The early introduction of percutaneous renal biopsy in Italy

BACKGROUND: Percutaneous renal biopsy, based on the use of an aspiration needle and the patient in the sitting position, was first described by Iversen and Brun in 1951. In 1954, Kark and Muehrcke described the use of the cutting Vim-Silverman needle on patients in the prone position, with a substantial improvement in the rate of success. The 1961 CIBA Foundation Symposium on renal biopsy marked the coming of age of this technique. During the 1950s in Italy, several individuals played a part in promoting and developing percutaneous renal biopsy. Because this pioneer work has received insufficient attention, we describe the contributions of Italians to the early introduction of this technique. METHODS: The Italian and international literature about percutaneous renal biopsy of the period 1951 through 1965 was reviewed. In addition, structured interviews with surviving members of the Italian researchers who first used renal biopsy were conducted. RESULTS: The first renal biopsies in Italy were performed in 1951 in Pisa by the group of Ernico Fiaschi (1913-1989). In their hands, renal biopsy became a tool to investigate the pathogenesis of renal diseases in particular, while simultaneously using the early application of immunofluorescence and electron microscopy. In 1954, Pietro Leonardi (1914-1991) and Arturo Ruol (born 1924) introduced renal biopsy in Padova; they used this technique extensively and published one of the first monographs on the subject. In 1957, Vittorio Bonomini (born 1928) introduced renal biopsy in Bologna, and in subsequent years used this technique to focus on the study of pyelonephritis. CONCLUSIONS: Our historical research shows that Italian groups were among the first to use and develop percutaneous renal biopsy both as a clinical tool and an investigative tool. This article gives international credit to their work.     

Maintenance dialysis in patients from developing countries: the experience of an Italian center

BACKGROUND: There are few studies concerning the clinical problems of patients from developing countries undergoing dialysis in European countries. This retrospective study aimed to describe the main clinical features of a group of these patients who happened to be on maintenance dialysis in our unit. METHODS: Analysis of the clinical features at presentation and at follow-up of a group of patients from developing countries who entered chronic dialysis in our unit over an 8 year period. RESULTS: From April 1994 to December 2001, 12 patients (eight males and four females, mean age 38.2 +/- 7.9 yrs) from developing countries (the Philippines (n=5); Egypt (n=4); Morocco (n=1); Mauritius (n=1); Sri-Lanka (n=1)) entered maintenance dialysis in our unit (six hemodialysis (HD) patients, six continuous ambulatory peritoneal dialysis (CAPD) patients). The cause of renal failure was severe/very severe hypertension in five patients (four of whom presented with very advanced end-stage renal disease (ESRD)), chronic glomerulonephritis in four patients, amyloidosis, type 2 diabetic nephropathy, and unknown causes in three patients. After a mean follow-up of 45.3 +/- 32.0 months (median 33, range 18-111), five patients continued on HD, two patients were on CAPD, whilst four patients received a renal transplant and one patient a renal and liver transplant. An important feature of our patients was the high infection rate (67%), such as tuberculosis (n=3), B and/or C viral hepatitis (n=4) and schistosomiasis (n=1). Of note were the clinical problems that developed after visits to the patients' native countries, during which the patients were dialyzed locally. After 5/20 visits (25%), three patients experienced a worsening of anemia (four incidences) and active hepatitis C development (one incidence). CONCLUSIONS: Our study demonstrates that patients from developing countries on maintenance dialysis differ from our local Italian dialysis population in several respects. These are young age, causes of renal failure, frequently late referral, high infection rates, and the clinical complications due to patients' visits to their native countries.     

In vitro erythrophagocytosis by renal tubular cells and tubular toxicity by haemoglobin and iron.

BACKGROUND: Patients with gross haematuria of glomerular origin may develop acute tubular necrosis and reversible renal failure. Erythrocytes within the cytoplasm of proximal tubular epithelial cells (PTECs) can be seen on examination of renal biopsies from these patients. It is possible, therefore, that the tubular damage is a result of cytotoxic breakdown products released during erythrocyte degradation. METHODS: To test this hypothesis, we evaluated (i) by transmission electron microscopy, the capability of a PTEC line to phagocytose and degrade erythrocytes in vitro; and (ii) the effect on the viability of PTCEs in vitro both after erythrophagocytosis and after incubation with haemoglobin, free iron or both. RESULTS: Electron microscopic examination of PTECs exposed to erythrocytes for 96 h showed that 22% of PTECs contained one or more erythrocyte. These were within phagolysosomes and showed varying stages of degradation, with collapse and breakdown of the cell membrane and invasion by cytoplasmic organelles (the so-called haemolytic pathway of erythrocyte degradation). Despite the phagocytosis and degradation of the erythrocytes, no cytotoxicity could be demonstrated under the experimental conditions used. However, the presence of haemoglobin, free iron or both in the culture medium was toxic to the PTECs, resulting in a significant reduction in the number of viable cells present. CONCLUSIONS: PTECs are able to phagocytose and degrade erythrocytes, and haemoglobin and iron are toxic to proximal tubular cells in vitro.     

Comparison of immunofluorescent findings in kidney after snap-freezing and formalin fixation

Two types of tissue preparation for immunofluorescent staining were compared with sections of the same kidney. In one, formalin-fixed paraffin-embedded kidney sections were incubated with pronase (IF-PRON). The optimal pronase exposure for bright, specific IF and a mild background IF, suitable for the whole set of antisera was determined (pronase 0.75 g/l of Tris buffer for 60 min) and this was used for the subsequent steps of the study. Snap-frozen sections were also stained (IF-FROZ). Positive and negative cases, IF intensity, distribution and location in IgA nephropathy, membranous nephropathy, proliferative lupus nephritis were compared by the 2 methods. The main antigens for each disease were adequately revealed by IF-PRON, so that a correct diagnosis was possible in all cases. IF-PRON was also applied to sections before and after prolonged storage of blocks in the files, to see whether or not retrospective analysis is possible. Only minor differences were found between the 2 series of sections. Finally, the exposure of the sections to the continuous fluorescent light showed that IF fading was less in fixed sections. We conclude that IF-PRON is a reliable method for renal pathology with some advantages over the IF-FROZ.     

Urine erythrocyte morphology in patients with microscopic haematuria caused by a glomerulopathy

The evaluation of urinary erythrocyte morphology (UEM) has been proposed for patients with isolated microscopic haematuria (IMH) to early orientate the diagnosis towards a glomerular or a nonglomerular disease. However, to date, the role of this test in patients with IMH has very rarely been investigated. Sixteen patients (ten children, six adults) with persistent IMH classified as glomerular on the basis of repeated UEM evaluations (55 urine samples, two to eight per patient) were submitted to renal biopsy. This showed a glomerular disease in 14/16 patients (87.5%) (nine thin basement membrane disease; three Alport syndrome; two other), whereas in two patients, no abnormalities were found. Of four microscopic criteria investigated to define a IMH as glomerular, >80% dysmorphic erythrocytes were not found in any sample, >or=40% dysmorphic erythrocytes alone were seen in seven samples (12.7%), >or=5% acanthocytes alone in 15 samples (27.3%) and erythrocytic casts in six samples (10.9%). There was >or=40% dysmorphic erythrocytes associated with >or=5% acanthocytes in 25 samples (45.5%). Sensitivity and positive predictive values in diagnosing a glomerular haematuria were 59.2% and 90.6%, respectively, for >or=40% dysmorphic erythrocytes, 69.4% and 85% for >or=5% acanthocytes/G1 cells and 12.2% and 100% for erythrocytic casts. Our findings demonstrate that the evaluation of UEM is useful to identify patients with an IMH of glomerular origin.     

A urine finding in obese patients.

Sir, We read with interest the report by Drs Chaudhry and Sedlacekon the presence in the urine sediment of starch particles, dueto obese patients’ use of starch-containing     

Dental amalgam, mercury toxicity, and renal autoimmunity.

Chronic exposure to elemental metallic mercury may induce an immunological glomerular disease. Since humans are exposed to mercury vapor (Hg0) from dental amalgam restorations and kidney is an important target organ of mercury vapor and mercury deposition in kidney increases proportionally with the dose, our aim was to test the occurrence of specific antibodies to antiglomerular basement membrane (anti-GBM-IgG) among individuals with adverse effects to mercury from dental amalgam fillings. We selected a group of patients (n=24) with a history of long-term exposure to mercury vapor from mercury-containing amalgam fillings and showing adverse effects that were laboratory confirmed. Enzyme-linked immunosorbent assays (ELISAs) were used to evaluate serum levels of antibodies to anti-GBM-IgG. None of the patients showed evidence of anti-GBM autoimmunity, either in subgroups with strong allergy to mercury or its compounds (i.e., organic mercury) or in those patients who had past thimerosal-containing vaccines coverage (7 of 24). There was no evidence of the presence of circulating anti-GBM antibodies in subjects suffering from adverse events due to long-term exposure to mercury from dental amalgams, even in individuals who presented allergy to mercury.     

Long-term outcome of Sch?nlein-Henoch nephritis in the adult

Sixteen adult patients with Sch?nlein-Henoch nephritis, selected by strict inclusion criteria, were studied retrospectively. At the time of discovery of the nephropathy, 11 patients had normal plasma creatinine and 5 other patients had renal insufficiency. All patients had renal biopsies, which were studied by both light and immunofluorescence microscopy. After a mean follow-up of 90.5 +/- 59.1 months (range 16-261), 3 patients were in chronic dialysis (18.7%), 8 other patients had renal function deterioration (50%), with creatinine clearance ranging from 31 to 60 ml/min. Four other patients had mild urinary abnormalities with normal plasma creatinine (25%) and only 1 patient was in complete clinical remission (6%). No clinical features at onset were predictive for the clinical outcome of the disease, while in the biopsies the percentage of crescents was higher in patients who developed renal insufficiency. High IgA serum levels were correlated (p = 0.0242) with a favorable course. It is concluded that Sch?nlein-Henoch nephritis of the adult carries a high long-term risk of renal dysfunction.