The aim of this review was to summarize recent advances in celiac disease (CD) published between 2006 and 2012.
CD affects ∼1% of most populations but remains largely unrecognized. During the past year, research has shown that the prevalence of CD has increased dramatically and not merely because of increased detection. Moreover, undiagnosed CD may be associated with increased mortality. Significant progress has been made in understanding how gliadin peptides can cross the intestinal border and access the immune system. New deamidated gliadin peptide antibodies have better diagnostic accuracy over other tests. The inclusion of duodenal bulb biopsy specimens may increase the rate of CD detection. Finally, refractory CD, although rare, is associated with a poor prognosis. The use of novel highly efficient exogenous prolyl endoproteases enzymes may help patients deal with occasional lapses in their diet or may protect highly sensitive individuals from inadvertent presence of gluten in food products. Nevertheless, the efficiency of this approach still needs precise assessment.
Mortality rates among patients with untreated CD increase two-fold every year as they age (gastrointestinal malignancies) and most can be prevented/reversed with early diagnosis and initiation of a gluten-free diet. CD is a global health problem that requires a multidisciplinary and increasingly cooperative multinational research effort.
The purpose of this study was to determine the effect of erythropoietin (EPO) treatment on HbA1c levels in diabetic patients on regular hemodialysis and to assess the reliability of HbA1c as a marker for glycemic control in such patients.
The study included 41 patients on regular hemodialysis who were EPO naive: 31 with diabetes mellitus and 10 nondiabetic controls. Baseline HBA1c and fasting blood glucose levels were measured and repeated after a 3-month course of EPO.
HbA1c decreased significantly after EPO therapy (P=0.01) and was associated with a significant decline in fasting blood glucose levels (P=0.001), with a significant negative correlation with hemoglobin (r=−0.185, P=0.03). HbA1c showed significant correlation with fasting blood glucose in diabetic patients before EPO therapy (r=0.82, P<0.0001). This correlation was found to be independent of other laboratory parameters. No correlation was found between HbA1c and fasting blood glucose levels after 3 months of EPO treatment.
HbA1c is not a reliable marker for glycemic control in hemodialysis patients, especially for those on EPO therapy.
Patients with long-standing diabetes mellitus undergoing surgical interventions are under considerable risk, hence posing a surgical challenge, as they may have cardiovascular and/or cardiac autonomic neuropathy (CAN). CAN is serious, often overlooked and underdiagnosed, with possible arrhythmias and silent ischemia that may be life threatening.
The aim of this study was to screen for one of the underdiagnosed high-risk problems by assessment of CAN in long-standing type 2 diabetic women undergoing stressful situations.
Hundred type 2 diabetic women scheduled for major surgery were assessed by autonomic function tests. CAN was assessed by analyzing heart rate variations during three standard tests (deep breathing, lying to standing, and the valsalva maneuver). Sympathetic functions were assessed by checking orthostatic hypotension. The CAN score of each patient was analyzed. Continuous 24 h ECG monitoring was performed to evaluate arrhythmia, corrected QT (QTc), and QT dispersion (QTd). Transthoracic Doppler echocardiography, with a focus on left ventricular hypertrophy, diastolic, and systolic dysfunctions, was carried out. Patients were classified as having mild (with only one abnormal test) or severe CAN when two or more abnormal function tests were present. Exclusion criteria included any systemic illness that could affect the results of the study or the autonomic functions, smoking, hypertension, and patients with evident ischemia.
CAN was detected in 70% of the patients studied, and 70% of them had a severe case of CAN. Postural hypotension was detected in 34% of the patients studied. QTc prolongation and QTd were frequent. ECG and Doppler echocardiography changes of left ventricular hypertrophy were more prevalent among patients with CAN. Diabetics with CAN were significantly older, had a longer duration of diabetes mellitus, and higher HbA1-c, higher pulse pressure, triglyceride, uric acid, and urinary albumin excretion rate. They also had a significantly increased left ventricular mass index and diastolic dysfunction.
Middle-aged women with long-standing diabetes are vulnerable to CAN with postural hypotension and prolonged QTc intervals, QTd, and increased left ventricular mass index. Identification of CAN is crucial to prevent the hazards of cardiovascular insults during stressful situations, and cases with severe CAN may require coronary artery disease screening preoperatively.
Patients hospitalized in medical ICUs (MICUs) with acute noncardiac illnesses may have underlying cardiovascular abnormalities, especially in Egypt where rheumatic heart disease is still frequently encountered. This may affect the diagnosis and/or plan of management. Routine cardiac examination may not be informative because of the acuteness of the illness and the need for frequent concurrent mechanical ventilation.
The purpose of this study was to utilize transthoracic echocardiography to define cardiac abnormalities, especially rheumatic valve disease that may be present in noncardiac patients.
Over a 4-month period, 75 patients without primary cardiac diagnoses admitted to the MICU of Kasr El Ainy hospital underwent transthoracic echocardiography (TTE). The MICU mortality rates and length of stay were compared in patients with and without significant cardiac abnormalities.
One or more cardiac abnormalities were observed in 61.3% patients of the studied group. Of these abnormalities, 15% were rheumatic in origin. Right atrial and right ventricular dilatation were the most encountered lesions, followed by left ventricular hypertrophy and pulmonary hypertension. Although there was no correlation between the presence of cardiac abnormalities and the length of ICU stay or mortality, the plan of management was affected in 14.67% of patients.
A significant proportion of patients admitted to the MICU with noncardiac illness had underlying cardiac abnormalities, and this affected the plan of management in a significant number of patients.
Atherosclerotic renovascular disease (ARVD) is defined as renal artery stenosis with an occlusion of 60% or more. It is an established cause of resistant hypertension and renal insufficiency. ARVD is evaluated using renal artery duplex ultrasound, which measures the degree of renal artery stenosis and renal resistance index. Treatment with renal artery balloon angioplasty and stents has been shown to improve blood pressure and renal function in some patients.
This was a prospective study evaluating the early effects of renal artery angioplasty and stenting in patients with ARVD as regards the blood pressure and renal function.
During March 2009 to September 2011, 37 patients (21 men and 16 women) with ARVD (unilateral or bilateral), resistant hypertension, and renal impairment were selected and divided into two groups: group A (25 patients) comprised patients who underwent renal artery balloon angioplasty and stenting (intervention group) and group B (12 patients) comprised those who were kept on medical treatment as controls and followed up without intervention.
Two weeks after intervention, eight patients (32%) stopped one medication, seven patients (28%) stopped two medications (i.e. one antihypertensive medication only), and five patients (20%) stopped all medications, whereas the blood pressure did not change in five patients (20%). The average mean systolic blood pressure of group A was 140 mmHg and the average serum creatinine level was 2.1. As regards group B, the average mean systolic blood pressure was 170 mmHg for patients who were on three antihypertensive medications, and the average serum creatinine level was 2.4.
The main effect of renal artery revascularization in ARVD is on blood pressure control in patients with resistant hypertension, with minimal influence on the renal function.
There is an established relationship between liver disease and hepatogenous diabetes mellitus, and a growing evidence for the role of vitamin D deficiency in the pathogenesis of type 1 and type 2 diabetes mellitus. However, data on the impact of vitamin D serum level on insulin resistance among liver cirrhosis patients are lacking.
The primary objective of the current study was to investigate the relationship between vitamin D status and insulin resistance among hepatitis C virus (HCV)-induced liver cirrhosis patients using a homeostasis model for assessment of insulin resistance (HOMA-IR). The secondary objectives were to assess the association between deterioration of liver function on the one hand and insulin resistance and vitamin D deficiency on the other.
Fifty patients with biopsy-proved HCV-induced liver cirrhosis were enrolled in this cross-sectional study. Routine clinical, laboratory, and imaging workout was performed to assess the degree of liver decompensation using the model of end-stage liver disease (MELD) score and the Child–Turcotte–Pugh Score (CTPS). Serum level of 25-hydroxy-vitamin D3 [25(OH)D3] was estimated. Fasting plasma glucose and fasting insulin were also measured to calculate HOMA-IR as an indicator of insulin resistance. Patients were subclassified according to serum 25(OH)D3 levels into tertiles, according to the MELD score into three groups, and according to CTPS into Child A, B, and C.
A significant inverse correlation was found between serum 25(OH)D3 level and insulin resistance as assessed by HOMA-IR, whether using one-by-one correlation (r=−0.976, P=0.000) or using 25(OH)D3 tertiles’ correlation (r=−0.830, P=0.000). Linear multiple regression analysis determined low serum 25(OH)D3 level as an independent predictor for increase in HOMA-IR among HCV-induced liver cirrhosis patients. No significant association was identified between low serum 25(OH)D3 level and the severity of liver dysfunction as assessed by the MELD score or CTPS.
The present study showed that low serum 25(OH)D3 level was an independent predictor for insulin resistance among patients with HCV-induced liver cirrhosis.
Obesity is established as an important contributor of increased diabetes mellitus, hypertension and cardiovascular disease, all of which can promote chronic kidney disease (CKD). Recently, there is a growing appreciation that even in the absence of these risks, obesity itself significantly increases CKD and accelerates its progression. The aim of this work is to evaluate the link between Renin-Angiotensin-Aldosterone System (RAAS) and FGF23-Klotho-1,25D3 axis and their impact in obese and non-obese CKD patients.
In a cross sectional randomized multi centers study, two hundred twenty six CKD patients stage III and IV (eGFR20–60 ml/min/m2) have enrolled in this study as follows: group I; 87 non diabetic CKD patients aged 20–40 years with body mass index (BMI) between 20–25 kgm/m2; group II; 130 non diabetic CKD patients aged 20–40 years with (BMI) >30 kgm/m2 and group III; 89 CKD patients aged >60 years. All patient have been tested for plasma leptinlevels, 1,25-dihydrocholicalciferole (1,25D3), plasmaparathormone (PTH) Serum calcium (Ca), serum phosphorus (PO4), and plasma FGF-23 , plasma renin activity (PRA), plasma angiotensinogen receptor 1 &2 (AT1 & AT2) and plasma aldosterone (ALD) and pulse wave velocity (PWV).
The eGFR was significantly reduced in the obese group II (eGFR=37.7±13.6) when compared with eGFR of the lean group I (eGFR=49.3±7.51) were P<0.001, but not significant when compared with the old age group III (eGFR=41.0±13.47). The obese group II shows significant increase in the ALD/PRA ratio when compared with the lean group I and old age group III (43.23±14.9) for group II vs 11.29±4.1 for group I, P<0.001 and 24.91±12.1 for group III, P<0.05 ). Regarding the FGF23-Klotho-vitD3 axis, its components of the obese group II (FGF23 259.55±138.6 Ru/ml; PTH 77.63±X32.4 pg/ml; S.PO 4.74±1.61 mg/dl) were significantly elevated when compared to the lean group I (FGF23 132.81±126.1 Ru/ml; PTH 59.18±24.7 pg/ml; S.PO4 3.85±0.92 mg/dl); the P values were <0.001, <0.01 and <0.05 respectively , while when compared with the old age group III (FGF23 179.33±237.4 Ru/ml; PTH 70.94±15.26 pg/ml; S.PO4 4.09±0.42 mg/dl), values were of less significance. Plasma insulin levels were significantly high in the obese group II (insulin=13.73±2.38fg/l) than the lean group I (insulin=5.59±2.31 fg/l) and P<0.001 and in group III p. insulin level was 10.7±1.68 (P<0.05).
Obesity per se is an independent risk factor in the development and progression of chronic kidney disease specially in young age patients.
Obstructive sleep apnea (OSA) syndrome is associated with cardiovascular complications attributed to endothelial dysfunction. There are contradictory reports on whether lactoferrin is protective or injurious to the blood vessels.
To determine circulating plasma lactoferrin level in OSA patients in relation to endothelial dysfunction and to assess its relation to other criteria of OSA.
In a cross-sectional study, 40 OSA patients were recruited after an established diagnosis in the sleep laboratory of the pulmonary medicine department. Doppler flow-mediated dilatation percentage (FMD%) was tested as an indicator of endothelial function. Anthropometric measurements, systolic and diastolic blood pressure, lipid profile, plasma lactoferrin level, fasting, and 2 h postprandial plasma glucose (PPG) were estimated in the patients and the control groups. Moreover, the apnea–hypopnea index, and the mean and nadir nocturnal oxygen saturation of OSA patients were determined.
OSA patients were found to have significantly higher BMI, waist circumference (WC), neck circumference, fasting plasma glucose (FPG), 2 h PPG, low-density lipoprotein-cholesterol, and lower plasma lactoferrin, FMD%, and high-density lipoprotein (HDL)-cholesterol compared with the control group. There was a significant direct correlation between FMD%, as an indicator of endothelial function, and plasma lactoferrin level as well as HDL-cholesterol, and an inverse correlation between FMD% and BMI, WC, FPG, 2 h PPG, and basal brachial artery diameter. Multiple regression analysis showed that lactoferrin was the only independent predictor for FMD% among OSA patients.
However, plasma lactoferrin level was inversely correlated with BMI, WC, FPG, and 2 h PPG, and was directly correlated with HDL-cholesterol and FMD%. Multiple regression analysis selected BMI and FMD% as the independent predictors for lactoferrin level.
The present study showed that low circulating plasma lactoferrin levels in OSA patients independently predict endothelial dysfunction as assessed by FMD%. High BMI in OSA patients negatively influences plasma lactoferrin levels unrelated to other OSA severity predictors.
A 37-year-old hypertensive housewife presented with a sudden onset of left-sided hemiplegia, hemianaesthesia, dysarthria and urinary incontinence. The condition was preceded by recurrent attacks of motor neurological deficits over a 3-year duration. She reported a history of a fall from a height at the age of 10, which was followed by a hearing deficit and a history of two caesarean sections after eclampsia. The blood pressure was 170/100 mmHg. Laboratory investigations revealed hyperglycaemia (fasting glucose 306 mg/dl) and normal kidney function tests. The computed tomography scans revealed old multiple bilateral cerebral infarcts with recent intracranial haemorrhage in the right parietal region. The inflammatory markers (ESR and CRP) and immune profile (ANA, anti-ds DNA and ANCA) were found to be normal. Cerebral angiography revealed a complete occlusion of the intracranial parts of both internal carotid arteries at their supraclinoid segments along with the proximal parts of the anterior cerebral artery and middle cerebral artery, with collaterals from the posterior circulation. Consequently, the diagnosis of moyamoya disease with the collaterals was confirmed. Antihypertensive medications and insulin were administered. Cerebral dehydration measures were undertaken with partial improvement. A superficial temporal artery–middle cerebral artery bypass operation was performed with some postoperative improvement. One month later, she suffered a new stroke with severe impairment of the level of consciousness; the computed tomography scans revealed a large recent cerebral infarct, her condition deteriorated rapidly and she died shortly thereafter.