSS software. Results: The prevalence of MBD was significantly higher in patients (P ¼ 0.006). CD patients with osteoporosis were older (P < 0.005), small bowel involvement and surgical resections were more frequent (P < 0.005), they more often exhibited a penetrating or stricturing phenotype (P < 0.05), duration of disease over 15 years (P < 0.005), and body mass index (BMI) under 18.5 kg/m2 (P < 0.01) were more often found. No association was found with steroid use. Patients with a Z-score < 2.0 more frequently had chronic active disease (P < 0.05). With regard to diet, low vitamin K intake was more frequent (P ¼ 0.03) and intake of total, monounsaturated, and polyunsaturated fat was higher in patients with Z-score < 2.0 (P < 0.05). With respect to genetics, carriage of the polymorphic allele for LTa252 A/G was associated with a higher risk of osteoporosis (P ¼ 0.02). Regression analysis showed that age over 40 years, chronic active disease, and previous colonic resections were independently associated with the risk of developing MBD. Conclusions: The prevalence of MBD was significantly higher in CD patients. Besides the usual risk factors, we observed that factors related to chronic active and long-lasting disease increased the risk of MBD.

Contributo para a determinação simultânea, por cromatografia líquida de alta resolução, de carotenoides, vitamina A e vitamina E em amostras compostas por diferentes matrizes alimentares

Trabalho Final de Mestrado para obtenção do grau de Mestre em Engenharia Química e Biológica

Calcificações vasculares nos doentes em diálise : elo de ligação entre doença óssea e doença vascular

RESUMO: A presente dissertação para tese de doutoramento apresenta o desenvolvimento e a validação de um método simples e original para o diagnóstico de calcificações vasculares em doentes em diálise, utilizando um score semiquantitativo criado por nós e obtido em RX simples da bacia e das mãos, denominado score de calcifi cação vascular simples. Demonstramos que este score vascular simples é preditor de risco cardiovascular nos doentes em diálise. O score de calcificação vascular simples associou-se ainda à baixa densidade mineral óssea avaliada por dual energy X -ray absortiometry (DXA) no colo do fémur. Verifi camos igualmente que, em doentes em diálise, as calcifi cações coronárias quantifi cadas pelo score de Agatston e o score de calcifi cação vascular simples se associaram a um menor volume ósseo avaliado em biopsias ósseas. Estes trabalhos corroboram a hipótese da existência de um elo de ligação entre a doença óssea e a doença vascular nos doentes em diálise, e um dos elementos que contribuem para este elo de ligação podem ser as calcificações vasculares. Este score de calcificação vascular simples avalia calcifi cações em artérias de grande, médio e pequeno calibre, e inclui os dois padrões radiológicos de calcificação: calcificação linear, associada à calcifi cação da camada média da parede arterial, e calcificação irregular, associada à calcifi cação da camada íntima arterial1. Nos diferentes trabalhos por nós publicados demonstramos que as calcificações vasculares avaliadas por este método simples e barato permitem a identificação de indivíduos com elevado risco cardiovascular. Este score vascular associa -se a maior risco de mortalidade cardiovascular2, de mortalidade de causa global3, de internamentos cardiovasculares2, de doença ardiovascular2, de doença arterial periférica2,4,de calcifi cações valvulares5 e de rigidez arterial3. As guidelines KDIGO (Kidney disease: improving global outcomes), publicadas em 2009,sugerem que os doentes renais crónicos nos estadios 3 a 5, com calcificações vasculares e valvulares, devem ser considerados como apresentando o mais elevado risco cardiovascular6. A elevada mortalidade dos doentes renais crónicos não é totalmente explicada pelos fatores de risco tradicionais7. A organização KDIGO defende, desde 2006, a hipótese da existência de um elo de ligação entre a doença óssea e a doença vascular8. Esta ligação pode ser explicada pelas alterações do metabolismo mineral e ósseo e pela sua interação com as calcificações vasculares. Verificamos, nos nossos trabalhos, uma associação entre calcifi cações vasculares e doença óssea. O baixo volume ósseo diagnosticado por análise histomorfométrica de biopsias ósseas foi preditor de maior risco de calcificações vasculares avaliadas pelo score de calcifi cação vascular simples (dados apresentados nesta dissertação, no capítulo 6) e pelo score coronário de Agatston num grupo de doentes em diálise9. A contribuição original deste artigo9 foi considerada merecedora de um editorial feito pelo Dr. Gérard London10, investigador líder na área da calcificação vascular dos doentes renais crónicos e actual Presidente da EDTA (European Dialysis and Transplantation Association). Fomos também os primeiros a descrever uma associação independente e inversa entre a densidade mineral avaliada no colo do fémur por DXA (dual energy X -ray absortiometry) com calcificações vasculares avaliadas pelo score de calcificação vascular simples, com rigidez arterial avaliada por velocidade de onda de pulsocarotidofemoral e com doença arterial periférica diagnosticada por critérios clínicos11. Fomos igualmente os primeiros a mostrar uma correlação signifi cativa entre a densidade mineral óssea avaliada por DXA no colo do fémur, mas não na coluna lombar, com a espessura cortical avaliada por análise histomorfométrica em biopsia óssea12. O nosso estudo atribui pela primeira vez à DXA um papel no diagnóstico de porosidade cortical nos doentes em diálise. A utilidade da avaliação diferencial da densidade mineral óssea cortical e trabecular necessita ainda de ser confirmada em estudos prospectivos. Este achado inovador do nosso estudo foi mencionado pela ERBP (European Renal Best Practice) no comentário feito à posição da KDIGO que considera ser reduzida a utilidade da densidade mineral óssea nos doentes em diálise13. Dois dos trabalhos incluídos nesta dissertação foram referenciados nas guidelines KDIGO 2009 para avaliar a prevalência das calcificações vasculares (KDIGO 2009: Tabela suplementar 10, Fig. 3.6) e para validar a associação entre calcificações vasculares e mortalidade cardiovascular (KDIGO 2009: Tabela suplementar 12, Fig. 3.7)6. A inclusão destes nossos dois estudos nas referências destas guidelines, que utilizaram o exigente sistema GRADE (Grades of recommendation, assessment, development, and evaluation) na classificação e selecção dos estudos, valida o interesse científico dos nossos trabalhos. O diagnóstico de calcificações vasculares tem um interesse prático para os doentes renais crónicos. A presença de calcifi cações vasculares é um sinal de alerta para a existência de um elevado risco cardiovascular, e esta informação pode ser utilizada para modificar a terapêutica nestes doentes6. Diferentes métodos podem ser usados para diagnosticar calcificações vasculares nos doentes em diálise14,15. O score de calcificação vascular simples tem a vantagem da simplicidade e de poder ser facilmente interpretado pelo nefrologista, sem necessidade de um radiologista. A reprodutibilidade deste score já foi demonstrada por diferentes grupos em estudos nacionais e internacionais16-24. Nestes estudos foi demonstrado que as calcifi cações vasculares avaliadas pelo método criado por nós são preditoras de maior risco de eventos cardiovasculares16, de amputações dos membros inferiores17, de velocidade de onda de pulso18,19, de calcificações corneanas e conjuntivais20 e de calcifi cações coronárias21. Também foi demonstrada uma associação inversa entre o score de calcificação vascular simples com os níveis séricos de PTH21, com os níveis de 25(OH)vitamina D 22,23 e com os níveis de fetuína A19,24. Todos estes estudos, realizados por diferentes grupos, que utilizaram o score de calcificação vascular simples na sua metodologia, comprovam a facilidade de utilização deste score e a concordância de resultados atestam a sua reprodutibilidade e a utilidade na avaliação dos doentes renais crónicos. ---------------------------ABSTRACT: This thesis presents the development and validation of a simple and original method to identify vascular calcifications in dialysis patients, using a semi -quantitative score that we have created and that is obtained in plain X -ray of pelvis and hands. This score was named in different publications as “simple vascular calcifi cation score”. We have demonstrated that this score is a predictor of higher cardiovascular risk in dialysis patients. The simple vascular calcification score was also associated with lower mineral bone density evaluated by DXA in femoral neck. In hemodialysis patients coronary calcifications evaluated by the coronary Agatston score and by the simple vascular calcification score were associated with lower bone volume analysed in bone biopsies. These studies corroborate the hypothesis of the existence of a link between bone disease and vascular disease in dialysis patients and one of the elements of this link may be vascular calcifications. This simple vascular calcification score identifi es calcifications in large, medium and small calibre arteries and includes the two radiological patterns of arterial calcifi cation: linear calcification which has been associated with the calcifi cation of the media layer of the arterial wall and irregular and patchy calcification which has been associated with the calcifi cation of the intima layer of the arterial wall1. In the several studies that we have published we have demonstrated that vascular calcifications evaluated by this simple and inexpensive method allow the identification of patients with high cardiovascular risk. This simple vascular calcification score is an independent predictor of cardiovascular mortality2, all -cause mortality3, cardiovascular hospitalizations2, cardiovascular disease2, peripheral artery disease2,4, valvular calcifi cations5 and arterial stiffness3.KDIGO (Kidney Disease: Improving Global Outcomes) guidelines published in 2009 suggest that chronic kidney disease patients in stages 3 to 5, with vascular and valvular calcifications should be considered to be at the highest cardiovascular risk6. The high mortality of chronic kidney disease patients is not completely explained by the traditional risk factors7 and KDIGO group supports, since 2006, the hypothesis of the existence of a link between bone disease and vascular disease8.This link may be explained by the alterations of the bone and mineral metabolism and their interaction with development and progression of vascular calcifications. We have also verifi ed in our studies the existence of an association between vascular calcifications and bone disease. Low bone volume diagnosed by histomorphometric analysis of bone biopsies, in a group of dialysis patients, was independently associated with the simple vascular calcification score (data presented in this thesis,chapter 6) and with coronary calcifications evaluated by the Agatston score9. The original contribution of this article published in CJASN9 deserved a commentary in an Editorial written by Prof. Gérard London10 leader investigator in this area and current EDTA (European Dialysis and Transplantation Association) President. We were also the fi rst group to describe an independent and inverse association between bone mineral density evaluated in the femoral neck by DXA (dual energy X -ray absortiometry) with vascular calcifications evaluated by the simple vascular calcification score, with arterial stiffness evaluated by carotid-femoral pulse wave velocity and with peripheral artery disease diagnosed by clinical criteria11. We were also the first group to demonstrate a significant correlation between bone mineral density evaluated by DXA in femoral neck but not in lumbar spine, with cortical thickness evaluated by histomorphometric analysis of bone biopsy12. Our study has attributed to DXA, for the first time, a role in the diagnosis of cortical porosity in dialysis patients. The clinical utility of the differential evaluation of bone mineral density in cortical or trabecular bone needs, however, to be confi rmed in prospective studies. This original fi nding of our study was mentioned by ERBP (European Renal Best Practice) commenting the KDIGO position in relation with the reduced utility of bone mineral density evaluation in dialysis patients13. Two of the studies included in this thesis have been integrated in a group of studies selected as references by the KDIGO guidelines published in 2009 to evaluate the prevalence of vascular calcifications in CKD patients (KDIGO 2009: Supplementary Table 10, Fig. 3.6) and to corroborate the association between vascular calcifications and cardiovascular mortality (KDIGO 2009: Supplementary Table 12, Fig. 3.7)6. The inclusion of both studies as references in the KDIGO guidelines that have used the exigent GRADE system (Grades of Recommendation, Assessment, Development, and Evaluation) in the classifi cation and selection of studies, validates the scientifi c value of our studies. The diagnosis of vascular calcifi cations has a practical interest for chronic kidney disease patients. The presence of vascular calcifications is an alert sign to the existence of a high cardiovascular risk and this information may be used to modify the treatment of these patients6. Different methods may be used to detect the presence of vascular calcifications in dialysis patients14,15. The simple vascular calcifi cation score has the advantage of being simple, inexpensive and easily evaluated by the Nephrologist without the need for a Radiologist interpretation. The reproducibility of this method has already been demonstrated by other groups in national and international studies16 -24. It was demonstrated in those studies that vascular calcifi cations evaluated by the method created by us, predict higher risk of cardiovascular events16, higher risk of lower limbs amputations17, higher pulse wave velocity18,19, corneal and conjuntival calcifi cations 20 and coronary calcifi cations21. A negative association between the simple vascular calcification score and PTH levels21, 25(OH) vitamin D levels22,23 and Fetuin A levels19,24 has also been demonstrated. All these studies performed by different groups that have used the simple vascular calcifi cation score in their methods demonstrate that this score is simple, useful and reproducible in the evaluation of chronic kidney disease patients simple, useful and reproducible in the evaluation of chronic kidney disease patients.

Achieving K/DOQI Targets with Cinacalcet in Dialysis Patients with Secondary Hyperparathyroidism. A Portuguese Observational Study

Secondary hyperparathyroidism is a common complication of chronic kidney disease. The elevated serum intact parathyroid hormone, phosphorus, calcium and calcium x phosphorus product have been independently associated with an increased relative risk of mortality. The standard therapy for secondary hyperparathyroidism, including active vitamin D analogues and phosphate binders, is often insufficient to allow patients to achieve the recommended Kidney Disease Outcomes Quality Initiative targets for bone and mineral metabolism. Randomised controlled phase III clinical studies in chronic kidney disease patients with secondary hyperparathyroidism have shown that cinacalcet treatment increases the proportion of patients achieving the recommended Kidney Disease Outcomes Quality Initiative targets for intact parathyroid hormone, phosphorus, calcium and calcium x phosphorus product. Aims: This observational multicentre study aims to evaluate cinacalcet’s ability to achieve and maintain Kidney Disease Outcomes Quality Initiative targets in a population with secondary hyperparathyroidism on chronic haemodialysis in Portugal. Patients and Methods: Patients on chronic dialysis that received cinacalcet during a free sampling programme were enrolled. Retrospective and prospective monthly data were collected from 3 months before until 6 months after the beginning of cinacalcet treatment. Additional assessment included a 12 month evaluation of all parameters. Results: 140 dialysis patients with secondary hyperparathyroidism were enrolled, 60% male, mean age 57.4±14.1 years. The mean intact parathyroid hormone, calcium, phosphorus, and calcium x phosphorus product values at baseline were 751.7±498.8 pg/ml, 9.7±3.8 mg/dl, 5.5±1.5 mg/dl, and 52.7±25.3 mg2/dl2, respectively. After 6 months’ cinacalcet treatment, 26.2%, 53.6%, 59.3%, and 81.0% of the patients achieved the Kidney Disease Outcomes Quality Initiative recommended levels for intact parathyroid hormone, calcium, phosphorus, and calcium x phosphorus product, respectively. The mean dose of cinacalcet at 6 months was 57.1±29.7 mg/day. Conclusions: The use of cinacalcet in clinical practice is an effective option for the treatment of secondary hyperparathyroidism in chronic dialysis patients, allowing more patients to reach and maintain the Kidney Disease Outcomes Quality Initiative targets.

Patologia óssea do insuficiente renal crónico: desafio clínico-biológico ; Caracterização da osteodistrofia renal e efeitos da biocompatibilidade de membranas de hemodiálise, na remodelação óssea

Resumo: Os resultados das nossas investigações, apresentadas ao longo desta dissertação,contribuíram para a otimização do diagnóstico invasivo e não invasivo da osteodistrofia renal e permitiram evidenciar a relevância, para a expressão clínica e histológica da ODR, de algumas articularidades específicas da população hemodialisada, nomeadamente: a utilização de membranas de hemodiálise mais biocompatíveis e com elevada permeabilidade, o recurso a técnicas de hemodiafiltração com otimização da capacidade convectiva, as limitações dos marcadores bioquímicos de remodelação óssea ou a insuficiência / deficiência em vitamina D nativa (bem como os resultados da suplementação com esta vitamina). Testámos, pela primeira vez em doentes hemodialisados, novos marcadores da formação e reabsorção óssea, que validámos mediante a comparação com os resultados da histomorfometria óssea. No seu conjunto, e de forma integrada, as nossas investigações permitiram-nos: - Evidenciar a diminuição da expressão do recetor da PTH/PTHrP na cartilagem de crescimento, num modelo animal de IRC, o que explica, pelo menos em parte, o atraso de crescimento observado nesta patologia, bem como a diminuição da resposta à ação da PTH; - Demonstrar as vantagens da determinação da isoforma óssea da fosfatase alcalina, em relação à fosfatase alcalina total, no diagnóstico diferencial entre baixa e elevada remodelação óssea; - Utilizar, pela primeira vez em hemodialisados, a piridinolina e a desoxipiridinolina no diagnóstico da reabsorção óssea. Este foi o primeiro marcador sérico específico da atividade osteoclástica, utilizado com sucesso em doentes anúricos em hemodiálise. Evidenciámos uma excelente correlação destes dois marcadores bioquímicos com a superfície osteoclástica e com o número de osteoclastos/mm2;- Demonstrar as acentuadas limitações de outros marcadores da formação e reabsorção óssea (nomeadamente a osteocalcina, o propeptido carboxiterminal do procolagénio tipo I-PICP, e o Telopeptido do colagénio tipo I – ICTP) com base nas correlações entre os doseamentos séricos ou plasmáticos destes marcadores e a biópsia óssea com avaliação histomorfométrica; -Evidenciar as limitações induzidas pela sobrecarga alumínica na interpretação dos níveis séricos dos marcadores não invasivos da remodelação óssea;-Testar a eficácia e segurança da utilização de “microdoses” de desferroxamina na terapêutica da intoxicação alumínica, em doentes com acentuada exposição a este metal;-Demonstrar que os doentes hemodialisados cronicamente com dialisadores de poliacrilonitrilo (membranas de alta permeabilidade),apresentavam menor ativação osteoblástica e osteoclástica, que os doentes dialisados com membranas de cuprofano(baixa permeabilidade), sendo os níveis de iPTH semelhantes em ambos os grupos estudados. Estes resultados apontam para uma menor ativação da remodelação óssea quando se utilizam membranas de hemodiálise mais biocompatíveis e/ou de maior permeabilidade, o que se poderá relacionar com a ultrafiltração de mediadores da ativação celular ou com a menor ativação dos mecanismos estimuladores da remodelação óssea, por parte destas membranas. Entre os mediadores da remodelação óssea que demonstrámos serem relevantes e estarem aumentados no soro de hemodialisados com membranas de baixo fluxo, contam-se a beta-2-microglobulina (2-M) e algumas citoquinas, com ação estimuladora das linhagens celulares envolvidas na remodelação óssea. Demonstrámos igualmente uma correlação positiva dos níveis séricos de 2-M com os níveis séricos da osteocalcina, da isoenzima óssea da fosfatase alcalina (marcadores da formação óssea) e com os níveis séricos da piridinolina (marcador da reabsorção óssea). Os níveis séricos de 2-M correlacionaram-se ainda, de forma negativa, com o volume osteoide (matriz óssea não calcificada). Nestes doentes hemodialisados, demonstrámos a presença de níveis séricos aumentados da interleucina-1, do antagonista do recetor da interleucina-1, da interleucina-6 e do recetor solúvel da interleucina-6. Salientamos as relações inversas que observámos, por um lado entre os níveis de antagonista do recetor da interleucina-1 e a superfície osteoblástica, e por outro lado entre o rácio do recetor da interleucina-6 / interleucina-6 (IL6-r/IL6) e a superfície osteoclástica. De acordo com estes nossos resultados originais, entendemos que a interferência nos níveis circulantes e na ativação local destes mediadores poderá justificar, em grande parte, o aumento da prevalência de doença óssea adinâmica, descrita por nós e por outros grupos. Evidenciámos uma elevadíssima prevalência de doença adinâmica (>50% dos doentes), numa população de hemodialisados sem exposição prévia ao alumínio, tratados de acordo com os K/DOQI “guidelines” e que ao longo de um ano mantiveram níveis séricos de cálcio e de fósforo controlados. Consequentemente, os doentes tratados de forma otimizada apresentaram uma prevalência surpreendentemente elevada de doença adinâmica. Os nossos resultados (classificados com o grau de evidência máxima pelos peritos KDIGO) contribuíram para dar suporte à grande diferença nos guidelines K/DOQI (2003) e KDIGO (2009) no que respeita aos valores alvo da PTH. Estamos conscientes que de que o facto de termos uma percentagem tão elevada de doença óssea adinâmica nas nossas populações de hemodialisados, bem como a demonstração de que alguns doentes com valores de PTH intacta (2ª geração) de cerca de 600 pg/ml tinham doença óssea adinâmica, condicionaram os novos objetivos KDIGO para a PTH. Os nossos resultados suportam, em nossa opinião, a adequação e vantagem da utilização dos critérios da KDIGO em vez dos KDOQI. Tendo em conta que os primeiros definem objetivos para a PTH entre 2 e 9 vezes o limite superior do normal e não se comprometem com valores alvo absolutos e rígidos (definidos previamente nos KDOQI entre 150 e 300 pg/mL), esta nova abordagem parece-nos mais correta.Na nossa investigação clínica, caracterizámos ainda a população hemodialisada portuguesa no que respeita aos níveis séricos de calcidiol, identificando a população com suficiência, insuficiência ou deficiência em vitamina D3. Documentámos uma acentuada prevalência de insuficiência e mesmo de deficiência nesta vitamina, numa vasta população de hemodialisados, a qual, muito provavelmente, reflete de forma fidedigna, o que se pode observar na restante população de doentes portugueses IRC em estádio 5d (em diálise). Descrevemos, pela primeira vez em doentes hemodialisados, uma associação entre deficiência em calcidiol e a presença de fatores de risco cardiovascular (que têm sido identificados nos doentes urémicos). A nossa investigação conduziu-nos a resultados originais, ao identificar os níveis baixos de 25(OH)vitamina D3 como um provável fator de risco cardiovascular em hemodialisados, visto que a deficiência nesta vitamina se associou, de forma muito significativa, ao aumento da prevalência de calcificações vasculares, a inflamação, a pressão de pulso mais elevada, a hipertrofia ventricular esquerda, a insuficiência cardíaca e a níveis séricos aumentados de “BNP-Brain natriuretic peptide”. Finalmente, numa avaliação prospetiva, de intervenção terapêutica, corrigimos a insuficiência ou deficiência em 25(OH)vitamina D3 e demonstrámos que essa correção se associou a uma redução dos fatores de risco cardiovascular. Esta última intervenção foi totalmente inovadora, visto ser a primeira avaliação prospetiva da evolução dos fatores de risco cardiovasculares, em função da suplementação com vitamina D nativa, em doentes hemodialisados. Em resumo, pensamos que os resultados das nossas investigações, acima sumarizadas e apresentadas ao longo dos diversos capítulos desta dissertação,contribuiram para uma nova perspetiva da osteodistrofia renal e para recolocar o foco da atenção dos nefrologistas no tecido ósseo e no eixo paratormona – vitamina D – remodelação óssea. Este eixo surje claramente envolvido em múltiplos processos fisiopatológicos, que suportam a elevada morbilidade e mortalidade (nomeadamente de causa cardiovascular) observada nos doentes urémicos.---------ABSTRACT: The results of our research, presented throughout this thesis, contributed towards the optimisation of the invasive and non-invasive diagnosis of renal osteodystrophy. They have also highlighted the importance, to the clinical and histological expression of the ODR, of some specific characteristics of the haemodialysis population, including: the use of biocompatible high permeability haemodialysis membranes, the use of haemodiafiltration techniques with convection enhancement, as well as the limitations of biochemical markers of bone turnover or native vitamin D insufficiency/deficiency (along with the supplementation results of this vitamin). New bone formation and resorption markers, which were validated by comparison with the results of bone histomorphometry, have been tested for the first time on haemodialysis patients.As a whole, and in an integrated approach, our research enabled us to: - Show the decrease of the PTH/PTHrP receptor expression in cartilage growth, used on an IRC animal model, which explains, to some extent, not only the delayed growth observed in this pathology, but also the slow response to PTH. - Point out the advantages of the determination of bone isoform of alkaline phosphatase, in relation to the total alkaline phosphatase, in the differential diagnosis between low and high-bone turnover.- Use pyridinoline and deoxypyridinoline in the diagnosis of bone resorption for the first time on haemodialysis patients. This was the first specific serum market of the osteoclastic activity, which was successfully used on anuric patients undergoing haemodialysis treatment. We also observed an excellent correlation of these biochemical markers with the osteoclastic surface and the number of osteoclasts/mm2. - Demonstrate the sharp limitations of other markers of bone formation and resorption (namely osteocalcin, carboxyterminal propeptide of type I-PICP procollagen and telopeptide of type I-ICTP collagen) based on correlations between these markers’ serum or plasma assays and bone biopsy with histomorphometric assessment.-Show the limitations induced by aluminium overload in the interpretation of serum levels of bone remodelling non-invasive markers.-Test the efficacy and the safety of the use of deferoxamine “microdoses” for treatment of aluminium overload among patients with high levels of serum aluminium. - Demonstrate that patients with chronic haemodialysis dialysers of polyacrylonitrile (high permeability membranes) show a lower osteoblastic and osteoclastic activation than those undergoing dialysis with cuprofan membranes (low permeability), being the iPTH levels similar in both groups of patients. These findings point towards a lower activation of bone remodelling when using more biocompatible dialysis membranes and/or of higher permeability, which may relate to the ultrafiltration of cell activation mediators or to the lower activation of the stimulating mechanisms of bone remodelling, regarding the membranes. Beta-2-microglobulin (2-M) and some cytokines that play a role/participate in bone remodelling are among the bone remodelling mediators, which we demonstrated to be relevant and to be increased in the serum of haemodialysis with low flow membranes. We also proved that there is a positive correlation of serum 2-M levels not only with serum osteocalcin levels, of the bone isoenzyme of alkaline phosphatase (bone forming markers), but also with levels of serum pyridinoline (bone resorption marker).Serum 2-M levels correlate negatively with the volume of osteoid (uncalcified bone matrix). We also demonstrated the presence of elevated serum levels of interleukin-1,interleukin-1 receptor antagonist, interleukin-6 and soluble interleukin-6 receptor in haemodialysis patients. We stress the inverse relationship which we observed on one hand between the interleukin-1 receptor antagonist levels and the osteoblastic surface and on the other between the ratio of interleukin-6 receptor / interleukin-6 (IL6-r/IL6) and the osteoblastic surface. According to these unique findings, we believe that the interference in the circulating levels and in the local activation of these mediators may partly explain the rising prevalence of adynamic bone disease. A high prevalence of adynamic disease has also been observed in a haemodialysis population (>50% of patients) with no previous exposure to aluminium. The patients were treated according to K/DOQI guidelines and maintained controlled serum calcium and phosphorus levels over one year. As a result, the patients who received optimised treatment showed a surprisingly high prevalence of adynamic disease. Our results, which were ranked with the highest degree of evidence by KDIGO experts, contributed to the great difference regarding the target values of PTH in the K/DOQI (2003) and KDIGO (2009) guidelines. We are aware that the finding of such a high percentage of adynamic bone disease in our haemodialysis population, as well as the evidence that some patients with intact PTH values (2nd generation) of 600 pg/ml suffered from adynamic bone disease, have hindered, the new KDIGO objectives to PTH.In our opinion, our results support the suitability and the advantage of using KDIGO criteria instead of KDOQI. This seems to be the right approach when taking into consideration that KDIGO sets objectives to PTH between 2 and 9 times the normal upper limit and does not compromise with the rigid and absolute target values (between 150 and 300 pg/mL) previously defined by KDOQI. In our clinical research, the Portuguese haemodialysis population was characterised in terms of serum clacidiol levels and identified as having vitamin D3 sufficiency, insufficiency or deficiency. It was also recorded the prevalence of severe vitamin D3 insufficiency and even deficiency in a large haemodialysis population, which most likely provides a reliable picture of the rest of the population in IRC Portuguese patients with 5d stage (undergoing dialysis). We described for the first time in aemosialysis patients an association between calcidiol deficiency and the presence of ardiovascular risk factors, (which have been identified on uraemic patients).Our research led us to unique findings by having identified the low levels of 25(OH) vitamin D3 as a likely cardiovascular risk factor in patients undergoing haemodialysis treatment, given that deficiency in this vitamin has been significantly associated not only with a rise in the prevalence of vascular calcifications, but also inflammation, left ventricular hypertrophy, high pulse pressure and high serum BNPBrain natriuretic peptide levels. Finally, based on a prospective assessment of therapeutic intervention, 25(OH)vitamin D3 insufficiency or deficiency was corrected and we were able to demonstrate that this same correction was associated with a reduction in cardiovascular risk factors. This was a forward-looking intervention regarding the supplementation of native vitamin D in haemodialysis patients, since it was the first prospective assessment of the evolution of cardiovascular risk factors. In short, the results of our research, summarised above and presented throughout the various chapters of this thesis, contributed towards a new perspective of the renal osteodystrophy and also to draw the nephrologists’ attention to the bone tissue and to the axis PTH – vitamin D – bone remodelling. This axis appears clearly involved in multiple physiopathological processes, which support the high morbidity and mortality rate, (particularly of cardiovascular causes), observed in uraemic patients.

Estudos sôbre óleos do fígado de cacão Desmobrânquios da família Sphyrnidae, Mir. Rib., gêneros Carcharias, Raf., Galeocerdo, Ranz., e Odontaspis, Shau

1. The author suggests a tecnique for the determination of vitamin A on shark liver oils in industrial plants. The advantages of using oly four ml. of reagent and of permitting a quickly rigorous reading by photoeletric cell, contribute to the possibility of the examination of a great number of samples daily; 2. It is described a survey on the vitamin A content of oils from shark livers, which has been made at the Finishing School Darcy Vargas, Marammaia Is., Rio de Janeiro State. The conclusions are the following: a) Male individuals have showed generally tendency for higher vitamin A pontency oils; b) The size of the fish does not interfere in the vitamin content of the oil (graphic 4); c) The data collected upon 3.085 individuals led to the conclusion that some species are richer in the reservated vitamin although it was possible to catch in the same specie fishes with widely variable potency in vitamin A. One fish belonging to the specie C. lamia produced the highest vitamin potency oil with 167.712 international units per gram; d) The fishing season appears to have no influence on the oils; e) The adventitous food seems to be the most important factor affecting the content of vitamin A of the shark-liver oils; 3. The presence and the quantity of vitamin D in those oils was investigated and two of the determinations are presented.

Glutathione deficit during development induces anomalies in the rat anterior cingulate GABAergic neurons: Relevance to schizophrenia.

A series of studies in schizophrenic patients report a decrease of glutathione (GSH) in prefrontal cortex (PFC) and cerebrospinal fluid, a decrease in mRNA levels for two GSH synthesizing enzymes and a deficit in parvalbumin (PV) expression in a subclass of GABA neurons in PFC. GSH is an important redox regulator, and its deficit could be responsible for cortical anomalies, particularly in regions rich in dopamine innervation. We tested in an animal model if redox imbalance (GSH deficit and excess extracellular dopamine) during postnatal development would affect PV-expressing neurons. Three populations of interneurons immunolabeled for calcium-binding proteins were analyzed quantitatively in 16-day-old rat brain sections. Treated rats showed specific reduction in parvalbumin immunoreactivity in the anterior cingulate cortex, but not for calbindin and calretinin. These results provide experimental evidence for the critical role of redox regulation in cortical development and validate this animal model used in schizophrenia research.

Pathfinding of corticothalamic axons relies on a rendezvous with thalamic projections.

Major outputs of the neocortex are conveyed by corticothalamic axons (CTAs), which form reciprocal connections with thalamocortical axons, and corticosubcerebral axons (CSAs) headed to more caudal parts of the nervous system. Previous findings establish that transcriptional programs define cortical neuron identity and suggest that CTAs and thalamic axons may guide each other, but the mechanisms governing CTA versus CSA pathfinding remain elusive. Here, we show that thalamocortical axons are required to guide pioneer CTAs away from a default CSA-like trajectory. This process relies on a hold in the progression of cortical axons, or waiting period, during which thalamic projections navigate toward cortical axons. At the molecular level, Sema3E/PlexinD1 signaling in pioneer cortical neurons mediates a "waiting signal" required to orchestrate the mandatory meeting with reciprocal thalamic axons. Our study reveals that temporal control of axonal progression contributes to spatial pathfinding of cortical projections and opens perspectives on brain wiring.

Myoclonies chez une personne très âgée; une cause fréquente et réversible [Myoclonia in an oldest old woman: a frequent and reversible etiology]

A 98-year-old woman was referred to our hospital because of myoclonia. The concentration of calcium and vitamin D in the serum was low. In this context, we concluded of neuromuscular irritability secondary to hypocalcaemia. The symptoms disappeared after a treatment of intravenous calcium. This case shows how important it is to investigate electrolytes in case of neuromuscular irritability symptoms in elderly people.

Evidence against a direct role of klotho in insulin resistance.

The klotho gene may be involved in the aging process. Klotho is a coactivator of FGF23, a regulator of phosphate and vitamin D metabolism. It has also been reported to be downregulated in insulin resistance syndromes and paradoxically to directly inhibit IGF-1 and insulin signaling. Our aim was to study klotho's regulation and effects on insulin and IGF-1 signaling to unravel this paradox. We studied klotho tissue distribution and expression by quantitative real-time polymerase chain reaction and Western blotting in obese Zucker rats and high-fat fed Wistar rats, two models of insulin resistance. Klotho was expressed in kidneys but at much lower levels (<1.5%) in liver, muscle, brain, and adipose tissue. There were no significant differences between insulin resistant and control animals. We next produced human recombinant soluble klotho protein (KLEC) and studied its effects on insulin and IGF-1 signaling in cultured cells. In HEK293 cells, FGF23 signaling (judged by FRS2-alpha and ERK1/2 phosphorylation) was activated by conditioned media from KLEC-producing cells (CM-KLEC); however, IGF-1 signaling was unaffected. CM-KLEC did not inhibit IGF-1 and insulin signaling in L6 and Hep G2 cells, as judged by Akt and ERK1/2 phosphorylation. We conclude that decreased klotho expression is not a general feature of rodent models of insulin resistance. Further, the soluble klotho protein does not inhibit IGF-1 and/or insulin signaling in HEK293, L6, and HepG2 cells, arguing against a direct role of klotho in insulin signaling. However, the hypothesis that klotho indirectly regulates insulin sensitivity via FGF23 activation remains to be investigated.

Prophytaxie de l'ostéoporose cortisonique: qui, quand et quoi [Prevention of cortisone-induced osteoporosis: who, when and what?]

Glucocorticoid-induced osteoporosis is a known phenomenon with already an increased fracture risk at 2.5 mg of prednisone daily over 3 months. This risk appears to be independent of bone densitometry results, in contradiction with published guidelines. With the creation of our Department of Musculoskeletal Medicine, we wanted to edict clear recommendations for the prevention of steroid-induced osteoporosis. In addition to the standard general measures to prevent osteoporosis and calcium and vitamin D supplementation, we advocate the use of a specific treatment for osteoporosis in all cases when the duration of corticosteroid therapy is not strictly limited and shorter than 3 months. Bisphosphonates are the treatment of choice, while the analogue of parathyroid hormone remains an alternative in cases with a very high fracture risk.