Is obesity a major cause of chronic kidney disease?

Excess weight gain is a major risk factor for essential hypertension and for end-stage renal disease (ESRD). Obesity raises blood pressure by increasing renal tubular sodium reabsorption, impairing pressure natriuresis, and causing volume expansion because of activation of the sympathetic nervous system and renin-angiotensin system and by physical compression of the kidneys, especially when visceral obesity is present. Obesity also causes renal vasodilation and glomerular hyperfiltration that initially serve as compensatory mechanisms to maintain sodium balance in the face of increased tubular reabsorption. In the long-term, however, these changes, along with the increased systemic arterial pressure, create a hemodynamic burden on the kidneys that causes glomerular injury. With prolonged obesity, there is increasing urinary protein excretion and gradual loss of nephron function that worsens with time and exacerbates hypertension. With the worsening of metabolic disturbances and the development of type II diabetes in some obese patients, kidney disease progresses much more rapidly. Weight reduction is an essential first step in the management of obesity, hypertension, and kidney disease. Special considerations for the obese patient, in addition to adequately controlling the blood pressure, include correction of the metabolic abnormalities and protection of the kidneys from further injury.     

Is congenital lobar emphysema a surgical disease?

Background

The management of congenital lobar emphysema has traditionally been surgical. Because of increased use of imaging, this lesion is frequently found in asymptomatic and mildly symptomatic children, prompting us to adopt a more conservative approach to these children.

Methods

All children with congenital lobar emphysema presenting between 1995 and 2002 were included. Medical records, imaging files, and pathology reports were reviewed.

Results

Twenty children (0-17 years) were identified. Eight were diagnosed antenatally. Fourteen were managed without surgery. Of the 11 symptomatic children, 6 showed spontaneous improvement.

Conclusions

The favorable outcome of both asymptomatic and mildly symptomatic children suggests that a nonoperative approach should be considered in these patients.     

Is there a deleterious effect of erythropoietin in end-stage renal disease?

The use of erythropoiesis-stimulating agents (ESAs) in patients with chronic kidney disease has declined as randomized controlled trials have demonstrated increased risk of cardiovascular complications and mortality without a marked benefit in quality of life. Several studies have suggested that exposure to high dosages of ESA, rather than raising of the hemoglobin concentration, explains this increased risk. Cotter and colleagues report that exposure to high dosages of ESA in patients with diabetes is associated with increased risk.     

Is inflammatory joint disease in HIV-infected patients a form of spondyloarthropathy?

In Congo-Brazzaville, the seroprevalence of HIV infection is in the range 7-8%, and AIDS is the leading cause of aseptic arthritis (60% of cases). PATIENTS, MATERIAL AND METHODS: The ESSG and Amor's criteria for spondyloarthropathy were evaluated in 83 patients with HIV infection admitted for aseptic arthritis to the rheumatology department of the Brazzaville teaching hospital, over an 8-year period. RESULTS: All 83 patients were CDC stage IV; 66 (80%) had polyarthritis and 17 (20%) oligoarthritis. A single patient met ESSG and Amor's criteria, with six points; one patient had five points and 15 had three points. The joint involvement was asymmetrical and nonerosive. Nonsteroidal antiinflammatory therapy ensured resolution of the manifestations within 4-8 weeks. The most common sites of involvement were the knees (84%), ankles (59%), and great toes (23%) at the lower limbs and the wrists (41%), elbows (29%), and metacarpophalangeal and interphalangeal joints (25%) at the upper limbs. CONCLUSION: Inflammatory arthritis in HIV patients does not meet ESSG or Amor's criteria for spondyloarthropathy.     

Is erectile dysfunction really a clinically useful predictor of cardiovascular disease?

OBJECTIVE: To evaluate the possible connection between erectile dysfunction (ED) and cardiovascular disease (CVD) in one of its more severe forms, namely myocardial infarction (MI). MATERIAL AND METHODS: The incidence of ED in men hospitalized due to MI (n=100) was compared with that reported in a questionnaire sent to an age-matched control population (n=129). RESULTS: The incidence of ED before MI (34%) was similar to that in the control population (30%). After MI, 53% reported ED. Smoking was much more common among the men with MI (82%) than among the controls (45%). Smoking was, however, only slightly more common among controls with (50%) than without (40%) ED. None of the men in the study group had consulted a physician due to ED before the MI and only 10/53 (19%) with ED after the MI had consulted a physician for this reason. Among the controls without a history of CVD, 18% reported ED, compared to 34% of the men before the MI but without clinical evidence of CVD and/or diabetes (p=NS). CONCLUSIONS: The well-known association between CVD and ED was confirmed. However, the lack of a sharp rise in the prevalence of ED prior to MI does not support the idea that ED is a clinically useful predictor of MI.     

Is the thyroidectomy a surgical standard procedure for therapy of Graves' disease?

Surgery is an important therapeutic option in the treatment of Graves' disease. Nevertheless it is still controversial discussed wether the extent of resection correlates with the rate of surgical complications and the therapeutic success. Therefore we performed a retrospective analysis on 75 surgically treated patients. 58 of these 75 patients were examined after a median interval of 34.2 months. The examination focussed on the appearance of temporary and permanent palsy of the recurrent laryngeal nerve, hypoparathyroidism, recurrences, and on the postoperative course of thyroid-stimulating-hormone-receptor antibody (TSH-ab) titers. Total thyroidectomy has been performed in 51 and bilateral resection with a remnant thyroid volume less than 2 ml each side in 24 patients. We could not confirm a significant difference concerning the postoperative complication rates between both groups. In the bilateral resection group we saw 3 cases of recurrent goitre and a more unfavourable course of TSH-ab titers than in the thyroidectomy group. For these reasons we propose the total thyroidectomy as surgical standard procedure for therapy of Graves' disease.     

Is microglandular adenosis a precancerous disease? A study of carcinoma arising therein

Microglandular adenosis (MGA) is a recently described and little appreciated proliferative glandular lesion of the breast that may mimic carcinoma both clinically and histologically. Several recent publications indicate that this lesion, while capable of recurrence if incompletely excised, is itself benign. In an earlier report from this institution we suggested that MGA might serve as the substrate for the development of mammary carcinoma. This report presents the pathologic findings in seven patients who developed carcinoma of the breast in association with MGA. The patients, aged 39-72, presented with firm masses that raised the clinical suspicion of carcinoma. The lesions reported here are linked not only by the presence of benign MGA associated with mammary carcinoma, but by a spectrum of atypical glandular proliferations ("atypical" MGA) that suggest transitions from MGA to infiltrating carcinoma. These carcinomas shared unusual histologic features which strengthen our impression that they are derived from MGA. On the basis of the experience presented in this study, it appears that MGA may on occasion serve as the substrate for the development of mammary carcinoma. For patients with uncomplicated MGA, complete excision of the lesion with clinical follow-up is recommended. When atypical hyperplasia is present in MGA, the lesion should be widely excised and the same caution exercised in following the patient as with other atypical hyperplasias. The treatment of carcinoma arising in MGA will depend on the stage of the disease. Presently we do not know whether these carcinomas have unusual clinical or biological characteristics.     

Is clinical expressiveness of Paget's disease of bone decreasing?

Recent data have suggested secular changes implying a current trend toward decreased clinical severity of Paget's disease of bone (PD). To test this hypothesis, we conducted a study comparing the characteristics of two groups of PD patients, as disclosed from a sample assessed systematically. The investigation was a hospital-based study of all cases followed up at our unit since 1980. Throughout the follow-up period, diagnosis was based on standard X-ray criteria and the same clinical assessment was applied. Group I (n = 124) represented patients born before 1926, whereas group II (n = 109) included those born after that year. A bone scan performed with 99mTc-EHDP was available for all patients. X-rays of the pelvis and spine, and views of any hot spot observed on the scintigraphy scans were reviewed. The skeletal extent of PD, based on bone scan uptake, was determined by using the index proposed by Coutris. Alkaline phosphatase and hydroxyproline excretion levels were determined in blood and urine, respectively. Baseline characteristics were recorded on a purpose-designed computerized database. The proportion of males (47% in group I vs. 65% in group II; p = 0.007) and the mean (+/-SD) age at diagnosis (69.0 +/- 8.15 vs. 54.3 +/-9.14; p < 0.001) differed significantly between groups. The year of birth showed a strong negative correlation with age at diagnosis (r = -0.83, p < 0.0001) and a weak, but significant, negative correlation with extent of bone lesion (r = -0.20; p = 0.002). Likewise, subjects born prior to 1926 showed a greater percentage of affected skeleton cases (9.6 plus minus 8.01 vs. 7.06 +/- 5.79; p = 0.001). Group I individuals who had pelvic and/or femoral bone lesions were more prone to suffer "pagetic coxopathy" (65% vs. 40%; p = 0.003) with "protrusio acetabuli" (32% vs. 17%; p = 0.01), and the percentage of patients showing radiographic Monckeberg-type vascular calcifications (36% vs. 14%; p = 0.0006) was higher than in those born after 1926. No other epidemiologically clinically, or biochemically relevant differences were seen in the crude analysis. Multivariate analysis identified extent of skeletal lesions (OR = 0.76; p = 0.01), age at diagnosis (OR = 0.79; p = 0.008), number of bones involved (OR = 1.53; p = 0.03), and occupation (p < 0.0001) as the predictive variables linked to year of birth. Our data are consistent with a temporal tendency toward a smaller number of bone lesions and a decreased percentage of instances of affected skeleton. An earlier age at recent diagnosis times and absence of any relevant clinical or biochemical differences seems more likely linked to recent changes in referral and sociological patterns.     

Is there a "point of no return" in progressive renal disease?

The pathogenesis of progressive renal damage is most probably multifactorial. Whatever the mechanisms involved in renal disease progression, the existence of a "point of no return" has been hypothesized, that is, a stage of structural and functional damage beyond which progression of renal disease occurs independently of dietary measures and/or pharmacological treatment. In experimental animals, dietary protein and phosphate restriction is not fully successful in ameliorating the progression of functional deterioration if administered when renal injury is severe and long standing. Similarly, late treatment with various pharmacological agents (mainly antihypertensive drugs) is less effective than early administration of the same substances. A serum creatinine of 176 mumol/L seems a critical point discriminating the results of either dietary protein and phosphate restriction or antihypertensive treatment in patients with chronic renal disease. The protective effects of both dietary and nondietary intervention seem to be most effective when at least 50% of the residual renal mass is still functioning. The extent to which glomerular sclerosis, vascular hyalinosis, and interstitial fibrosis have already developed can probably blunt or avert the expected results of treatment. Some clinical tests may identify those patients who would benefit from measures such as the reduction in glomerular hemodynamic stress, the long-term inhibition of the renin-angiotensin system, and the aggressive treatment of systemic hypertension. The continuous search for a rational preventive treatment before the disease process has reached the "point of no return" will undoubtedly constitute a formidable task for the modern nephrologist.     

Is high levels of vitamin D a new risk factor for Peyronie's disease?

The aim of this study is to investigate whether serum vitamin D level predicts the risk of Peyronie's disease. Calcium and inflammatory cytokines play an important role during fibrocalcification of the plaques in Peyronie's Disease. TGF‐β1 is one of the most fibrogenic cytokines. Increasing serum vitamin D levels is considered that induce expression of TGF‐β1. Serum vitamin D levels and TGF‐β1 are related with calcifications of some soft tissues in previous studies. One hundred and three Peyronie patients and 162 healthy volunteers were included in the study. In both groups, demographic data, medical history, physical examination and erectile capacity were recorded. Serum 25‐hydroxyvitamin D, total cholesterol, low‐density lipoprotein, high‐density lipoprotein, triglyceride and testosterone levels were measured. The mean level of serum 25 (OH) D was significantly higher in men with Peyronie's disease compared with the controls (32.6 ± 7.9 ng/ml vs. 18.5 ± 6.6 ng/ml respectively. p < 0.001). There is a relationship between Peyronie's disease and high serum vitamin D levels. Also, increased low‐density lipoprotein and total cholesterol levels, diabetes mellitus, and cardiovascular diseases were associated with Peyronie's disease.     

Is breast cancer in young Latinas a different disease?

BACKGROUND: Breast cancer appears to be more aggressive in young women (< or =35 years). Race/ethnicity may further influence prognosis. The purpose of this review is to determine whether breast cancer in young Latinas differs from that in other women. METHODS: Our institutional (1977-2000) and state (1988-2000) tumor registries were reviewed and breast cancer cases analyzed. Data are expressed as mean +/- SEM. RESULTS: At our institution, 56 (7%) of 748 breast cancer patients were < or =35 years old; 32 (57%) were Latina. Compared with non-Latinas, Latinas presented at a younger age (P <0.05) and had more stage III/IV disease (38% versus 29%; P >0.05) and bilaterality (22% versus 8%; P >0.05), and worse 5-year survival (63% versus 83%; P >0.05). Statewide data were consistent with our institutional data. CONCLUSIONS: Latinas comprise a disproportionate share of our young breast cancer population, and may suffer more aggressive disease than other young women. Young Latinas may benefit from more vigilant screening and should be considered for novel therapeutic protocols.