We measured serum cholesterol, triglyceride, and lipoprotein Lp(a) concentrations in serum of 37 patients with massive proteinuria of different origin, comparing values with those for age- and sex-matched controls and finding significantly increased Lp(a) concentration in the total group of patients compared with controls. Lp(a) concentration was not correlated with serum cholesterol, triglyceride, serum creatinine, daily urinary protein loss, or selectivity index. Selecting the patients according to their histological diagnosis obtained by renal needle biopsy, we found divergent results in seven patients with minimal change disease (MCD) compared with 11 patients with membranoproliferative glomerulonephritis. Lp(a) in MCD patients did not differ from that controls (101 +/- 102 and 90 +/- 115 mg/L) and correlated positively with total daily urinary protein loss (r = 0.7962, P less than 0.05). In contrast, the patients with membranoproliferative glomerulonephritis had significantly higher Lp(a) values than the controls (219 +/- 222 mg/L), and Lp(a) concentrations correlated negatively with the daily protein loss in urine (r = -0.6545, P less than 0.05). The most surprising results were the marked Lp(a) concentrations in serum of three patients with primary amyloidosis and nephrosis syndrome. Our results indicate a regulatory role of the kidney in the metabolism of Lp(a) and different effects on the serum Lp(a) concentration, depending on the type of damage to renal tissue.

Oncological screening tests are necessary in all incidentalomas. Tumours > or = 30 mm should be operated but smaller ones can be followed-up, because they are usually benign and rarely show progressive growth. Cortical adenomas with subtle hormonal overproduction and hypertension, diabetes or osteoporosis should be operated, irrespective of their size, but in the absence of relevant clinical symptoms they can be followed-up.

Delivering reduced dose of immunosuppression for elderly patients was associated with satisfactory outcome and favorable treatment-related complication profile. The higher mortality in the elderly could be attributed mainly to baseline cardiovascular morbidity.

BackgroundImmunosuppressive therapy has improved the outcome of ANCA-associated vasculitis (AAV), but infectious morbidity and mortality remained high. Recognizing its risk factors seems crucial for prevention, aiming to increase survival of these patients.MethodsWe investigated the incidence and types of infections and assessed predictive factors in 132 patients with severe systemic AAV.ResultsPatients with lower than median incidence of total infections/patient-year during induction had lower baseline serum creatinine, dialysis requirement and Charlson comorbidity index (CCI), compared to those with higher than median incidence (P = 0.037; P = 0.024; P = 0.001; respectively). In subgroups with below and above than median number of severe infections/patient-year during induction, differences were found in baseline creatinine (P = 0.002) and dialysis requirement (P = 0.001); comparing the same cohorts during maintenance immunosuppression, baseline dialysis requirement, diabetes, CCI, and dose of cyclophosphamide (CYC) administered as induction therapy differed significantly (P = 0.019; P = 0.015; P = 0.001; P = 0.015, respectively). Severe infections were predicted by baseline serum creatinine (OR 1.002 [CI 1.001–1.003]) and pulmonary manifestation (OR 2.153 [CI 1.017–4.560]) during induction immunosuppression. In multivariable Cox regression model all-cause mortality was independently predicted by severe infection (HR 1.998 [CI 1.214–3.287]). Among the 168 positive cultures Gram-negative bacteria were responsible for blood stream infections in 33%, and respiratory tract infections in 72%.ConclusionsAdvanced renal failure, pulmonary involvement and high degree of comorbidities increase the risk of infection in AAV. Those who suffer infection during induction immunosuppression have worse long-term survival. Our findings indicate the need for high vigilance for infections and close follow-up of comorbidities when treating AAV.

To assess its differential diagnostic value, dehydroepiandrosterone sulfate (DHEA-S) was measured in a nonselected cohort of 84 patients with incidentally detected adrenal tumors (incidentaloma). Of the 38 histologically confirmed cases, 6 of 12 patients with primary or metastatic malignant tumor of the adrenals and 7 of 14 patients with benign cortical adenoma had low DHEA-S levels. Thus, the sensitivity, specificity, and predictive value of a low DHEA-S level to indicate a benign adrenal tumor were 0.35, 0.50, and 0.60, and the values to indicate a cortical adenoma were 0.50, 0.67, and 0.47, respectively. Of the 14 cases of histologically confirmed benign cortical adenoma, 10 had signs of hormonal activity, but DHEA-S was suppressed in only 7 cases. Thus, the sensitivity, specificity, and predictive value of a low DHEA-S level to indicate clinically significant hormonal activity of a benign cortical adenoma were 0.60, 0.75, and 0.86, respectively. For comparison, 5 of 5 males and 2 of 5 females with metastatic carcinomatosis, but without involvement of the adrenals, also had low DHEA-S levels. The data clearly show that in nonselected cases of incidentaloma a suppressed DHEA-S level is not a good predictor of hormonal activity and that DHEA-S measurement may be valuable only after having ascertained the cortical origin and benign feature of the tumor.