Membranous glomerulopathy in a patient with selective IgA deficiency: is there a link?

We report a 42-year-old woman, who presented with proteinuria (3.85 g/day) and malleolar oedema. She had a medical history of Graves' disease, recurrent upper respiratory tract infections, episodes of Raynaud phenomenon and dysphagia. Biochemistry showed a selective IgA deficiency (SIgAD). Percutaneous renal needle biopsy showed diffuse global thickening of the glomerular basement membranes on light microscopy and granular deposits of IgG and C3 along the glomerular basement membranes on immunofluorescence. The pathological diagnosis was membranous glomerulopathy stage II. A treatment with dietary salt restriction and an angiotensin-converting enzyme inhibitor was initiated, resulting in a reduction of proteinuria. Despite the fact that selective IgA deficiency is associated with various autoimmune disorders, the association with glomerular disease is rather rare and the pathogenesis is not fully understood.     

Spondyloarthritis after bariatric surgery: is there a link?

Presently, bariatric surgery is considered the most effective treatment for reducing excess body weight and maintaining weight loss in severely obese. On the other hand, several early and late complications have been described after this procedure. This article reports two patients who developed a spondyloarthritis-like syndrome after bariatric surgery. Probable etiopathogenic mechanisms are discussed.     

Diabetes mellitus and cognition: is there a link?

The occurrence of diabetes and dementia is very high in older patients. The fact that both conditions are concurrent raises the question of a possible link between the two. Cognitive functions of non-demented patients with diabetes have been extensively studied. In type 1 diabetes, only a mild decrease of the speed of information processing and of the psychomotor efficiency has been shown. Cognitive decline seems to be related to poor metabolic control and not to hypoglycaemia. In older patients with type 2 diabetes, memory and executive functions have been found impaired. Longitudinal studies of the literature have shown that diabetic patients have a higher chance of developing dementia than non-diabetic patient, with a relative risk (RR) between 1.26 and 2.83. The risk of vascular dementia was increased in 3 out of 5 studies, with a RR ranging between 2 and 2.6. With regard to Alzheimer's disease, the results are conflicting. Half of the studies found an increased risk in diabetic patients (RR: 1.3-2). The possible causal mechanisms of dementia in diabetic patients remain hypothetical. MRI studies showed varying degrees of cortical atrophy, cerebral infarcts and deep white matter lesions. In neuropathological studies, senile plaques and neurofibrillary tangle were not found with higher severity in the brain of diabetic patients than in the brain of age-matched controls. Several hypotheses have been raised to explain the relationship between diabetes and cognitive decline. Micro and macrovascular changes in the brain could induce cerebral hypoxia and ischemic conditions resulting in cellular death or white matter lesions. The occurrence of vascular lesions might reduce the threshold at which dementia will occur in Alzheimer disease. The deposition of advanced glycation end products doesn't spare the brain and they have been found in senile plaques, where they can reduce the solubility of proteins such as the beta amyloid and Tau proteins. Some authors favour the hypothesis of a brain insulin resistance because, in a few small studies, insulin was found to improve memory.     

Diabetes, bilirubin and amputations: is there a link?

A study by Chan et al in this issue of Diabetologia (DOI:10.1007/s00125-012-2818-4) reports that low plasma bilirubin levels are associated with an increased risk of amputation in patients with type 2 diabetes mellitus participating in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study. These findings raise the interesting and clinically relevant hypothesis that bilirubin protects against risk of amputation in patients with type 2 diabetes. This commentary considers some of the limitations associated with research aiming to define any link between circulating bilirubin levels and vascular disease. Numerous confounding factors (several of which may be present in patients with type 2 diabetes) may explain why the literature regarding this potentially protective role of bilirubin remains controversial.     

GERD and H. pylori: is there a link?

The incidence of gastroesophageal reflux disease (GERD) and esophageal adenocarcinoma have increased in recent years as the incidence of peptic ulcer disease and distal gastric cancer have declined. Given the simultaneous decline in Helicobacter pylori infection, it is tempting to propose a relationship between H. pylori infection and these opposing time trends. Although H. pylori infection clearly does not cause GERD, it may protect certain susceptible individuals from developing GERD and its complications. The most likely mechanism in which H. pylori infection protects against GERD is by decreasing the potency of the gastric refluxate in patients with corpus predominant gastritis. A variety of implications of H. pylori infection on GERD treatment have also arisen in recent years. These focus on the risk of gastric atrophy while on proton pump inhibitor therapy and the efficacy of proton pump inhibitors before and after eradication of H. pylori. This article puts into perspective our current understanding of the complex, incompletely understood relationship between H. pylori infection and GERD.     

Lung transplantation and lung cancer: is there a link?

Lung transplantation offers a major survival benefit in selected patients with end-stage pulmonary disease. In recent years, there is accumulating evidence of an increase in solid organ tumors and especially in primary lung cancer. There is also some anecdotal evidence that lung transplantation may be beneficial as a treatment option in some patients with lung cancer, such as the ones with extensive bronchoalveolar cell carcinoma. In this review, we analyze the literature data reporting the incidence of lung cancer after lung transplantation with its inherent risk factors, and we summarize the available data on possible treatment of lung cancer by lung transplantation. Finally, bronchial epithelial chimerism as possible cause for lung cancer is discussed.     

Growth hormone deficiency and coeliac disease: an unusual association?

OBJECTIVE: To assess the occurrence of growth hormone deficiency (GHD) in patients with coeliac disease (CD). STUDY DESIGN: A total of 1066 children diagnosed elsewhere with short stature were referred to our centre for second-line evaluation in a 6-year period. All patients were screened for CD by antiendomysial antibodies (EMA) and those with positive sera underwent intestinal biopsy. RESULTS: Among the 1066 short children, 210 (19.7%) had GHD and 12 (1.12%; chronological age from 3.6 to 12.3 years, bone age from 1.5 to 10.5 years, SDS height from -3.05 to -0.48), having positive EMA, showed histologically confirmed CD. Nine of these latter 12 CD children had a beneficial effect on growth rate after the first year of gluten-free diet, while the remaining three showed no catch-up growth. A careful endocrinological investigation in these three CD boys showed an isolated GHD in two cases and a multiple GHD in one case. The congenital origin of GHD is supported by the congenital abnormalities documented by magnetic resonance imaging. GH therapy associated with gluten-free diet led to an increased growth rate. CONCLUSION: GH secretion should be evaluated in coeliac patients showing no catch-up growth after a period on a gluten-free diet in spite of reversion to seronegativity for EMA. In the case of GHD and CD, replacement GH therapy should be started during a gluten-free diet.