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Objectives Medicines optimization (MO) in patients with chronic kidney disease (CKD) is at high risk at transition points of different ambulatory care levels such as nephrologists in outpatient clinics and general practitioners (GPs). We examined if adding a clinical pharmacist to the therapeutic team promotes implementation of nephrologists’ drug therapy recommendations by GPs’ and reduces drug-related problems (DRPs). Methods A prospective, controlled intervention study was conducted in the nephrology outpatient clinic of the Klinikum Fulda, Germany. The control and intervention phases took place successively. Patients with CKD stage 3–5 and at least one concomitant disease, for example, arterial hypertension or type-2 diabetes were recruited consecutively in three subgroups (naive, 1 contact, ≥2 contacts with nephrologist) from June 2015 to May 2019. GPs’ acceptance and frequency of DRPs without (control group [CG]) and with (intervention group [IG]) pharmacist’s interventions were compared after 6 months. Interventions include educational training events for GPs between control- and intervention phase, medication therapy management and pharmaceutical patient counselling. Key findings In total, 256 patients (CG = 160, IG = 96) were recruited into the study. GPs’ acceptance of nephrologists’ medication recommendations increased significantly among naive patients and those with one prior contact with the nephrologist (CG/IG: naive = 72.8%/95.5%, 1 contact = 81.1%/94.4%; P < 0.001). DRPs per patient were significantly reduced in all subgroups (P < 0.001). Conclusions Interdisciplinary collaboration between the nephrologist, GPs and clinical pharmacist resulted in better MO for patients with CKD.

In 2021 new KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the management of glomerular diseases were published.For ANCA-associated glomerulonephritis the new recommendations comprise a more rapid steroid taper during induction treatment with cyclophosphamide or rituximab, the advice against routine use of plasma exchange, the choice of drug for and duration of maintenance treatment in accordance with predictors of relapse. A kidney transplant should be performed after at least 6 months of remission irrespective of the ANCA titer in ANCA-associated disease, and 6 months after absence of anti-GBM-antibodies in anti-GBM-disease.KLINISCHE, SEROLOGISCHE, HISTOPATHOLOGISCHE DIAGNOSTIK DER ANCA-ASSOZIIERTEN VASKULITIS: Zentraler Bestandteil der Diagnostik der AAV mit renaler Manifestation sind die Bestimmung von PR3- und MPO-ANCA sowie die Nierenbiopsie. Die Behandlung sollte in einem in AAV erfahrenen Zentrum erfolgen und rasch begonnen werden.Die Remissionsinduktion bei ANCA-assoziierter GN erfolgt mit Cyclophosphamid oder Rituximab in Kombination mit Kortikosteroiden. Die Leitlinie gibt Hilfestellung zur Therapieauswahl. Studienbasiert wird eine schnellere Steroidreduktion empfohlen.Zur Remissionserhaltung stehen Rituximab und Azathioprin zur Verfügung. Die Leitlinie gibt Hilfestellung zu Auswahl und Dauer der Therapie, die sich insbesondere nach dem Rezidivrisiko richtet.Die Plasmapherese gehört zur Standardtherapie der Anti-GBM-Erkrankung, ist jedoch bei der ANCA-assoziierten GN einer Einzelfallentscheidung bei fulminantem Verlauf vorbehalten.Eine Nierentransplantation kann bei ANCA-assoziierter GN nach mindestens 6-monatiger Remission unabhängig vom ANCA-Status erfolgen, bei Patienten mit Anti-GBM-Erkrankung nur nach negativem Antikörpernachweis.

The coronavirus disease 2019 (COVID-19) pandemic has also resulted in substantial challenges for nephrology worldwide. Patients with chronic kidney diseases are a particularly vulnerable patient group in this context and in severe courses of COVID-19 the kidneys are most frequently affected by organ failure after the lungs.In order to reliably evaluate the prevalence and mortality of dialysis patients in Germany with respect to COVID-19, during the first wave in spring 2020 the German Society of Nephrology implemented a registry for dialysis patients. Weekly data on the number and course of dialysis patients affected by COVID-19 were recorded and analyzed.The prevalence of COVID-19 in dialysis patients in Germany developed in two waves, similar to the course of the pandemic in the general population. In spring the prevalence in dialysis patients reached 1.4% and considerably declined during the summer. In December during the second wave of the pandemic the prevalence again rose to 1.9%, despite comprehensively implemented hygiene measures in dialysis centers. Similar to other industrial nations, dialysis patients in Germany also showed a very high lethality of COVID-19 of up to 20%.Immediate consequences for hygiene measures in dialysis institutions as well as vaccination strategies and vaccination prioritization for this patient group and the personnel treating them can be derived from the high mortality in dialysis patients. A consequence of the frequent involvement of the kidneys during infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in patients who had not previously suffered from advanced kidney disease should be the consistent nephrological aftercare.HINTERGRUND: Die Coronavirus-disease-2019(COVID-19)-Pandemie hat auch die Nephrologie weltweit vor große Herausforderungen gestellt. Zum einen stellen Patienten mit Nierenerkrankungen in diesem Zusammenhang eine besonders vulnerable Patientengruppe dar, und zum anderen sind die Nieren bei schweren COVID-19-Verläufen nach den Lungen am häufigsten vom Organversagen betroffen.Um zuverlässige Daten zu COVID-19-Prävalenz und -Mortalität bei Dialysepatienten in Deutschland zu erheben, hat die Deutsche Gesellschaft für Nephrologie bereits während der 1. Welle der Pandemie im Frühjahr 2020 ein Register aufgebaut. Wöchentlich wurden Angaben zu Anzahl und Verlauf der COVID-19-Dialysepatienten in Deutschland erhoben und ausgewertet.Die Prävalenz von COVID-19 bei Dialysepatienten in Deutschland zeigte einen doppelgipfligen Verlauf ähnlich wie in der Allgemeinbevölkerung. Während diese im Frühjahr bei Dialysepatienten auf 1,4 % stieg, fiel sie im Sommer deutlich ab und erreichte im Dezember im Rahmen der 2. Pandemiewelle einen Wert von ca. 1,9 %, trotz mittlerweile flächendeckend eingeführter umfangreicher Hygienemaßnahmen in den Dialysezentren. Ähnlich wie in anderen Industriestaaten weisen auch Dialysepatienten in Deutschland eine sehr hohe COVID-19-Letalität von etwa 20 % auf.Aus der ermittelten Letalität bei Dialysepatienten lassen sich unmittelbare Konsequenzen für Hygienemaßnahmen in den Dialyseeinrichtungen sowie zu Impfstrategie und -priorisierung dieser Patientengruppe und des sie behandelnden Personals ableiten. Eine Konsequenz des häufigen Befalls der Niere im Rahmen einer Infektion mit dem „severe acute respiratory syndrome coronavirus 2“ (SARS-CoV-2) bei zuvor noch nicht an einer fortgeschrittenen Nierenerkrankung leidenden Patienten sollte die konsequente nephrologische Nachsorge sein.

Granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) are the most frequent primary necrotizing small vessel vasculitides. In these formerly fatal diseases remission can be induced by stage- and activity-adapted immunosuppressive regimens in the majority of patients. This does not lead to drug-free long-term remission or even cure. Consequently, maintenance of remission medication is needed. Recent randomized controlled trials demonstrated that maintenance treatment with the anti-B-cell antibody Rituximab, administered 6-monthly as opposed to azathioprine leads to a significantly lower relapse rate but a similar profile of adverse events. These data enabled the extension of the approval of Rituximab for maintenance of remission treatment of GPA and MPA in Germany in 2018. Guidelines and expert recommendations concerning measures of infection prevention and vaccination of immunosuppressed patients as well as the management of hypogammaglobulinemia and cytopenia on Rituximab are presented in this review.Die Granulomatose mit Polyangiitis (GPA) und die mikroskopische Polyangiitis (MPA) stellen als primäre nekrotisierende Kleingefäßvaskulitiden die häufigsten ANCA-assoziierten Vaskulitiden dar. Bei diesen, früher oft tödlich verlaufenden Erkrankungen kann heute durch eine Stadien-adaptierte Immunsuppression in den meisten Fällen eine Remission erzielt werden. Diese mündet jedoch nicht in eine Heilung oder medikamentenfreie Langzeitremission. Es bedarf deshalb einer remissionserhaltenden Therapie. Aktuelle randomisierte kontrollierte Studien zeigen, dass unter einer remissionserhaltenden Behandlung mit halbjährlich verabreichtem anti-B-Zell-Antikörper Rituximab weniger Rezidive auftreten als unter der bisherigen Standardmedikation mit Azathioprin bei vergleichbarem Nebenwirkungsprofil. Diese Daten führten 2018 zur Zulassung von Rituximab als remissionserhaltende Therapie der GPA und MPA. Unter einer solchen Rituximab-Therapie muss mit einer Immunglobulindepletion sowie späten Zytopenien mit begleitenden Infekten gerechnet werden. Leitlinien und Expertenempfehlungen zu Infektprophylaxen, Impfungen und Immunglobulinsubstitution werden in diesem Beitrag vorgestellt.

Organ transplantation as an option to overcome end-stage diseases is common in countries with advanced healthcare systems and is increasingly provided in emerging and developing countries. A review of the literature points to sex- and gender-based inequity in the field with differences reported at each step of the transplant process, including access to a transplantation waiting list, access to transplantation once waitlisted, as well as outcome after transplantation. In this review, we summarize the data regarding sex- and gender-based disparity in adult and pediatric kidney, liver, lung, heart, and hematopoietic stem cell transplantation and argue that there are not only biological but also psychological and socioeconomic issues that contribute to disparity in the outcome, as well as an inequitable access to transplantation for women and girls. Because the demand for organs has always exceeded the supply, the transplant community has long recognized the need to ensure equity and efficiency of the organ allocation system. In the spirit of equity and equality, the authors call for recognition of these inequities and the development of policies that have the potential to ensure that girls and women have equitable access to transplantation.

The rapid progressive glomerulonephritis is an emergency case. Renal function is rapidly lost within weeks or a few months (rarely within days) due to necrotizing extracapillary proliferative crescentic glomerulonephritis. Early diagnosis and treatment improve prognosis, as the best prognostic marker is creatinine when treatment is initiated. Three classes can be distinguished by immunofluorescence in histology. Firstly, there are no or only few immunoglobulins found (anti-neutrophil cytoplasmic antibody [ANCA]-associated vasculitis). Secondly, there is linear immunofluorescence due to antibodies against the glomerular basement membrane (anti-glomerular basement membrane [GBM] disease or Goodpasture syndrome); and thirdly, there is a granular pattern of immunoglobulin deposition (for example systemic lupus erythematosus [SLE], Schoenlein-Henoch purpura or cryoglobulinaemia). The immunosuppressive repertoire has improved (such as induction therapy in ANCA-associated vasculitis with lower total steroid dose, cyclophosphamide pulses or rituximab). New treatment approaches are on their way and the prognosis regarding life expectancy and renal function has improved. There are still challenging questions to answer like treatment duration and markers of recurrence.

In patients with ANCA-associated vasculitis renal involvement is frequently seen and the severity of renal manifestation is very important for therapeutic strategies and prognosis. Clinically rapid loss of renal function, nephritic sediment and proteinuria in a non-nephrotic range are characterizing a focal segmental necrotizing pauci-immune glomerulonephritis with extrarenal proliferations. Induction treatment depends on the severity of manifestations. With a normal renal function methotrexate can be used in combination with steroids. In patients with organ threatening involvement but creatinine below 500 µmol/l cyclophosphamide pulses or Rituximab should be used together with steroids, initially with i. v. pulses. Rituximab is more effective in PR3-ANCA vasculitis and should be used in relapsing disease, in young patients to avoid gonadal toxicity and in patients with an increased risk of malignancies. In patients on dialysis or with creatinine 500 µmol/l plasma exchange should be added. Maintenance treatment (mainly with azathioprine) is necessary as at least 50 % of the patients develop relapses. Rituximab seems more effective, however it is not approved for maintenance treatment and no long-term data are available. Adjuvant treatment, long-term side effects and the increased incidence of cardiovascular events have to be included in the follow-up of vasculitis patients. In end-stage renal disease patients relapses occur but are more difficult to diagnose and treat with higher incidence of infections. Transplantation should be offered as patient and transplant survival is good.

ANCA-associated vasculitides are characterized by inflammatory destruction of small vessels accompanied by enhanced cleavage of membrane-bound proteins. One of the main proteases responsible for ectodomain shedding is disintegrin and metalloproteinase domain-containing protein 17 (ADAM17). Given its potential role in aggravating vascular dysfunction, we examined the role of ADAM17 in active proteinase-3 (PR3)-positive ANCA-associated vasculitis (AAV). ADAM17 concentration was significantly increased in plasma samples from patients with active PR3-AAV compared with samples from patients in remission or from other controls with renal nonvascular diseases. Comparably, plasma levels of the ADAM17 substrate syndecan-1 were significantly enhanced in active AAV. We also observed that plasma-derived ADAM17 retained its specific proteolytic activity and was partly located on extracellular microparticles. Transcript levels of ADAM17 were increased in blood samples of patients with active AAV, but those of ADAM10 or tissue inhibitor of metalloproteinases 3, which inhibits ADAMs, were not. We also performed a microRNA (miR) screen and identified miR-634 as significantly upregulated in blood samples from patients with active AAV. In vitro, miR-634 mimics induced a proinflammatory phenotype in monocyte-derived macrophages, with enhanced expression and release of ADAM17 and IL-6. These data suggest that ADAM17 has a prominent role in AAV and might account for the vascular complications associated with this disease.

A prospective randomised trial to compare two different durations of maintenance immunosuppressive therapy for the prevention of relapse in anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV).Patients with AAV were recruited 18-24 months after diagnosis if they were in stable remission after cyclophosphamide/prednisolone-based induction followed by azathioprine/prednisolone maintenance therapy. They were randomised (1:1) to receive continued azathioprine/prednisolone to 48 months from diagnosis (continuation group) or to withdraw azathioprine/prednisolone by 24 months (withdrawal group). The primary endpoint was the relapse risk, from randomisation to 48 months from diagnosis.One hundred and seventeen patients were randomised and 110 remained to the trial end. At entry, median serum creatinine was 116 μmol/L (range 58-372), 53% were ANCA positive. The percentage of patients presenting with relapse was higher in the withdrawal than in the continuation treatment group (63% vs 22%, p0.0001, OR 5.96, 95% CI 2.58 to 13.77). ANCA positivity at randomisation was associated with relapse risk (51% vs 29%, p=0.017, OR 2.57, 95% CI 1.16 to 5.68). Renal function, ANCA specificity, vasculitis type and age were not predictive of relapse. Severe adverse events were more frequent in the continuation than withdrawal groups (nine vs three events), but the continuation group had better renal outcome (0 vs 4 cases of end-stage renal disease), with no difference in patient survival.Prolonged remission maintenance therapy with azathioprine/prednisolone, beyond 24 months after diagnosis reduces relapse risk out to 48 months and improves renal survival in AAV.ISRCTN13739474.

Objective The objective of this article is to evaluate the safety and clinical outcome of rituximab treatment in systemic lupus erythematosus (SLE) patients refractory to standard of care therapy in a real-life setting in Germany. Methods The GRAID registry included patients with different autoimmune diseases who were given off-label treatment with rituximab. Data on safety and clinical response were collected retrospectively. In SLE patients, clinical parameters included tender and swollen joint counts, fatigue, myalgia, general wellbeing, Raynaud’s and the SLEDAI index. Laboratory tests included dsDNA antibody titres, complement factors, hematologic parameters and proteinuria. Finally, the investigators rated their patients as non-, partial or complete responders based on clinical grounds. Results Data from 85 SLE patients were collected, 69 female and 16 male, with a mean disease duration of 9.8 years. The mean follow-up period was 9.6 ± 7.4 months, resulting in 66.8 patient years of observation. A complete response was reported in 37 patients (46.8%), partial response in 27 (34.2%), no response in 15 (19.0%). On average, major clinical as well as laboratory efficacy parameters improved substantially, with the SLEDAI decreasing significantly from 12.2 to 3.3 points. Concerning safety, one infusion reaction leading to discontinuation of treatment occurred. Infections were reported with a rate of 19.5 (including six severe infections) per 100 patient years. Conclusion With the restrictions of a retrospective data collection, the results of this study confirm data of other registries, which suggest a favourable benefit-risk ratio of rituximab in patients with treatment-refractory SLE.

Objective.Rituximab (RTX) therapy is a treatment option in patients with refractory antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). We investigated the tolerability and clinical efficacy of RTX in a cohort of patients with refractory AAV.Methods.Clinical and safety data of patients with AAV treated with RTX were retrospectively assessed from the data of a German national registry.Results.In total, 58 patients were included in this analysis (50/58 with granulomatosis with polyangiitis; 8/58 with microscopic polyangiitis who received at least 1 cycle, 17 patients who received 2 cycles, and 3 patients who received 3 cycles of RTX). Response was classified as complete and partial in 22 (40%) and in 29 cases (52.7%), respectively. Four patients (7.3%) were classified as nonresponders.Conclusion.RTX was well tolerated with good clinical efficacy in patients with refractory AAV.

Early and accurate detection of acute kidney injury (AKI) is needed to prevent the progression to chronic kidney disease and to improve outcome. Here we used capillary electrophoresis-mass spectrometry to identify urinary peptides predictive of AKI in a training set of 87 urine samples longitudinally collected from patients in an intensive care unit. Within this patient cohort, 16 developed AKI while 14 maintained normal renal function. The sequence of twenty peptides significantly associated with AKI was identified. They were found to be degradation products of six proteins. These formed a diagnostic pattern. Peptides of albumin, α-1-antitrypsin, and β-2-microglobulin were upregulated but fragments of fibrinogen α and collagens 1 α(I) and 1 α(III) were downregulated in AKI. After cross-validation of the training set, a good diagnostic performance of the marker pattern was found with an area under the ROC curve of 0.91. This was confirmed in a blinded validation set of 20 patients in the intensive care unit and 31 allogeneic hematopoietic stem cell transplantation patients, of which 13 had and 18 had not experienced an episode of AKI. In comparison to more established markers of AKI such as serum cystatin C and urinary kidney injury molecule-1, interleukin-18, and neutrophil gelatinase associated-lipocalin, the proteomic marker pattern was found to be of superior prognostic value, detecting AKI up to 5 days in advance of the rise in serum creatinine.

About 30 years ago circulating endothelial cells (CEC) were first observed in peripheral blood. Since then CEC have been established as a reliable indicator of vascular injury and damage and more sophisticated detection techniques, such as immunomagnetic isolation and fluorescence-activated cell sorting (FACS), have become available. However even today there remains controversy as to the best approach to isolate and enumerate these cells. Here, we review the isolation and enumeration of CEC with an emphasis on CD146-driven immunomagnetic isolation and FACS as the two competing techniques. We describe advantages and pitfalls of both approaches. Moreover, we provide a list of clinical studies in this field and describe the possible clinical utility of CEC as a surrogate marker for vascular damage and dysfunction. In addition, we review the phenotype of CEC and discuss mechanisms of detachment. Recent evidence has also revealed interesting interactions between CEC and healthy endothelium in vitro although the relevance of these findings for human vascular disease in vivo remains unclear. Finally, we highlight differences between circulating endothelial cells and endothelial progenitor cells. In summary, CEC must be regarded as a sensitive and specific marker of endothelial damage as well as a potential mediator in vascular disease.

Recent studies have demonstrated that CXCL13 serum levels correlate significantly with systemic lupus erythematosus (SLE) disease activity. However, experimental studies show that CXCL13 production can also be induced by bacterial exposure as well as in response to inflammatory cytokines. This report asks whether CXCL13 serum levels are elevated in patients with evidence of bacterial infections and whether there is a correlation with the C-reactive protein (CRP) levels or the severity of illness in critically ill patients. CXCL13 levels were compared in 39 patients with active SLE (without concomitant infection), 40 non-SLE patients with sepsis, and 40 healthy controls by enzyme-linked immunosorbent assay (ELISA) methodology. We also tested storage conditions and freeze–thaw cycles for stability of CXCL13 in serum samples. Our studies demonstrated that the median CXCL13 serum levels were significantly elevated in patients with SLE [median 83 pg/ml (interquartile range 38–366)] or sepsis [359 pg/ml (151–459)] compared with healthy controls [32 pg/ml (27–41), p

Saddle-nose deformity is a well-recognized stigma of patients affected by Wegener granulomatosis (WG). However, plastic surgical repair is seldom performed. In this study, the authors aimed to evaluate their own patients exclusively reconstructed by costal cartilage L-strut of the nose for this specific deformity.During a 5-year-period, four women with an average age of 33 years underwent reconstructive rhinoplasty of their saddle-nose deformity caused by WG, which in every case was in remission regarding the nose at the time of surgery. Restoration of the nasal framework was performed by an L-shaped rib cartilage graft.The external form and function of the newly reconstructed nose was preserved during an average follow-up period of 42 months for all the patients. No resorption of the rib cartilage graft was observed. A review of the literature found a total of 22 nasal reconstructions for patients affected by WG.According to this patient series and a review of the literature, external nasal reconstruction for patients affected by WG appears to be safe and effective if the disease is in remission before any operation. Despite concern that high-dose immune suppression therapy may increase the risk of failure in primary nasal dorsal repair, this could not be observed in the patients of this series, all of whom were receiving immunosuppressive medication. Therefore, nasal reconstruction to improve the physical appearance and thus the psychological well-being of these chronically ill patients seems to be justified.

Because of its availability, ease of collection, and correlation with physiology and pathology, urine is an attractive source for clinical proteomics/peptidomics. However, the lack of comparable data sets from large cohorts has greatly hindered the development of clinical proteomics. Here, we report the establishment of a reproducible, high resolution method for peptidome analysis of naturally occurring human urinary peptides and proteins, ranging from 800 to 17,000 Da, using samples from 3,600 individuals analyzed by capillary electrophoresis coupled to MS. All processed data were deposited in an Structured Query Language (SQL) database. This database currently contains 5,010 relevant unique urinary peptides that serve as a pool of potential classifiers for diagnosis and monitoring of various diseases. As an example, by using this source of information, we were able to define urinary peptide biomarkers for chronic kidney diseases, allowing diagnosis of these diseases with high accuracy. Application of the chronic kidney disease-specific biomarker set to an independent test cohort in the subsequent replication phase resulted in 85.5% sensitivity and 100% specificity. These results indicate the potential usefulness of capillary electrophoresis coupled to MS for clinical applications in the analysis of naturally occurring urinary peptides.

Objectives. The chemokine CXCL13, also known as BCA-1 (B-cell-attracting chemokine-1) or BLC (Blymphocyte chemoattractant), is a major regulator of B-cell trafficking. We have recently shown that excessive expression of dendritic cell-derived CXCL13 is a distinctive early event for nephritis in a murine model of systemic lupus erythematosus (SLE). Furthermore, in kidney biopsies from SLE patients, CXCL13 protein and mRNA are strongly expressed in B-cell-containing inflammatory lesions. Here, we ask whether serum levels of CXCL13 correlate with disease activity and renal involvement in SLE patients. Methods. CXCL13 was measured in sera obtained from 91 patients with SLE and 40 healthy controls by ELISA methodology. Disease activity was calculated according to the SLE Disease Activity Index (SLEDAI). Results. Median (IQR) serum CXCL13 concentrations were increasingly higher across the following groups: healthy controls [31.6 (26.8–41.3) pg/ml], SLE patients with inactive disease (SLEDAI

Much progress has been made in understanding the pathogenesis of anti-neutrophil cytoplasmic antibodies (ANCA)-associated small-vessel vasculitis and interaction between ANCA and micro-vascular endothelial cells are centre stage. The interactions of these key players culminate in respiratory burst of the neutrophil with release of radicals and proteases and subsequent endothelial cell and tissue damage. During the last decade, markers have become available to assess the extent and/or acuity of vascular damage in a clinical setting. First, circulating endothelial cells (CEC) have emerged as reliable surrogate markers of endothelial damage in vasculitis. More recently, endothelial microparticles have been used and appear to reflect damage and activation of the cells. Data on endothelial progenitor cells in vasculitis are sparse but intriguing while a genuine progenitor cell deficiency remains controversial. The severely damaged phenotype of CEC in vasculitis led to the hypothesis that such circulating apoptotic and/or necrotic debris may itself be a mediator of disease and first data from experimental studies have added proof to this assumption. Such effects may well contribute to a pro-inflammatory environment in ANCA-associated small-vessel vasculitis and in vascular disease in general. Here, we review mechanisms and markers of endothelial damage and repair in ANCA-associated vasculitis and put these findings into perspective.

Objective: To investigate the role of the angiopoietin–tyrosine kinase with Ig-like and epidermal growth factor-like domains (Ang–Tie) system in systemic lupus erythematosus (SLE). Endothelial activation is emerging as a key event for leukocyte recruitment and accelerated atherosclerosis in SLE. Recently, the endothelial-specific Ang–Tie ligand–receptor system has been identified as a major regulator of vascular responsiveness to inflammatory stimuli. Methods: Ang1 (by immunoradiometric sandwich assay (IRMA)) and Ang2 (by ELISA) were measured in sera of 43 patients with SLE and 30 healthy controls. Expression of Ang2 was studied by immunohistochemistry in biopsies of human lupus nephritis. Results: Circulating Ang2 concentrations were increased and concentrations of Ang1 decreased in patients with active SLE compared to healthy controls. This tendency was still present in inactive SLE, although less pronounced. Individual Ang2 concentrations correlated well with SLE Disease Activity Index (SLEDAI) score, proteinuria, double-stranded DNA (dsDNA) titre and soluble vascular cell adhesion molecule 1 (sVCAM-1). In a multivariate regression analysis, renal involvement was the only independent predictor for elevated Ang2. Serum Ang2 was identified as a strong predictor for disease activity by receiver operating characteristic (ROC) procedures and regression tree models. Protein expression of Ang2 was upregulated in glomeruli of patients with lupus nephritis. Conclusions: These data indicate that Ang2-mediated disruption of protective Ang1/Tie2 signalling is operational in SLE. Ang2 might facilitate endothelial inflammation, permeability and contribute to premature atherosclerosis. Furthermore, circulating Ang2 may be a valuable new biomarker for disease activity in SLE. Strategies to control the deleterious effects of Ang2 may open new perspectives to prevent endothelial inflammation in SLE.

OBJECTIVE Endothelial cells play a central pathogenetic role in ANCA-associated small-vessel vasculitis (AAV). Circulating endothelial cells (CECs), as a marker of endothelial damage, have been shown to be elevated in vasculitis. More recently, endothelial microparticles (EMPs) were found to be increased in active childhood vasculitis. The role of EMP in adult AAV and the relationship between EMP and CEC is unclear. PATIENTS AND METHODS We studied 26 patients with AAV, 12 healthy volunteers and 10 patients with IgA nephropathy as disease control. Platelet-poor plasma was ultracentrifuged. MPs were identified and enumerated with flow cytometry, Annexin V, CD62E and CD105 antibodies. Leucocyte- and platelet-derived MPs were also measured. CEC were isolated and enumerated with CD146-driven immuno-magnetic isolation. RESULTS EMPs are significantly elevated in patients with active vasculitis (CD62E: mean 248 MP/microl +/- 198 s.d.; CD105: 121 +/- 135/microl) compared with patients in remission/partial remission (CD62E: 55 +/- 30/microl, P = 0.001; CD105: 16 +/- 12/microl, P = 0.002) and healthy volunteers (CD62E: 66 +/- 33/microl, P = 0.002; CD105: 25 +/- 26/microl, P = 0.007). The MP count correlates with disease activity measured by the Birmingham Vasculitis Activity Score (BVAS) (CD62E: r = 0.703; CD105: r = 0.445, P < 0.023). CONCLUSION EMPs are elevated in active adult AAV. EMP levels correlate with disease activity and might serve as a marker of endothelial activation and damage. Differential detection of endothelial, platelet- and leucocyte-derived MPs may provide more insight in to the pathogenesis of AAV.

B-cell depletion with rituximab, a chimeric anti-CD20 antibody, is a novel treatment for refractory and relapsing ANCA-associated small-vessel vasculitis. Data are limited and most reports describe single patients or small numbers of patients followed prospectively.We report a single-centre experience with 15 patients who received rituximab for refractory or relapsing ANCA-associated vasculitis. All patients had been treated with corticosteroids and cyclophosphamide and a variety of other second-line immunosuppressive agents. None of the patients had evidence of infection and received four infusions of 375 mg/m(2) of rituximab. Disease activity was assessed in accordance with the Birmingham Vasculitis Activity Score (BVAS). BVAS, C-reactive protein and ANCA titres were recorded at baseline and during follow-up.B-cell depletion was achieved in all patients. Partial or complete remission was seen in 14 of 15 patients with a significant decline in BVAS compared to baseline (P0.007). One patient with granulomatous ANCA-associated vasculitis did not respond to rituximab. There were no side effects during rituximab infusion. Transient leucopenia was observed in two patients. One patient with bronchial stenosis died of pneumonia 5.5 months after the initiation of rituximab treatment. One initially anti-HBc-positive/HBsAg-negative patient experienced a reactivation of hepatitis B, developed end-stage renal failure and died after refusal of dialysis.We report the largest case series of rituximab use for ANCA-associated vasculitis so far. Our data support that the drug is capable of inducing partial or complete remission in refractory or relapsing patients. Leucopenia and infectious complications remain a matter of concern.

We evaluated the utility of SDS-PAGE/Western blot and CE coupled with MS (CE-MS) for detection of urinary polypeptide biomarkers of renal disease in patients with IgA-associated glomerulonephritides. In a reference cohort of 402 patients with various renal disorders and 207 healthy controls, we defined CE-MS patterns of renal damage and IgA nephropathy (IgAN). In a blinded analysis of a separate cohort of patients with IgAN (n = 10), Henoch-Schoenlein purpura (HSP) with nephritis (n = 10), and IgA-associated glomerulonephritis due to hepatitis C virus (HCV)-induced cirrhosis (n = 9), and healthy controls (n = 12), we compared SDS-PAGE/Western blot and CE-MS against clinical urinalysis for detection of urinary proteins/polypeptides. Urinalysis indicated proteinuria for 50, 90, and 33% of patients, respectively, and for none of the healthy controls. SDS-PAGE/Western blot showed urinary polypeptides abnormality for 90, 80, and 67% of patients, respectively, and for none of the healthy controls. CE-MS indicated a Renal Damage Pattern in 80, 80, and 100 of patients, respectively, and in 17% of healthy controls, with the more specific IgAN Pattern in 90, 90, and 1%, respectively, and in none of the healthy controls. Based on differences in CE-MS patterns, the disease mechanisms may differ among various IgA-associated glomerulonephritides. These exploratory findings should be evaluated in a prospective study with contemporaneous renal biopsy and urinary testing. If validated, it may be feasible to adapt the CE-MS methodology to develop novel tests to detect renal injury at earlier stages, assess clinical manifestations, and monitor responses to therapy in patients with IgA-associated renal diseases.

During the last decade, circulating endothelial cells (CECs) have been used as a surrogate marker of endothelial damage in a variety of vascular disorders. The severely damaged phenotype of CECs in vasculitis led to the hypothesis that such circulating apoptotic and/or necrotic debris may itself be a mediator of disease. Very recently, first evidence has emerged to support this assumption [1]. The aim of this editorial comment is to provide a brief review of CECs, describe clinical applications with an emphasis on renal disease, and put the new pathogenetic findings into perspective. We also suggest further avenues of research.

The main goal of therapy for lupus nephritis is to achieve remission, as this has a major impact on patient and renal survival. Furthermore, early treatment success has been shown to improve long-term prognosis. This has traditionally been achieved with intravenous cyclophosphamide, but recent data show that mycophenolate mofetil is equally effective and causes fewer adverse effects. Research is ongoing to find new treatment targets. Possible future therapies include monoclonal antibodies against CD20 (rituximab), CD22 (epratuzumab) and CD40, and therapies targeted at cytokine secretion, immunoglobulin secretion, B-cell maturation and T-cell proliferation and differentiation. Rituximab has shown promise in patients with active proliferative lupus nephritis, which suggests that B-cell depletion may be successful. Anti-double-stranded DNA antibodies correlate with flares of lupus nephritis and may represent another therapeutic target. Therapy with LIP 394, which crosslinks anti-double-stranded DNA antibodies in solution or on the B-cell surface, has been shown to reduce flares. Cardiovascular disease is a major cause of mortality in systemic lupus erythematosus, and this must also be addressed if long-term outcomes are to be improved. Many patients with systemic lupus erythematosus have subclinical atherosclerosis quite early in the disease course, and the risk of coronary artery disease at any level of traditional cardiovascular risk factors is higher than in the general population. Specific lupus-associated risk factors include the inflammatory process itself and anticardiolipin antibodies. Possible strategies to reduce the risk include reduction of disease activity to improve endothelial function and reduction of steroid dose whenever possible. Therapy with aspirin or statins may be another possibility. Thus treatment of lupus nephritis is evolving from standardised therapy to individualised therapy based on analysis of organ involvement, risk factors and cytokine, antibody or cell profiles.

Objective Antineutrophil cytoplasmic antibody–associated vasculitis (AAV) is characterized by necrotizing vessel wall inflammation, paralleled by the detachment of endothelial cells. The repair of such endothelial defects is crucial for the maintenance of regular structure and function of the injured vessels. Bone marrow–derived endothelial progenitor cells (EPCs) are thought to play a pivotal role in the regeneration of damaged endothelium. The aim of this study was to investigate whether EPCs are involved in vascular repair in AAV. Methods We assessed disease activity, CD34+ hematopoietic progenitor cells (HPCs) using flow cytometry, EPCs using an in vitro assay, and circulating endothelial cells (CECs) by immunomagnetic isolation from the peripheral blood of 31 patients with active AAV at 1, 3, and 6 months after the initiation of immunosuppressive therapy. Results In patients with untreated active disease, HPC and EPC numbers were comparable with those in healthy control subjects (n = 64). With the induction of remission, the number of HPCs and EPCs increased significantly, from a median of 1.5 cells/μl (range 0.0–7.0) to a median of 3.2 cells/μl (range 0.76–9.2) (P < 0.001) and from a median of 261 cells/high-power field (range 171–643) to a median of 470 cells/high-power field (range 168–996) (P < 0.021), respectively. In contrast, the initially elevated number of CECs decreased significantly (P < 0.001). We observed no correlation between the number of HPCs or EPCs and the leukocyte count, the thrombocyte count, or kidney function. Conclusion In patients with AAV, the numbers of circulating CD34+ HPCs and EPCs increased significantly after the institution of immunosuppressive therapy and disease remission. This finding points to a role of circulating CD34+ HPCs and EPCs in endothelial repair in vasculitis. Targeted stimulation of these cells might represent a new possibility of improving vascular healing in AAV.

Circulating endothelial cells (CECs) have been detected in a variety of vascular disorders, but their interactions with healthy endothelium remain unknown. The aim of this study was to evaluate the response of human endothelial cells (ECs) to apoptotic or necrotic ECs in an in vitro model and to delineate pathogenetic pathways. Here we show that incubation of the human microvascular endothelial cell line (HMEC-1) with apoptotic ECs resulted in increased expression of chemokines and enhanced binding of leukocytes to HMEC-1 cells, whereas exposure of HMEC-1 cells to necrotic ECs caused no changes in leukocyte-binding affinity. Both apoptotic and necrotic cells were bound and engulfed by HMEC-1 cells and primary human umbilical vein endothelial cells (HUVECs). We therefore suggest that exposures to apoptotic and necrotic ECs induce different patterns of chemokine synthesis and leukocyte adhesion in healthy ECs. These data indicate that CECs are not only markers of vascular damage but may induce proinflammatory signals in the endothelium.

To evaluate numbers of circulating endothelial cells (CECs) in ANCA associated vasculitis and compare vasculitic relapse with limited granulomatous disease.Sixteen patients with vasculitic relapse of ANCA associated vasculitis and 12 patients with limited granulomatous disease due to Wegener's granulomatosis (WG) were studied. Six patients with newly diagnosed vasculitic disease and six patients with vasculitis with infectious complications were also studied. Twenty two patients in remission were studied, as were 20 healthy controls. Counting of CECs was performed with anti-CD146 driven immunomagnetic isolation and staining with Ulex Europaeus lectin 1(UEA-1).Patients with vasculitic relapse had markedly increased numbers of circulating endothelial cells (12-800 cells/ml, median 88 cells/ml) as did patients with newly diagnosed systemic vasculitis (20-216 cells/ml, median 56 cells/ml). Patients with limited granulomatous disease due to WG had only slightly increased cell numbers (4-44 cells/ml, median 20 cells/ml), which were similar to those of patients in remission (4-36 cells/ml, median 16 cells/ml). Numbers of CECs in patients with granulomatous disease were significantly lower than in those patients with relapse or new onset vasculitis (p0.001). Cell numbers in patients with relapse and new onset vasculitis declined with immunosuppressive treatment. Patients with infection had 4-36 cells/ml (median 10 cells/ml). A cut off value of 20 cells/ml for a positive result yielded 64% specificity and 95% sensitivity for active systemic vasculitis; the positive predictive value was 63% and the negative predictive value 95%.Markedly increased numbers of CECs discriminate active vasculitis from limited granulomatous disease and remission. These findings add further proof to the concept of CECs as a marker of ANCA associated small vessel vasculitis.

During hematopoietic stem cell transplantation (HSCT), endothelial damage is the pathological hallmark of veno-occlusive disease of the liver, thrombotic microangiopathy, capillary leak syndrome and graft-versus-host disease. Events prior to conditioning, the conditioning regimen itself as well as calcineurin inhibitors may all induce endothelial damage. Unfortunately, the relative importance of these factors and their interactions, the time frame of endothelial damage and individual susceptibility remain unknown. Moreover, it is conceivable that conditioning regimens differ markedly in their propensity to initiate endothelial damage. Monitoring endothelial damage and response to treatment is hampered by the current lack of suitable markers. In this regard, an ideal marker should be sensitive and specific and indicate the development of an endothelial disorder prior to the onset of symptoms and organ dysfunction. Soluble markers, such as thrombomodulin, are easily amenable with immunoassays; yet, the interpretation of their levels is hampered by the influence of comorbidity. Evaluation of circulating endothelial cells in HSCT demonstrated a marked and dose-dependent increase in cell numbers after conditioning. The challenge ahead is to establish and evaluate novel markers of endothelial damage to permit early detection of disease, monitor response to treatment and evaluate different conditioning regimens.

Proteomic patterns established with capillary electrophoresis and mass spectrometry for diagnostic purposes. Background Proteomics applied in large scale may provide a useful diagnostic tool. Methods We developed an online combination of capillary electrophoresis with mass spectrometry, allowing fast and sensitive evaluation of polypeptides found in body fluids. Utilizing this technology, polypeptide patterns from urine are established within 45 minutes. About 900 to 2500 polypeptides as well as their concentrations are detected in individual urine samples without the need for specific reagents such as antibodies. To test this method for clinical application, we examined spot urine samples from 57 healthy individuals, 16 patients with minimal change disease (MCD), 18 patients with membranous glomerulonephritis (MGN), and 10 patients with focal segmental glomerulosclerosis (FSGS). Results One-hundred seventy-three polypeptides were present in more than 90% of the urine samples obtained from healthy individuals, while 690 polypeptides were present with more than 50% probability. These data permitted the establishment of a "normal" polypeptide pattern in healthy individuals. Polypeptides found in the urine of patients differed significantly from the normal controls. These differences allowed the distinction of specific protein spectra in patients with different primary renal diseases. Abnormal pattern of proteins were found even in urine from patients in clinical remission. Conclusion The data indicate that capillary electrophoresis with mass spectrometry coupling provides a promising tool that permits fast and accurate identification and differentiation of protein patterns in body fluids of healthy and diseased individuals, thus enabling diagnosis based on these patterns.

BACKGROUND: Cardiovascular disease is the main cause of death with a functioning graft in renal transplant recipients. Elevated levels of C-reactive protein (CRP) and evidence of chronic Chlamydia pneumoniae infection have been linked to cardiovascular disease and survival in patients with normal renal function and patients with end-stage renal disease on dialysis. So far, no such data have been available in renal transplant recipients. METHODS: CRP, immunoglobulin (Ig)G and IgA antibodies to C. pneumoniae, and classic risk factors were compiled in 143 patients who underwent renal transplantation between January 1989 and April 1991. Samples were collected at transplantation, 1 year later, and at study end. Cardiovascular disease, death, and graft loss were documented during follow-up. RESULTS: A total of 44 patients died during a mean follow-up of 10 years. Cardiac events were responsible for 37% of deaths. Age, gender, number of antihypertensive drugs, and seropositivity for IgG and IgA antibodies to C. pneumoniae, but not CRP levels, were significantly associated with cardiac death. C. pneumoniae serology and CRP levels, however, did not influence graft survival. Age, presence of diabetes, calcium phosphorus ion product, number of antihypertensive drugs, serum creatinine at 1 year, and presence of chronic rejection were all negatively correlated with graft survival. CONCLUSIONS: Serologic evidence of chronic C. pneumoniae infection is associated with mortality as the result of cardiovascular disease in renal transplant recipients. CRP serum levels do not predict cardiac death in renal transplant recipients, in contrast with patients with normal renal function and patients on dialysis.

The on-line coupling of capillary electrophoresis (CE) with electrospray-time-of-flight mass spectrometry (MS) has been used to obtain patterns of peptides and proteins present in the urine of healthy human individuals. This led to the establishment of a “normal urine polypeptide pattern”, consisting of 247 polypeptides, each of which was found in more than 50% of healthy individuals. Applying CE–MS to the analysis of urine of patients with kidney disease revealed differences in polypeptide pattern. Twenty-seven polypeptides were exclusively found in samples of patients. Another 13, present in controls, were missing. These data indicate that CE–MS can be applied as powerful tool in clinical diagnostics.

Microvascular endothelial cells play a key role in transplant immunology. They are also important targets for calcineurin inhibitors. We recently demonstrated elevated numbers of circulating endothelial cells in renal transplant recipients with and without rejection in comparison with healthy controls. Because these patients received either cyclosporine or tacrolimus, we speculated that endothelial damage from calcineurin inhibitors might be responsible for these findings. In the present study, we tested the hypothesis that treatment with calcineurin inhibitors leads to an increase in circulating endothelial cells. We studied 57 renal transplant recipients: 19 on a calcineurin inhibitor–free immunosuppressive regimen and 38 patients on a standard immunosuppressive regimen, including cyclosporine, and matched them for age and serum creatinine. Endothelial cells were isolated from peripheral blood with anti-CD-146–coated immunomagnetic Dynabeads™ and were counted by fluorescence microscopy. Patients with cyclosporine therapy had elevated numbers of circulating endothelial cells (median 26, range 12 to 82 cells/mL) compared with healthy controls (median 6, range 0 to 82 cells/mL; P P

Objective Histological evidence is considered the only proof of primary central nervous system vasculitis (PCNSV). However, brain biopsy is often omitted or delayed because of the invasiveness and possible complications of the procedure. Circulating endothelial cells (CEC) were shown to be elevated in patients with active antineutrophil cytoplasmic antibody-associated vasculitis. We hypothesise that CEC are also elevated in patients with active PCNSV and may contribute to the diagnosis. Methods CEC were assessed in 18 patients, 3 of whom had biopsy-proven PCNSV and 15 clinical, cerebrospinal fluid and imaging data, highly suggestive of PCNSV. In 3 of these 15 patients CEC assessment was performed after initiation of successful immunosuppressive therapy. CEC numbers of all patients were compared to those of 16 healthy volunteers and 123 subjects with cerebrovascular risk factors and/or ischaemic stroke, who had been studied in our group before. CEC were assessed by immunomagnetic isolation from peripheral blood. Results In patients with proven and suspected active PCNSV, CEC were extremely elevated (>400 cells/ml in most of the patients) and significantly higher than in healthy and disease controls (p≤0.01 for each group). CEC significantly decreased with immunosuppressive treatment. Conclusions For the first time it is shown that CEC are significantly elevated in patients with active PCNSV in contrast to other pathologies associated with brain infarction and correlate with disease activity. Sensitivity and specificity of the method for diagnosing PCNSV and the use of the method for treatment monitoring should be addressed in future prospective studies with a larger patient group.

The haemolytic uraemic syndrome (HUS) is the most frequent cause of acute renal failure in childhood. We investigated L-arginine/NO pathway in 12 children with typical HUS and 12 age-matched healthy control subjects. Nitrite and nitrate, the major NO metabolites in plasma and urine, asymmetric dimethylarginine (ADMA) in plasma and urine, and dimethylamine (DMA) in urine were determined by GC-MS and GC-MS/MS techniques. Urinary measurements were corrected for creatinine excretion. Plasma nitrate was significantly higher in HUS patients compared to healthy controlsP=0.021, whereas urine nitrate was borderline lower in HUS patients compared to healthy controlsP=0.24. ADMA plasma concentrations were insignificantly lower, but urine ADMA levels were significantly lower in the HUS patientsP=0.019. Urinary DMA was not significantly elevated. In HUS patients, nitrateR=0.91but not nitrite, L-arginine, or ADMA concentrations in plasma correlated with free haemoglobin concentration. Our results suggest that both NO production and ADMA synthesis are decreased in children with typical HUS. We hypothesize that in the circulation of children with HUS a vicious circle between the L-arginine/NO pathway and free haemoglobin-mediated oxidative stress exists. Disruption of this vicious circle by drugs that release NO and/or sulphydryl groups-containing drugs may offer new therapeutic options in HUS.

Accelerated arteriosclerosis with cardiovascular disease is the main cause of death in end-stage renal disease patients. Increased, levels of C-reactive protein (CRP) and evidence of chronic Chlamydia pneumoniae infection have been identified as risk factors for cardiovascular disease in the general population. We tested the hypothesis that elevation of CRP, indicating chronic inflammation, and positive serum antibody titres for C. pneumoniae are associated with an increased cardiovascular mortality in patients on chronic peritoneal dialysis.We measured CRP and antibodies to C. pneumoniae in 34 patients on peritoneal dialysis. CRP was measured by a sensitive ELISA and C. pneumoniae antibodies by microimmunofluorescence. In addition, risk factors such as lipids, smoking status and hypertension were assessed. Coronary artery disease (CAD) was defined by cardiac stress testing and/or angiography. Patients showing clinical evidence of systemic or peritoneal dialysis-associated infection during the investigation period of 6 months (between 1990 and 1991) were excluded.The incidence of CAD was significantly increased in patients with CRP values1.5 mg/l (odds ratio 7.0, P0.022) during 72 months of follow-up. In addition, in patients seropositive for IgA C. pneumoniae antibodies, the incidence of CAD was significantly increased (odds ratio 7.2, P0.014). These findings resulted in an increased risk of death in patients with mean CRP values1.5 mg/l at the start of the study (odds ratio 20.0, P0.001). Furthermore, in patients seropositive for IgA C. pneumoniae antibodies, the risk of death (odds ratio 10.2, P0.005) was significantly increased. There was a highly significant correlation between CRP and seropositivity for IgA C. pneumoniae antibodies (r=0.445, P0.01).Increased circulating CRP and seropositivity for C. pneumoniae in patients on chronic peritoneal dialysis are associated with reduced survival due to cardiovascular complications. CRP and C. pneumoniae antibodies may indicate a chronic inflammatory process as an underlying cause and/or result of arteriosclerosis.

Recently we showed systemic complement activation in patients with immunoglobulin A (IgA) nephropathy (measured by "activated C3" [actC3], in other words, neoantigens developing on breakdown products after C3 activation) and reported that plasma levels of actC3 can indicate disease activity and renal outcome. In this study we investigated whether plasma C3a and C-reactive protein (CRP), which require tests that are more readily available, have a similar diagnostic and predictive value. CRP was measured using a highly sensitive enzyme-linked immunosorbent assay and C3a using a specific immunoassay. CRP and C3a levels were significantly higher in 56 patients with IgA nephropathy as compared with 55 healthy controls. C3a levels in IgA nephropathy patients were also significantly increased in comparison with 42 patients with hypertension or nonimmune renal diseases. Neither C3a nor CRP levels correlated with those of actC3 in IgA nephropathy patients. We also compared 10 IgA nephropathy patients with stable, normal renal function with eight IgA nephropathy patients progressing from normal to impaired renal function during mean follow-ups of 7.1 and 5.1 years, respectively. Mean CRP but not C3a levels during the observation period were significantly higher in IgA nephropathy patients with disease progression than in those with stable renal function. Conclusion: Systemic complement activation can be detected by measurement of plasma C3a in IgA nephropathy, but C3a levels cannot substitute for actC3 in predicting renal prognosis. Subclinical induction of the acute phase response is also present in patients with progressive IgA nephropathy, but again its prognostic value is limited. Repeated determinations performed over prolonged time courses may possibly improve the prognostic value of CRP levels.

A 55-year-old woman with systemic lupus erythematosus was admitted with fever of unknown origin. She had been on an immunosuppressive regimen for the past 8 years including steroids and Azathioprine. Laboratory parameters revealed a markedly elevated C-reactive protein of 189 mg/l, antinuclear antibodies of 1:2,560, a hemoglobin level of 9.0 g/dl, and a severe lymphopenia (total lymphocytes 49.4/microl, CD4(+) cells 2/microl, CD8(+) cells 7/microl). Neither blood culture samples nor computed tomography and magnetic resonance imaging of the chest and abdomen nor a trans-esophageal echocardiography revealed positive results. A bone marrow biopsy did not show signs of hematologic disease, but revealed a small granuloma rife with acid-fast bacilli, which were later confirmed to be Mycobacterium genavense by gene sequencing. To our knowledge, this is the first case involving M. genavense infection in a patient with systemic lupus erythematosus. In contrast to other reports regarding disseminated M. genavense infection, the patient is still alive and well.

In the 19th century, Friedrich von Recklinghausen discovered that blood vessels possess a lining [1]. It has been estimated that 1.2 trillion of these cells cover a surface of 400 m. They are not, as Recklinghausen had believed, a mere tapestry . Instead, endothelial cells regulate vascular tone via nitric oxide, ensure the homoeostasis of coagulation, and participate in immune events via complex interactions with circulating cell subsets [2]. Endothelial dysfunction and damage have been the focus of investigators during the past decade and various approaches have been employed. Flow-mediated dilatation of the brachial artery has gained widespread use but the technique remains cumbersome. Endothelial damage can be assessed by soluble markers, such as thrombomodulin or von Willebrand factor, circulating endothelial cells (CECs) [3] and, more recently, endothelial microparticles [4]. Likewise, repair of endothelial damage has been studied ever since Jeffrey Isner and colleagues at Tufts University described bone marrow-derived endothelial progenitor cells (EPCs) [5]. Unfortunately, these cells still lack a clear-cut phenotype as reviewed elsewhere [6]. In this issue of the Journal, Bonello and colleagues from Marseille [7] report a remarkable study on CECs and EPCs in patients with stable coronary artery disease who underwent percutaneous catheter intervention (PCI). It was already known that numbers of CECs are elevated after myocardial infarction (MI) [8]. In fact such studies had already been done in the 1970s, albeit with primitive methodology [9]. Furthermore, EPCs have been demonstrated previously after MI [10]. What additional information does this study provide? Bonello and co-workers studied a cohort of patients with stable coronary artery disease and not with acute coronary syndromes. It is remarkable that elevated numbers of CECs are also found after angioplasty in stable coronary artery disease. These cells must derive from endothelial damage by the catheter procedure itself, as cell numbers had been normal at baseline. Immunomagnetic isolation is a very sensitive approach as the technique was originally devised to isolate circulating tumor cells. Flow cytometry may also have its advantages although a direct comparison between the two techniques is not available so far. Mechanisms of endothelial cell detachment remain simple whenmechanical force is themost likely cause, as in the present study. In contrast, we do not know the sequence of events in inflammatory disorders [11]. Factors that protect against endothelial detachment, such as cadherins, integrins and fibronectin, exist as well [11]. Little, if anything, is known about the kinetics of CEC clearance from peripheral blood. Bonello demonstrated a peak of CEC values after 6 h while cell numbers declined to baseline after 1 week. Such data need further corroboration, probably from animal models. Further studies should elucidate the fate of CECs, mechanisms of clearance and interactions with other cells [11]. Figure 1 summarizes the concept of endothelial cell detachment. Bonello and co-workers next analyzed hematopoietic progenitor cells and EPCs, and found an increase in progenitor cells as early as at the end of the procedure. It is amazing to observe this very timely reaction of EPCs as an endothelial rescue squad . Various mechanisms have been proposed to explain how EPCs are alerted to ongoing endothelial damage. At present, vascular endothelial growth factor (VEGF) is best characterized. Elevated serum levels of VEGF have been demonstrated as a sequel to ischemic injury and VEGF has been shown to mobilize EPCs from bone marrow [5]. More recently, the discovery that erythropoietin (EPO) regulates EPCs [12] has sparked considerable interest, not only among nephrologists who use this drug on a daily basis. These observations provided a tantalizing opportunity to manipulate the EPC system in vascular disease. Studies into the use of EPO in stroke and MI are currently under way. Administration of EPO would be much less cumbersome than the direct application of stem cells as described after MI [13]. More regulators of EPCs are currently emerging and others still await Correspondence: Alexander Woywodt, Division of Nephrology, Department of Medicine, Hannover Medical School, Carl-NeubergStrasse 1, 30625 Hannover, Germany. Tel.: +49 511 532 6319; fax: +49 511 552366; e-mail: woywodt. alexander@mh-hannover.de Journal of Thrombosis and Haemostasis, 4: 976–978

Background. In patients with autoimmune diseases such as vasculitis or systemic lupus erythematosus (SLE), end-stage renal disease develops in a high percentage of patients, and kidney transplantation has become a therapeutic option. However, only limited data about the prognosis and outcome after kidney transplantation are available. Methods. Long-term graft survival and graft function of renal transplant recipients with SLE, Wegener's granulomatosis, microscopic polyangiitis, Goodpasture's syndrome, and Henoch-Schonlein purpura were evaluated in a single center. In addition, the incidence of renal and extrarenal relapses and the impact of the immunosuppressive therapy on the course of the autoimmune disease were studied. Results. Renal transplant recipients with autoimmune diseases such as vasculitis and SLE had a patient survival rate (94% after 5 years) and a graft survival rate (65% after 5 years) comparable to those of patients with other causes of end-stage renal disease (patient survival 88% and graft survival 71% after 5 years). Graft losses due to the underlying disease were rare. Extrarenal relapses occurred in three patients with Wegener's granulomatosis, one patient with microscopic polyangiitis, and three patients with SLE, but were less frequent compared with the period with chronic dialysis therapy. Autoantibody levels in patients with SLE, Wegener's granulomatosis, or microscopic polyangiitis did not seem to influence the outcome. Conclusions. Renal transplantation should be offered to patients with autoimmune diseases. Follow-up should include the short-term control of renal and extrarenal disease activity.

Objective. To investigate the influence of disease-related coping strategies and depressiveness on healthrelated quality of life (HRQOL) in primary systemic vasculitis (PSV) patients. Methods. One hundred and twenty-two patients with definite diagnosis of PSV were examined in a crosssectional study. HRQOL (SF-36), depressiveness (BDI), illness perception (B-IPQ) and coping strategies (FKV-LIS) were measured using validated instruments. Additional disease-related and demographic data were retrieved from the patients’ records. Results. HRQOL in PSV patients was reduced compared with the SF-36 norm sample. Specific organ manifestation, size of vessel involvement and disease activity were not related to HRQOL. Linear regression modelling revealed a questionable relationship of emotional to physical HRQOL (P = 0.003, potential suppression effect of BDI), whereas both domains were influenced by depressiveness (P4 0.001). Physical HRQOL was additionally related to fatigue and widowed marital status, while emotional HRQOL was associated with a depressive coping style. Conclusion. HRQOL is impaired in PSV as compared with the general population. Current depressiveness strongly affects physical as well as mental HRQOL. Cognitive intervention strategies should be established in order to improve quality of life in PSV patients.

Training in cardiac auscultation is a core element of undergraduate teaching but recent studies have documented a remarkable decline in auscultatory skills. Therefore there is an interest in new ways to teach cardiac auscultation. In analogy to phonocardiography, an electronic system for simultaneous auscultation and visualisation of murmurs was sought. For this purpose, an electronic stethoscope was linked to a laptop computer and software created to visualise auscultatory findings. In a preliminary trial in undergraduate students, this approach greatly facilitated teaching. Amalgamating traditional phonocardiography with a multimedia approach, this system represents a novel tool for bedside teaching of cardiac auscultation.

Background. The activation of neutrophils and monocytes by ANCA, resulting in the release of reactive oxygen species and proteases like myeloperoxidase (MPO), is essential to the pathogenesis of ANCAassociated vasculitis. As the A allele of the G-463A MPO gene polymorphism is associated with diminished activity of MPO, it is conceivable that the presence of this allele protects against MPO–ANCAassociated vasculitis. Methods. Allelic frequencies of the G-463A polymorphism were studied in 119 ANCA-associated vasculitis patients, 48 with MPO–ANCA and 71 with proteinase 3 (PR3)–ANCA. Results. Allelic frequencies of MPO G-463A promoter polymorphism did not differ between MPO–ANCAand PR3–ANCA-associated vasculitis patients. Moreover, allelic distribution was similar to that of the normal population. Conclusions. The data suggest that G-463A polymorphism does not seem to contribute to either MPO–ANCA- or PR3–ANCA-associated vasculitis formation.

Impaired endotoxin-induced interleukin-1β secretion, not total production, of mononuclear cells from ESRD patients. Lipopolysaccharide (LPS)-induced interleukin-1 beta (IL-1β) and tumor necrosis factor alpha (TNFα) production and secretion from peripheral blood mononuclear cells (PBMC) were determined in a longitudinal study with repeated measurements in PBMC from patients with chronic uremia not on hemodialysis (N = 8), end-stage renal disease (ESRD) patients (N = 8), and healthy controls (N = 7). ESRD patients were studied while using low-flux Cuprophan dialyzers and again using high-flux AN 69 dialyzers. Total (cell-associated plus secreted) LPS-induced IL-1β production was enhanced in uremic patients, but similar to controls in ESRD patients on Cuprophan. In contrast, LPS-induced IL-1β secretion (secreted amounts in % of total production) was similar to controls in uremic patients, but significantly reduced in ESRD patients on Cuprophan (P < 0.01). During AN 69 hemodialysis, LPS-induced total IL-1β production remained unchanged but IL-1β secretion increased significantly (P < 0.05) compared to Cuprophan dialysis. Increased IL-1β secretion coincided with a suppression in PGE2 synthesis (P < 0.02). Similarly, blockade of endogenous PGE2 by indomethacin increased LPS-induced IL-1β secretion (P < 0.01) but did not enhance total IL-1β production in PBMC from controls and patients on Cuprophan hemodialysis. Neither total production nor secretion of TNFα was different comparing the three study groups. We conclude that LPS-induced IL-1β secretion, but not total production, is impaired in PBMC from ESRD patients on long-term Cuprophan hemodialysis. This functional change in the PBMC response is specific for IL-1β, not due to uremia per se but hemodialysis-dependent and reversible. Hemodialysis with AN 69 suppresses endogenous PGE2 synthesis in PBMC which is associated with increased LPS-induced IL-1β secretion in the presence of unchanged total IL-1β production. We speculate that PGE2 could inactivate the IL-1β converting enzyme which is essential for processing and secretion of mature IL-1β.

Aldosterone (Aldo) is involved in vascular remodeling and inflammation; however, the mechanisms are imperfectly defined. We hypothesized that Aldo alters endothelial integrity and modifies paracellular permeability. Human umbilical vein endothelial cells were exposed to Aldo (10 –9 mol/L) and alterations in paracellular permeability, assembly of tight and adherens junctions and activation of intracellular signaling pathways were determined. Aldo increased endothelial permeability for molecules ≤70 kDa within 60 minutes. A transient loss of cortical actin with formation of actin stress fibers and disruption of continuous adherens and tight junction strands accompanied these changes. Mineralocorticoid receptor blockade, inhibition of RhoA, or disruption of extracellular-regulated protein kinase1/2 signaling pathways attenuated the Aldo-related effects. Moreover, Aldo-induced cytoskeletal rearrangement led to rapid dephosphorylation of protein kinase B and subsequent deactivation of endothelial nitric oxide synthase. Ex vivo tracer flux experiments with Evans blue–conjugated albumin demonstrated a concordant response to Aldo in freshly isolated umbilical arteries. Furthermore, low-dose cortisol (3×10 –10 to 3×10 –9 mol/L) mimics the effect of Aldo on endothelial integrity, and Aldo, by upregulating11β-hydroxysteroid dehydrogenase type 2, might even aggravate this deleterious effect of low-dose cortisol. We suggest that these mechanisms may contribute to the vasculopathy induced by inappropriate mineralocorticoid receptor activation.

Circulating endothelial cells (CECs) were first detected in the 1970s although convenient techniques to isolate them have only recently become available [1]. These cells have now been shown to be present in a variety of vascular disorders but only a few reports have appeared since the mid-1990s. Very recently we were able to demonstrate grossly elevated numbers of CECs as a novel marker of disease activity in patients with ANCA-associated vasculitis [2]. It appears that this approach to vascular injury has not been appreciated so far and that its use should be evaluated in other vascular disorders as well.

Background The diagnosis of uraemic encephalopathy is considered if patients with end-stage renal disease present with neuropsychiatric symptoms. However, cognitive deficits may occur in patients with chronic kidney disease (CKD) long before any overt neurological symptoms can be observed. We hypothesized that cognitive dysfunction in patients with CKD both, treated and untreated by haemodialysis, may correspond to metabolic changes in distinct brain regions. Methods We performed magnetic resonance spectroscopy (MRS) ((1)H-MRS) of the brain in 23 non-dialysed patients with CKD (Stages 4-5) and in 15 haemodialysed patients. Healthy controls (n = 63) adjusted for age and education were recruited from the social environment of the patients' population. Attention, learning and memory were assessed by psychometric testing. Results MRS alterations were predominantly found in the white matter. Concentrations of creatine-containing compounds (Cr) were decreased in dialysed and non-dialysed patients. Choline concentration (Cho) and combined N-acetylaspartate and N-acetylaspartylglutamate concentration (NAx) were reduced only in dialysed patients. Disturbance in memory and learning ability as well as attention deficits were observed in both patient groups. Of note, attention deficits were more severe in dialysed patients. MRS results correlated with attention deficits in dialysed patients. Conclusions CKD patients without clinical signs of uraemic encephalopathy showed metabolic disturbances in distinct brain regions as well as cognitive impairments. Haemodialysis was accompanied with more severe cognitive dysfunction and metabolic alternations than CKD alone. Although the small sample size limits the interpretation of the data, a negative impact of haemodialysis on cognitive function must be considered.

Background Plasma exchange may be effective adjunctive treatment for renal vasculitis. We performed a systematic review and meta-analysis of randomized controlled trials of plasma exchange for renal vasculitis. Study Design Systematic review and meta-analysis of articles identified from electronic databases, bibliographies, and studies identified by experts. Data were abstracted in parallel by 2 reviewers. Setting & Population Adults with idiopathic renal vasculitis or rapidly progressive glomerulonephritis. Selection Criteria for Studies Randomized controlled trials that compared standard care with standard care plus adjuvant plasma exchange in adult patients with either renal vasculitis or idiopathic rapidly progressive glomerulonephritis. Intervention Adjuvant plasma exchange. Outcome Composite of end-stage renal disease or death. Results We identified 9 trials including 387 patients. In a fixed-effects model, the pooled RR for end-stage renal disease or death was 0.80 for patients treated with adjunctive plasma exchange compared with standard care alone (95% CI, 0.65-0.99; P = 0.04). No significant heterogeneity was detected (P = 0.5; I2 = 0%). The effect of plasma exchange did not differ significantly across the range of baseline serum creatinine values (P = 0.7) or number of plasma exchange treatments (P = 0.8). The RR for end-stage renal disease was 0.64 (95% CI, 0.47-0.88; P = 0.006), whereas the RR for death alone was 1.01 (95% CI, 0.71-1.4; P = 0.9). Limitations Although the primary result was statistically significant, there is insufficient statistical information to reliably determine whether plasma exchange decreases the composite of end-stage renal disease or death. Conclusions Plasma exchange may decrease the composite end point of end-stage renal disease or death in patients with renal vasculitis. Additional trials are required given the limited data available.