Tesis por compendio / [ES] De entre las metodologías disponibles para estudiar la digestión de alimentos, los modelos de digestión in vitro se plantean como procedimientos válidos para este propósito. La digestión in vitro consiste en simular el proceso de digestión en el laboratorio, reproduciendo las condiciones fisiológicas en cuanto a composición de los fluidos digestivos (electrolitos y enzimas), pH, temperatura, fuerzas mecánicas y duración de las etapas oral, gástrica e intestinal. Abordar el estudio de la digestión de nutrientes es de especial relevancia en patologías que cursan con alteraciones pancreáticas o hepáticas, asociadas a una digestión de lípidos comprometida en la etapa intestinal, debido a la disminución de secreción de pancreatina, bicarbonato y sales biliares. Este es el caso de la fibrosis quística con insuficiencia pancreática, y los pacientes que padecen esta afección deben seguir la terapia de sustitución de enzimas pancreáticas, que consiste en el suministro exógeno de pancreatina encapsulada. Sin embargo, la dosis de este suplemento debe ajustarse a las características de los alimentos y no se dispone de ningún método válido para tal fin. Para hacer frente a este reto, en el proyecto financiado con fondos europeos MyCyFAPP se ha logrado desarrollar un método para ajustar la dosis óptima de los suplementos enzimáticos utilizados en la terapia. La presente tesis doctoral se realizó en el marco de dicho proyecto. Concretamente, esta tesis tiene como objetivo abordar el estudio de la digestión de lípidos en los alimentos de origen animal (carne y productos cárnicos, huevos, queso y pescado) en el contexto de la fibrosis quística. Para abordar este objetivo se aplicó un modelo de digestión in vitro estático con el fin de explorar el papel de las características inherentes a los alimentos (estructura de la matriz alimentaria como resultado del procesado) y los factores relacionados con el individuo (pH, concentración de sales biliares y concentración de pancreatina) como factores determinantes de la lipólisis en alimentos de origen animal. A lo largo de los cuatro capítulos presentados, centrados en el huevo, la carne, el queso y el pescado, se presenta un diseño experimental común para estudiar la lipólisis, la proteólisis y la degradación de la matriz. En cada estudio, las diferentes técnicas de procesado aplicadas a los alimentos evaluados también permitieron evaluar el efecto de las propiedades inherentes a los alimentos en los resultados del estudio. Los resultados han contribuido al desarrollo de un nuevo método basado en la evidencia para optimizar la terapia de reemplazo de enzimas pancreáticas e informan a la comunidad científica sobre nuevos conocimientos en el comportamiento de diferentes alimentos sometidos al proceso de digestión. / [CA] De les metodologies disponibles per estudiar la digestió d'aliments, els models de digestió in vitro es plantegen com a procediments vàlids per a aquest propòsit. La digestió in vitro consisteix en simular el procés de digestió al laboratori, reproduint les condicions fisiològiques pel que fa a la composició dels fluids digestius (electròlits i enzims), pH, temperatura, forces mecàniques i durada de les etapes oral, gàstrica i intestinal. Abordar l'estudi de la digestió de nutrients és d'especial rellevància en patologies que cursen amb alteracions pancreàtiques o hepàtiques, associades a una digestió de lípids compromesa en l'etapa intestinal, a causa de la disminució de secreció de pancreatina, bicarbonat i sals biliars. Aquest és el cas de la fibrosi quística amb insuficiència pancreàtica. Els pacients que pateixen aquesta afecció han de seguir la teràpia de substitució d'enzims pancreàtics, que consisteix en el subministrament exogen de pancreatina encapsulada. No obstant això, la dosi d'aquest suplement ha d'ajustar-se a les característiques dels aliments i actualment no es disposa de cap mètode vàlid per a tal fi. Per enfrontar a aquest repte, en el projecte finançat amb fons europeus, MyCyFAPP, s'ha aconseguit desenvolupar un mètode per a ajustar la dosi òptima dels suplements enzimàtics utilitzats en la teràpia. La present tesi doctoral es va realitzar en el marc d'aquest projecte. Concretament, aquesta tesi té com a objectiu abordar l'estudi de la digestió de lípids en els aliments d'origen animal (ous, carn i productes carnis, formatge i peix) en el context de la fibrosi quística. Per a abordar aquest objectiu es va aplicar un model de digestió in vitro estàtic amb la finalitat d'explorar el paper de les característiques inherents als aliments (estructura de la matriu alimentària com a resultat del processament) i els factors relacionats amb l'individu (pH, concentració de sals biliars i concentració de pancreatina) com a factors determinants de la lipòlisi en aliments d'origen animal. Als quatre capítols presentats, centrats en l'ou, carn, formatge i peix, es presenta un disseny experimental comú per a estudiar la lipòlisi, la proteòlisi i la degradació de la matriu. En cada estudi, les diferents tècniques de processament aplicades als aliments avaluats també van permetre avaluar l'efecte de les propietats inherents als aliments en els resultats de l'estudi. Els resultats han contribuït al desenvolupament d'un nou mètode basat en l'evidència per a optimitzar la teràpia de substitució d'enzims pancreàtics i informen la comunitat científica sobre nous coneixements en el comportament de diferents aliments sotmesos al procés de digestió. / [EN] Among the available methodologies to study food digestion, in vitro digestion models have raised as a valid procedure. In vitro digestion consists of simulating the digestion process in the laboratory, by reproducing the physiological conditions in terms of digestive fluids composition (electrolytes and enzymes), pH, temperature, mechanical forces and duration of the oral, gastric and intestinal stages. Addressing the study of nutrient digestion is of special relevance in pathologies coursing with pancreatic or hepatic alterations, which are associated with compromised intestinal lipid digestion due to reduced secretion of pancreatin, bicarbonate and bile salts. This is the case of Cystic Fibrosis along with pancreatic insufficiency, and the patients suffering this condition have to follow pancreatic enzyme replacement therapy, the exogenous supply of encapsulated pancreatin. However, the dose of this supplement should be adjusted to the specific characteristics of foods, and no valid method was available for such purpose. To tackle this challenge, the EU-funded project MyCyFAPP succeed to develop a method to adjust the optimal dose the enzyme supplements used in the therapy. The present doctoral thesis was conducted as a relevant part of this project. Concretely, this thesis aims at addressing the study of lipid digestion in foods to generate new knowledge regarding nutrient digestion in animal origin dietary sources (egg, meat and meat products, cheese and fish) in the context of Cystic Fibrosis. To address this goal a static in vitro digestion model was applied. The role of inherent-to-food characteristics (resulting food matrix structure from processing) and host related factors (pH and bile salts concentration and pancreatin concentration) were explored as determinants of lipolysis in animal-origin foods. Along the four chapters presented, focused on egg, meat, cheese and fish, a common experimental design was applied to study lipolysis, proteolysis and matrix degradation. In each study, different processing techniques applied to the assessed foods allowed for evaluating the effect of inherent-to-food properties on the study outcomes as well. The results have contributed to the development of a new evidence-based method to optimise pancreatic enzyme replacement therapy, and inform the scientific community about new insights on the behaviour of different foods undertaking the digestion process. / Authors of this paper acknowledge the European Union and the Horizon 2020 Research and Innovation Framework Programme (PHC-26-2014 call Self-management of health and disease: citizen engagement and mHealth) for fully funding this research in the context of MyCyFAPP Project, under grant agreement number 643806. The authors would like to thank the Conselleria de Educació i Investigació de la Generalitat Valenciana and also the European Union (“El Fondo Social Europeo (FSE) invierte en tu futuro”) for the PhD scholarship given to Andrea Asensio Grau (ACIF/2017/008). This study was developed thanks to the equipment funded with the support from the Generalitat Valenciana IDIFEDER/2018/041 (PO FEDER Comunitat Valenciana 2014-2020). Finally, we thank Antonio Martínez Cañada, from the Data Science and Biostatistics Unit of Instituto de Investigación Sanitaria La Fe, and Arash Javanidejad for the English corrections. / Asensio Grau, A. (2021). In vitro approach of dietary and host related factors affecting digestion of animal-origin foods under cystic fibrosis disease [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/171512 / Compendio

Die primäre Nebennierenrinden-Insuffizienz ist ein potenziell lebensbedrohliches Krankheitsbild. Die frühzeitige Diagnosestellung sowie Einleitung einer adäquaten Therapie sind ebenso essenziell wie die Klärung der Ätiologie. Bei Kindern ist die Krankheit vornehmlich genetisch bedingt, jedoch gelingt die Identifikation der genetischen Ursache in bis zu 30% der Fälle nicht. Auch bei unserer Indexpatientin konnte in den bisher mit der Nebennierenrinden-Insuffizienz assoziierten Genen keine Mutation, die die Krankheit erklärt, identifiziert werden. Infolgedessen wurden Gesamtgenomsequenzierungen der Patientinnen-DNA sowie der DNA der Eltern durchgeführt. Dabei wurde eine heterozygote de novo Stop-Mutation c.136C>T (p.Gln46*) im NXNL1-Gen identifiziert. Da oxidativer Stress als Pathomechanismus der Nebennierenrindeninsuffizienz bekannt ist und bereits gezeigt wurde, dass NXNL1 in der Retina eine Rolle in der Redoxhomöostase spielt, gerieten dieses Gen sowie die Stop-Mutation in den Fokus der Untersuchungen. Im Rahmen der Arbeit wurde das durch NXNL1 codierte gleichnamige Protein NXNL1 bezüglich Lokalisation, Funktion unter oxidativem Stress sowie Einfluss auf die Steroidbiosynthese in der Nebennierenrinde untersucht. Zeitgleich wurde evaluiert, ob die bei der Patientin detektierte Stop-Mutation die Lokalisation und Funktion des Proteins beeinflusst. Infolge fehlender Expression des Gens in herkömmlichen Zelllinien wurden mittels stabiler Transfektion von NCI-295R - sowie NCI-H295RA-Zellen mit NXNL1-WT- bzw. NXNL1-Q46*-Vektor-DNA adrenokortikale Zellmodelle generiert. Mittels Immunfluoreszenz konnte gezeigt werden, dass NXNL1 sowohl im Zytosol als auch im Zellkern der stabil transfizierten NCI-H295R- sowie NCI-H295RA-Klone lokalisiert ist. Weiterhin führte die stabile Transfektion mit NXNL1-WT-DNA zum verbesserten Überleben unter oxidativem Stress. Der Nachweis des aufgrund der Stop-Mutation verkürzten NXNL1 gelang weder im Western Blot noch mittels Immunfluoreszenz. Der Schutz des Zellüberlebens, den NXNL1 in stabil mit NXNL1-WT-DNA transfizierten Zellen unter oxidativem Stress bot, ging infolge der Stop-Mutation verloren. Interessanterweise hatte sowohl die Transfektion mit NXNL1-WT-DNA als auch mit NXNL1-Q46*-DNA Einfluss auf das Glutathionsystem der adrenokortikalen Zellklone unter oxidativem Stress. Die Abnahme der GSH/GSSG-Ratio sowie Zunahme der GSSG-Konzentration waren unter oxidativem Stress bei den untersuchten Klonen signifikant geringer als bei den Vergleichszellen. Auf die Steroidbiosynthese der adrenokortikalen Zellen hatte weder die Transfektion mit NXNL1-WT- noch mit NXNL1-Q46*-DNA nachweislichen Einfluss, sodass die vorliegende Arbeit Hinweise dafür liefert, dass NXNL1 in der Nebennierenrinde das Zellüberleben unter oxidativem Stress schützen kann, jedoch keine spezifische Funktion im Hormonstoffwechsel hat. Es ist denkbar, dass die Stop-Mutation im NXNL1 infolge des fehlenden Schutzes des Zellüberlebens unter oxidativem Stress bei der Indexpatientin zur Nebennierenrinden-Insuffizienz beigetragen haben kann. Bei einer vornehmlich autosomal rezessiv vererbten Krankheit wie der Nebennierenrinden-Insuffizienz ist es dennoch unwahrscheinlich, dass die heterozygote Stop-Mutation allein zur Krankheit führte. Dass ein ebenfalls in der Gesamtgenomsequenzierung detektierter Polymorphismus im Exon 2 des NXNL1 c.461A>T (p.Glu154Val) zusammen mit der Stop-Mutation in Exon 1 zu einem compound heterozygoten Vererbungsmuster geführt haben könnte, wurde ausgeschlossen. Um zu überprüfen, ob weitere Mutationen die Nebennierenrinden-Insuffizienz bei der Patientin bedingen, wurden zusätzlich eine Trio Analyse sowie optische Genomkartierung durchgeführt. Dabei wurden Mutationen in mehreren Genen detektiert, darunter SRCAP und INPP5B, deren Einfluss auf die Nebennierenrinden-Insuffizienz nicht genauer untersucht wurde und fraglich bleibt. Ein modulierender Einfluss ist denkbar. Trotz der weitreichenden Untersuchungen konnte nicht abschließend geklärt werden, inwiefern die Stop Mutation im NXNL1 zur Nebennierenrinden-Insuffizienz bei der Patientin beigetragen hat. Es wurde deutlich, dass die ätiologische Klärung insbesondere genetischer Krankheiten komplex und die Klärung der Krankheitsursache auch nach eingehender Untersuchung nicht immer möglich ist. Dennoch wird mit der Untersuchung neuer genetischer Varianten im Zusammen-hang mit seltenen Krankheiten ein wichtiger Beitrag geleistet, um den mensch¬lichen Organismus auf molekularer Ebene zu verstehen. / Primary adrenal insufficiency (PAI) is a potential life-threatening disease. Early diagnosis and initiation of an adequate therapy are just as essential as clarifying the etiology. In children, the disease is mainly genetically caused. However, the causing mutation remains unclear in up to 30% of cases. In our index case no disease-causing mutation in genes that are known to cause PAI was found either. Whole genome sequencing of the patients‘ and her parents‘ DNA revealed that the patient carries a heterozygous de novo stop mutation in NXNL1 (c.136C>T, p.Gln46*). Since oxidative stress is a known pathomechanism in PAI and NXNL1 plays a role in redox homeostasis, it was assumed that the mutation found in the index patient might contribute to PAI. In these studies, NXNL1 and its coded protein were investigated regarding localisation, function under oxidative stress conditions and influence on steroidogenesis in the human adrenal gland. Furthermore, it was evaluated, if the stop mutation found in our patient, influences the regular localization and function of NXNL1. Since NXNL1 was not expressed by conventional cell lines, cell models were generated via stable transfection. Adrenocortical NCI-H295R and NCI-H295RA cells were transfected either with NXNL1-wild type (WT) or NXNL1-Q46* vector DNA. It was shown that WT-NXNL1 is located in the cytoplasm, as well as in the nucleus of the adrenocortical cell clones. Furthermore, stable transfection with NXNL1-WT-DNA led to better survival under oxidative stress conditions. It was impossible to detect the mutated NXNL1 using Western blot and immunofluorescence. Furthermore, with NXNL1-Q46*-DNA transfected cells were not able to increase cell viability under oxidative stress. Interestingly, transfection with NXNL1-WT-DNA as well as transfection with NXNL1-Q46*-DNA influenced the glutathione system of the adrenocortical cells under oxidative stress conditions. The decrease of GSH/GSSG ratio and increase of GSSG concentration were significantly lower in transfected cells than in control cells under oxidative stress conditions. Neither transfection with NXNL1-WT-, nor with NXNL1-Q46*-DNA had proven influence on steroidogenesis of adrenocortical cells. Thus, the present work indicates that NXNL1 can protect cell survival under oxidative stress in adrenocortical cells but has no specific function in the adrenal hormone metabolism. Therefore, it is possible, that the mutation detected in NXNL1 could have contributed to patients PAI not directly through disrupting steroidogenesis but due to the lack of protection of cell survival under oxidative stress conditions. Since PAI is usually inherited in an autosomal recessive manner it is suspected that the heterozygous mutation in NXNL1 did not contribute to PAI alone. It was excluded that a polymorphism detected in Exon 2 of NXNL1 (c.461A>T, p.Glu154Val) was inherited compound heterozygous, together with the stop mutation. In order to investigate whether further mutations could have contributed to PAI in the patient, trio analysis and optical genome mapping were performed. With these methods mutations in various genes such as SRCAP and INPP5B were detected, which were not examined in detail. Even if the influence of these variants remains unclear, modulating effects are possible. Despite the extensive investigations, it could not be clarified to what extent the stop mutation in NXNL1 contributed to PAI in the patient. This shows once more, how complex it is to answer the question of etiology, especially in genetically caused diseases. Nevertheless, investigating new genetic variants related to rare diseases contributes to better understanding of the human organism on a molecular level.

Velofarynxinsufficiens (VFI) innebär en nedsatt förmåga att under tal och födointag stänga till mellan mun- och näshåla vilket leder till ett avvikande tal. Operation med svalglambå är en metod som kan användas för att behandla VFI och tidigare forskning har visat goda resultat avseende dess effekt på talet. Dock menar vissa forskare att operationen kan ha negativa effekter och att den bakomliggande orsaken till insufficiensen kan påverka graden av framgång. Aktuell studie ämnade undersöka huruvida operation med svalglambå påverkade talet vid VFI samt belysa om några skillnader fanns mellan olika patientgrupper avseende operationens effekt på tal. De olika patientgrupperna var (a) patienter med spalt, (b) patienter med spalt i kombination med ett syndrom eller en sekvens och (c) patienter med VFI utan förekomst av spalt. Eftersom tidigare studier dessutom indikerat att postoperativ talbehandling hos logoped kan vara relevant för vissa patienter undersöktes det också under vilka omständigheter det skedde. Journaler, inklusive perceptuella lyssnarbedömningar av talet genomförda av logopeder, och enkätsvar studerades för de 66 patienter som deltog. Dessa utgjorde 43,1% av alla 153 patienter som genomgått operation med svalglambå på Akademiska sjukhuset i Uppsala år 2000-2011. Talbedömningar genomförda före och ett år efter operation visade att talet förbättrades avseende förståelighet (p<0,001), hypernasalitet (p=0,005) och tryckreducerad artikulation (p=0,001) samtidigt som hyponasalitet inte ökade (p=0,55). Patienter med spalt i kombination med syndrom eller sekvens uppvisade större förbättring av hypernasalitet jämfört med de andra grupperna (p=0,037). 32 patienter gick i postoperativ talbehandling hos logoped och patienter med enbart spalt fick behandling i något högre utsträckning än patienter med gomspalt i kombination med syndrom eller sekvens. Kompensatorisk artikulation var den enda talavvikelsen vars förekomst kunde relateras till att patienten gick i postoperativ talbehandling. Resultaten indikerar att operation med svalglambå är en lämplig metod för att behandla VFI oavsett bakomliggande orsak. Nyckelord: Velofarynxinsufficiens, svalglambå, LKG, syndrom, primär VFI, talavvikelse, talbehandling / Velopharyngeal insufficiency (VPI) refers to the failure of separating the oral cavity from the nasal cavity during speech and deglutination. This leads to increased airflow through the nose and is the cause of resonance disturbances such as hypernasality and nasal emission. Previous studies evaluating the success of pharyngeal flap surgery to treat VPI have indicated satisfying result although some studies stress side effects due to postoperative constrictions. The underlying cause of VPI has been shown to influence the postoperative result. With this background we investigated the differences in speech, pre-, and one year post pharyngeal flap surgery and compared the three groups (a) cleft palate, (b) cleft palate in combination with a syndrome or a sequence, and (c) VPI without cleft palate. We also investigated the co-occurance of postoperative speech therapy regarding different speech parameters and the underlying cause of VPI. 66 of the 153 patients who underwent a pharyngeal flap surgery at Akademiska sjukhuset in Uppsala 2000-2011 agreed to participate in the study. 32 patients attended postoperative speech therapy. The data was collected through medical records and a survey and included perceptual analyses of speech pre-, and post surgery performed by speech and language pathologists. According to the results from the perceptual assessment, the pharyngeal flap surgery resulted in improved speech; intelligibility (p<0.001), hypernasality (p=0.005) and weak consonant pressure (p=0.001). Hyponasality did not increase significantly (p=0.55). Patients with cleft palate in combination with a syndrome or a sequence showed greater improvement regarding hypernasality (p=0.037). The only speech disturbance co-occurring with the presence of postoperative speech therapy was compensatory articulation. Patients with cleft palate seemed to receive postoperative speech therapy in a higher extent than patients with cleft palate in combination with a syndrome or a sequence. These results indicate that pharyngeal flap surgery is a successful way of treating VPI disregarding underlying cause. Keywords: Velopharyngeal insufficiency, pharyngeal flap, cleft palate, syndrome, primary VPI, speech deviation, speech therapy

<p>UVOD: Komplikacije terminalne bubrežne isuficijencije (TBI) kada se jačina glomerularne filtracije (JGF) smanji ispod 10 mL/min moguće je lečiti jedino hroničnom dijalizom ili transplantacijom bubrega tj. nadoknadom potpuno ili delimično izgubljene bubrežne funkcije. Uz blagovremenu edukaciju bolesnika o progresivnom toku hronične bubrežne bolesti, mogućnostima dijaliznog tretmana i transplantacije bubrega, treba na vreme obezbediti stalni funkcionalni vaskularni pristup za hemodijalizu (HD) hirur&scaron;kom intervencijom kreiranja arteriovenske fistule (AVF), po mogućnosti najmanje 6 meseci pre anticipiranog započinjanja HD, jer je za njenu maturaciju potrebno 4 do 6 nedelja. Primarna AVF je op&scaron;tepreporučeni najbolji stalni vaskularni pristup za bolesnike kod kojih se planira hemodijaliza. Najče&scaron;ći razlog za disfunkciju vaskularnog pristupa za hemodijalizu su u 80% slučajeva trombozne komplikacije, koje se u 90% slučajeva javljaju na venskom segmentu AVF i posledica su progresivne venske neointimalne hiperplazije. Pored histolo&scaron;kih karakteristika zida venskog krvnog suda i hemodinamskih uslova, u etiopatogenezi ovog &raquo;adaptivnog odgovora&laquo; vrlo značajnu ulogu igraju endotel i ostale komponente hemostaznog sistema (trombocitna, koagulaciona i fibrinolizna), imunolo&scaron;ki i citolo&scaron;ki činioci i genetski faktori. Prevencija nastanka rane tromboze vaskularnog pristupa za hemodijalizu kod bolesnika sa TBI je moguća primenom antitromboznih lekova, tj. antitrombocitne ili antikoagulantne terapije. CILJ: Proceniti efikasnost primenjenih antitromboznih lekova (tiklopidina i nadroparin-kalcijuma) u prevenciji nastanka rane tromboze/afunkcionalnosti AVF za hemodijalizu za vreme njene maturacije unutar 6 nedelja od kreiranja u bolesnika sa TBI. Ispitati nivo biomarkera hemostaznog sistema i markere trombofilije u bolesnika sa TBI pre kreiranja AVF u cilju dopune uzroka nastanka rane tromboze/afunkcionalnosti arteriovenskih fistula za hemodijalizu. Ispitati učestalost trombofilije i njen uticaj na funkcionalnost AVF i uporediti efikasnost primenjenih preventivnih režima između bolesnika sa i bez trombofilije. MATERIJAL I METODE: U ispitivanje su uključene osobe oba pola sa prethodno postavljenom dijagnozom TBI kod kojih nisu postojale kontraindikacije za planirno hirur&scaron;ko kreiranje prvog stalnog vaskularnog pristupa za hemodijalizu u vidu autologne arteriovenske fistule (AAVF). Nakon hirur&scaron;kog kreiranja radiocefalične arteriovenske fisule u distalnoj trećini podlaktice nedominantne ruke (89/121), intermedijalne (4/121) ili proksimalne (28/121) AAVF u studiju je uključen 121 ispitanik, koji su u cilju procene uticaja različitih antitromboznih lekova na sprečavanje nastanka rane tromboze fistula za hemodijalizu kod bolesnika sa TBI ispitanici su podeljeni u 3 grupe: Grupa I, kontrolna; 40 ispitanika koji nakon kreiranja AVF nisu dobijali antitromboznu terapiju, Grupa II; 42 ispitanika kod kojih je dan nakon kreiranja AVF započeta primena antitrombocitnog leka iz grupe tienopiridina, Ticlodix&reg; (ticlopidin) tbl a 250 mg, 2 x &frac12; tbl dnevno tokom 6 nedelja i Grupa III; 39 ispitanika kod kojih je dan nakon kreiranja AVF započeta subkutana primena antikoagulantnog leka iz grupe niskomolekularnih heparina, Fraxiparine&reg; (nadroparin-kalcijum) 2850 anti Xa i.j. (0.3 ml) dnevno tokom 6 nedelja. Jednokratno određivanje laboratorijskih parametara pokazatelja bubrežne funkcije, metabolizma glukoze i hroničnog zapaljenja, funkcionalnosti hemostaznog sistema, trombofilnih markera i genskog polimorfizma vr&scaron;eno je unutar dve nedelje pre hirur&scaron;kog kreiranja AAVF. Kriterijum za utvrđivanje ishoda uticaja antitrombozne terpije predstavlja maturacija AVF koja je definisana kao uspe&scaron;na ako je započeto sprovođenje efikasne hemodijalize najranije 6 nedelja nakon njenog hirur&scaron;kog kreiranja po proceni nadležnog nefrologa. Dijagnoza prisustva tromboze AVF postavljena je od strane nadležnog vaskularnog hirurga/nefrologa fizikalnim pregledom tokom njene maturacije, koji je podrazumevao inspekciju, palpatorno utvrđivanje odsustva karakterističnog trila i auskultatornih karakteristika protočnosti AVF ili ultarsonografskim pregledom od strane radiologa. REZULTATI: Između ispitivanih grupa u odnosu na broj tromboziranih/ afunkcionalnih AVF tokom njene maturacije (12/40 vs. 4/42 vs. 5/39; P=0.033), ustanovljena je značajna statistička razlika kao i poređenjem broja tromboziranih/afunkcionalnih AVF tokom sazrevanja u kontrolnoj grupi u odnosu na grupu ispitanika (objedinjene Grupe II i Grupa III) koja je primala antitromboznu profilaksu (12/40 vs. 9/81; P=0.009). Daljom analizom ispitivanih grupa, utvrđena je statistički značajna razlika u broju tromboziranih/afunkcionih AV fistula između kontrolne Grupe I i Grupe II (P=0.019). Testiranjem razlike u broju tromboziranih/ afunkcionalnih AVF između ispitanika kontrolne Grupe I i Grupe III nije dobijena statistički značajna razlika, kao ni između Grupe II i Grupe III. Zastupljenost broja tromboziranih/afunkcionalnih distalnih AVF za vreme njihove maturacije (12/33 vs 2/31 vs. 3/24; P=0.008) se između ispitivanih grupa značajno statistički razlikovala kao i zastupljenost tromboziranih/afunkcionalnih distalnih AVF tokom sazrevanja u kontrolnoj grupi u odnosu na grupu ispitanika koja je primala antitromboznu profilaksu (12/34 vs. 5/55; P=0.002). Testiranjem statističke razlike u broju tromboziranih/afunkcionalnih distalnih AVF između ispitanika kontrolne Grupe I i Grupe II utvrđena je statistički značajna razlika (P=0.005), dok između Grupe I i Grupe III (P=0.051), kao ni između Grupe II i Grupe III (P=0.439) nije dobijena statistički značajna razlika. Između podgrupa ispitanika kod kojih je do&scaron;lo do tromboze/afunkcionalnosti AVF 21/121 (17.35%) i podgrupe ispitanika sa funkcionalno maturiranom AVF 90/121 (82.64%), značajna statistička razlika ispitanih hemostaznih parametara je bila prisutna u vrednostima agregabilnosti trombocita uz kolagen kao induktor (59.33&plusmn;33.1 vs. 75.04&plusmn;29.6; P=0.033). Značajna statistička razlika je zabeležena i u zastupljenosti sledećih trombofilnih markera: deficita PC (3/21 vs. 3/100; P=0.030), APC-R (4/21 vs. 5/100; P=0.026), prisustva antifosfolipidnih ACL IgM antitela (1/21 vs. 0/100; P=0.028), heterozigotnog polimorfizma FV G1691A (3/21 vs. 3/100; P=0.03) i homozigotne mutacije gena FII G20210A (1/21 vs. 0/100; P=0.028), između podgrupa bolesnika sa tromboziranom afunkcionalnom i funkcionalnom AVF. Takođe je značajna statistička razlika između podgrupa bolesnika kod kojih je do&scaron;lo tromboze/afunkcionalnosti AVF i podgrupe ispitanika sa funkcionalno maturiranom AVF bila prisutna u odnosu na postojanje ranijih tromboza (23/21 vs 19/100; P=0.000) kao i zastupljenosti izolovanih venskih tromboza (9/21 vs. 2/100; P=0.000). Prediktivni potencijal pojedinačnih parametara za maturaciju AVF ispitan je univarijantnom logističkom regresionom analizom. Prilikom ispitivanja uticaja pojedinačnih parametara na maturaciju fistule, zapazili smo da su ispitanici koji su primali antitromboznu terapiju imali 3 puta veću &scaron;ansu za funkcionalno maturiranu AVF [OR 3.45 (1.3-9.03)] u odnosu na bolesnike bez terapije. Ispitanici koji su imali prethodne tromboze su imali vi&scaron;estruko povi&scaron;en rizik [OR 6.92 (2.51-19.06)] za nastanak tromboze/afunkcionalnost AVF tokom maturacije. Prilikom ispitivanja uticaja pojedinačnih parametara na rizik od pojave tromboze/afunkcionalnosti distalne AVF, zapažamo da primena antitrombozne terapije [OR 5.4 (CI 1.7 - 17.35)] petostruko snižava rizik za nastanak tromboze/ afunkcionalnosti distalne AVF, odnosno da primena antitrombozne terapije petostruko povećava &scaron;ansu za adekvatnu maturaciju distalne AVF. Ispitanici koji su imali aterosklerotske KVB [OR 0.32 (0.1-0.98)] i ranije tromboze [OR 0.14 (0.04-0.44)] su imali za 68% i 86% manju verovatnoću za adekvatnu maturaciju distalne AVF (334). Trombofilija je bila prisutna u 59/121 (48.8%) ispitanika. U odnosu na markere aktivacije koagulacione komponente hemostaznog sistema i inflamatorne pokazatelje, između podgrupa ispitanika sa ili bez trombofilije statistički značajna razlika je bila prisutna u vrednostima koncentracije FVIII (170.35&plusmn;103.97 vs. 235.26&plusmn;124.80; P=0.02) i odnosa trombociti/limfociti (181&plusmn;64.58 vs. 148.11&plusmn;66.15; P=0.026). U odnosu na lokalizaciju AVF, u podgrupi ispitanika sa trombofilijom i tromboziranom/ afunkcionalnom AVF, njih 8/11 su pripadale distalnim AVF, 3/11 proksimalnim AVF, dok je u podgrupi ispitanika bez trombofilije i tromboziranom/afunkcionalnom AVF, njih 9/10 imalo distalnu, a 1/10 proksimalnu AVF. U grupi bolesnika sa trombofilijom nije zabeleženo prisustvo statistički značajne razlike u efikasnosti primenjenih antitromboznih režima merene učestalo&scaron;ću tromboza/afunkcionalnosti AVF u odnosu na bolesnike sa trombofilijom koji nisu primali antitromboznu terapiju (5/19 vs. 2/18 vs. 4/22; P=0.493). U grupi ispitanika bez trombofilije utvrđeno je postojanje statistički značajne razlike u učestalosti tromboza/afunkcionalnosti AVF između grupe sa i bez primene antitromboznih lekova kako u ukupnom broju tromboziranih/afunkcionalnih AVF (7/21 vs. 2/24 vs. 1/17; P=0.030). Iako je zastupljenost tromboza/afunkcionalnosti AVF u bolesnika sa kombinovanom trombofilijom če&scaron;ća u odnosu na ispitanike koji su imali drugu vrstu ili uop&scaron;te nisu imali trombofiliju (6/18 vs. 15/103; P=0.052), ona nije dostigla statistički značajnu vrednost. ZAKLJUČAK: Profilaktička primena antitromboznih lekova (tiklopidina i nadroparin-kalcijuma) smanjuje učestalost pojave rane tromboze i pojavu primarne nefunkcionalnosti AVF za hemodijalizu tokom njene maturacije. Primena antitrombozne terapije petostruko snižava rizik za nastanak tromboze/ afunkcionalnosti distalne AVF tokom njene maturacije. Bolesnici koji su imali prethodne tromboze imaju vi&scaron;estruko povi&scaron;en rizik za nastanak tromboze AVF tokom njene maturacije. Kod bolesnika koji su imali aterosklerotske KVB i ranije tromboze verovatnoća za adekvatnu maturaciju distalne AVF je niža za 68% , odnosno 86%. U na&scaron;em istraživanju nije utvrđeno postojanje superiornosti antikoagulantne u odnosu na antitrombocitnu profilaksu tj. oba primenjena režima su bila podjednako efikasna. U terminalnoj bubrežnoj insuficijenciji prisutan je značajan poremećaj funkcionalnosti hemostaznog sistema koji se očituje u disfunkciji endotela i poremećenoj (sniženoj) funkcionalnosti trombocita, prisustvu prokoagulantnog stanja koje se manifestuje povi&scaron;enom trombinskom aktivno&scaron;ću, povi&scaron;enom koncentracijom činilaca koagulacije i smanjenom fibrinoliznom aktivno&scaron;ću. Če&scaron;ća zastupljenost ukupnih ranijih tromboza (arterijskih i venskih), če&scaron;ća zastupljenost izolovanih venskih tromboza i učestalije prisustvo trombofilije prezentovano deficitom PC, prisustvom rezistencije na APC, prisusustvom antifosfolipidnih antikardiolipinskih antitela IgM, heterozigotnog polimorfizma FV G1691A, homozigotne mutacije FII G201210A i niža vrednost agregabilnosti trombocita uz kolagen kao induktor su markeri koji su u na&scaron;em ispitivanju signifikantno če&scaron;će zastupljeni kod ispitanika sa trombozom/ afunkcijom AVF za hemodijalizu tokom njenog sazrevanja. Trombofilija je prisutna kod 48.8% bolesnika saTBI, ali na&scaron;im ispitivanjem nije utvrđen njen uticaj na nastanak rane tromboze/afunkcionalnosti AVF izuzev u grupi bolesnika sa kombinovanom trombofilijom. Mali broj krvarećih komplikacija u na&scaron;oj studiji ukazuje na bezbednost primenjenog preventivnog režima. Na osnovu dobijenih rezultata može se preporučiti profilaktička primena tiklopidina ili nadroparin-kalcijuma u preventivnim dozama kod bolesnika sa TBI neposredno nakon kreiranja AVF. Primenu profilakse tromboznih komplikacija kod bolesnika sa novokreiranom AVF preporučujemo posebno kod bolesnika koji su imali prethodne tromboze i/ili kliničke manifestacije aterosklerotskih kardiovaskularnih bolesti.</p> / <p>INTRODUCTION: Complications in end stage renal disease (ESRD) when the glomerular filtration rate (GFR) decreases below 10mL/min can only be treated by chronic dialysis or kidney transplant ie. total or partial renal replacement therapy. With prompt education of the patient regarding the progressive course of the chronic kidney disease, possibilities of dialysis treatment and kidney transplantation, the patient should timely be granted permanent functional vascular hemodialysis (HD) access through surgical intervention by creating arteriovenous fistula (AVF), preferably at least 6 months prior to the anticipated start of HD, as period for its maturation is between 4 and 6 weeks. Primary AVF is the generally best recommended permanent vascular access for patients planned for dialysis. The most common reason for dysfunction of the vascular access for hemodialysis are thrombotic complications in 80% of the cases, 90% of which appear in the venous segment of AVF as the consequence of progressive venous neointimal hyperplasia. Beside the histological characteristics of the venous blood vessel wall and hemodynamic conditions, in the etiopathogenesis of this &ldquo;adaptive answer&rdquo;, endothel and other components of the hemostatic system (platelet, coagulation and fibrinolysis), immunological and cytological components as well as genetic factors play a very important role. Prevention of occurrence of early thrombosis of vascular access for hemodialysis in patients with ESRD is possible by treatment with antithrombotic drugs, ie. antiplatelet or anticoagulant therapy. OBJECTIVE: Estimate the efficiency of applied antithrombotic drugs (ticlopidine and nadroparincalcium) in prevention of occurrence of early thrombosis/dysfunction of AVF for hemodialysis during its time of maturation within the 6 week period. Examine the level of biomarkers of the hemostatic system and thrombophilic markers in patients with ESRD before the creation of AVF with the goal of finding additional causes of occurrence of early thrombosis/dysfunction of arteriovenous fistula for hemodialysis. Determine the incidence of thrombophilia and its impact on the functionality of AVF and compare the efficiency of applied preventive regimen between patients with and without thrombophilia. MATERIAL AND METHODS: The study included persons of both sexes with previously established diagnosis of ESRD in which there were no contraindications for the planned surgical creation of the first permanent vascular access for hemodialysis in the form of autologous arteriovenous fistula (AAVF). After the surgical creation of the radiocephalic arteriovenous fistula in the distal third of the forearm of the non-dominant hand (89/121), intermedial (4/121) or proximal (28/121) AAVF, the total number of 121 patients were included in the study and divided into three groups in order to estimate the influence of different antithrombotic drugs in prevention of early thrombosis for hemodialysis in patients with ESRD: Group I, control; 40 subjects which did not receive antithrombotic therapy after the creation of AVF, Group II; 42 subjects which started receiving an antithrombotic drug from the tienopiridine group, Ticlodix&reg; (ticlopidine) 2 x &frac12; of 250mg tbl, daily, during the period of 6 weeks, after the creation of AVF, and Group III; 39 subjects which started subcutaneously receiving a drug from the low-molecular weight herapin group, Fraxiparine&reg; (nadroparine-calcium) 2850 anti Xa i.j. (0.3 ml) daily, during the period of 6 weeks. One-time determination of laboratory parameters and renal function, glucose metabolism and chronic inflammation, hemostatic system functionality, thrombophilic markers and gene polymorphism was performed within two weeks prior to surgical creation of AAVF. The criteria for determining the outcome of the impact of antithrombotic therapy is the maturation of AVF, which is defined as successful if the implementation of effective hemodialysis started at least 6 weeks after its creation, where the effectiveness of hemodialysis is estimated by a competent nephrologist. The diagnosis of the presence of AVF thrombosis was set by a competent vascular surgeon/nephrologist through physical examination during its maturation, which included inspection, palpatory determination of absence of the characteristic thrill and auscultatory characteristics of the flow of AVF, or by ultrasonographic examination by the radiologist. RESULTS: Between the groups in terms of number of thrombosed/dysfunctional AVF during its maturation (12/40 vs. 4/42 vs. 5/39, P = 0.033), a significant statistical difference was established, as well as by comparing the number of thrombosed/dysfunctional AVF during maturation in the control group compared to the group of respondents (unified Group II and Group III) which received antithrombotic prophylaxis (12/40 vs. 9/81, P = 0.009). Through further analysis of the examined groups, a statistically significant difference was observed in the number of thrombosed/dysfunctional AV fistula between the control Group I and Group II (P = 0.019). There was no statistically significant difference noticed in the numbers of thrombosed/dysfunctional AVF between the subjects in the control Group I and Group III, as well as between Group II and Group III. Presence of the number of thrombosed/dysfunctional distal AVF during their maturation (12/33 vs 2/31 vs. 3/24, P = 0.008) between the groups statistically significantly varied, as well as the presence of the number of thrombosed/dysfunctional distal AVF during the maturation in the control group as compared to the group of subjects who received antithrombotic prophylaxis (12/34 vs. 5/55; P=0.002). By testing statistical differences in the number of thrombosed/dysfunctional distal AVF between the subjects in the control Group I and Group II a statistically significant difference (P = 0.005) was established, while there was no statistically significant difference between Group I and Group III (P = 0.051), nor between Group II and Group III (P = 0.439). Among the subgroup of patients with thrombosis/dysfunction of AVF 21/121 (17.35%) and the subgroup of subjects with functionally maturated AVF 90/121 (82.64%), a statistically significant difference of the examined hemostasis parameters was present in the values of platelet aggregation with collagen as the inducer (59.33 &plusmn; 75.04 vs. 33.1 &plusmn; 29.6; P = 0.033). A significant statistical difference was recorded in the presence of the following thrombophilic markers: deficit of PC (3/21 vs. 3/100; P = 0.030), APC-R (4/21 vs. 5/100; P = 0.026), the presence of antiphospholipid ACL IgM antibodies ( 1/21 vs. 0/100; P = 0.028), heterozygous FV G1691A polymorphism (3/21 vs. 3/100; P = 0.03) and homozygous gene mutation FII G20210A (1/21 vs. 0/100; P = 0.028), between the subgroups of patients with thrombosed/dysfunctional and functional AVF. There also was a significant statistical difference between the groups of patients which encountered thrombosis/dysfunction of AVF and subgroups of subjects with functional maturated AVF in relation to the existence of previous thrombosis (23/21 vs. 19/100; P = 0.000) and the presence of isolated venous thrombosis (9/21 vs. 2/100; P = 0.000). Predictive potential of individual parameters for AVF maturation was tested by univariate logistic regression analysis. During the examination of the influence of individual parameters on fistula maturation, we observed that subjects who received antithrombotic therapy were 3 times more likely to develop functionally maturated AVF [OR 3.45 (1.3-9.03)] as compared to subjects who did not receive any treatment. Subjects which previously had thrombosis had a multiple times increased risk [OR 6.92 (2:51 to 19:06)] of developing thrombosis/dysfunctional AVF during its maturation. When examining the influence of individual parameters on the risk of thrombosis/dysfunction of the distal AVF, we noted that the implementation of antithrombotic therapy [OR 5.4 (CI 1.7 - 17:35)] reduced risk of thrombosis/dysfunction of the distal AVF by five times, ie. that the implementation of antithrombotic therapy increases the chance for adequate distal AVF maturation by five times. The subjects that had atherosclerotic cardiovascular diseases (CVD) [OR 0.32 (0.1-0.98)] or previous thrombosis [OR 0.14 (0.04-00.44)] had a 68% or 86% less chance for adequate distal AVF maturation (334). Thrombophilia was present in 59/121 (48.8%) patients. In relation to the markers of activation of coagulation components of the hemostatic system and inflammatory markers, among subgroups of subjects with or without thrombophilia a statistically significant difference was present in the FVIII concentration (170.35 &plusmn; 103.97 vs. 235.26 &plusmn; 124.80; P = 0.02) and the platelets/lymphocytes ratio (181 &plusmn; 64.58 vs. 148.11 &plusmn; 66.15; P = 0.026). In relation to the localization of AVF, in the subgroup of subjects with thrombophilia and thrombosed/dysfunctional AVF, 8/11 of them belonged to distal AVF, 3/11 proximal AVF, while in the subgroup of subjects without thrombophilia and thrombosed/dysfunctional AVF, had 9/10 distal and 1/10 proximal AVF. In the group of subjects with thrombophilia there was no record of the presence of statistically significant differences in the efficiency of antithrombotic regimen which was measured by the frequency of thrombosis/dysfunction of AVF as compared to subjects with thrombophilia which did not receive antithrombotic therapy (5/19 vs. 2/18 vs. 4/22, P = 0.493). In the group of subjects without thrombophilia statistically significant differences were found in the frequency of thrombosis/dysfunctions of AVF among groups with and without the use of antithrombotic drugs in the total number of thrombosed/dysfunctional AVF (7/21 vs. 2/24 vs. 1/17, P = 0.030). Although the presence of thrombosis/dysfunction of AVF in patients with combined thrombophilia was more frequent compared to those who had other types of, or did not have thrombophilia (6/18 vs. 15/103; P = 0.052), it did not reach a statistically significant value. CONCLUSION: Prophylactic use of antithrombotic drugs (ticlopidine and nadroparin-calcium) reduces the incidence of early thrombosis and the occurrence of primary AVF dysfunction for hemodialysis during its maturation. Implementation of antithrombotic therapy reduced risk of thrombosis/ dysfunction of the distal AVF during its maturation by five times. Patients who have had previous thrombosis have multiple times greater risk of AVF thrombosis during its maturation. In patients who had atherosclerotic CVD or previous thrombosis, the probability for adequate maturation of distal AVF is lower by 68% or 86%. In our study there was no evidence of superiority of anticoagulant compared to antiplatelet prophylaxis ie. both regimens were equally effective. In ESRD there is significant disarrangement of hemostatic system functionality, which is reflected in endothelial dysfunction and disturbed (reduced) platelet functionality, the presence of procoagulant condition that is manifested by elevated thrombin activity, increased levels of clotting factors and reduced fibrinolytic activity. More frequent presence of total previous thrombosis (arterial and venous), higher frequency of isolated venous thrombosis and frequent presence of thrombophilia presented by the deficit of PC, the presence of resistance to APC, presence of anticardiolipin antiphospholipid antibodies IgM, heterozygous FV G1691A polymorphism, homozygous mutation FII G201210A and lower value of collagen induced platelet aggregation are the markers in our study which are significantly more frequent in patients with thrombosis/dysfunction of AVF for hemodialysis during its maturation. Thrombophilia is present in 48.8% of patients with ESRD, however our study does not determine its impact on early thrombosis/dysfunction of AVF except in the group of patients with combined thrombophilia. A small number of bleeding complications in our study points to the safety of the applied preventive regimen. Based on the obtained results, prophylactic use of ticlopidine or nadroparin-calcium in preventive doses can be recommended for patients with ESRD immediately after AVF creation. Prophylactic treatment of thrombotic complications in patients with newly created AVF is recommended especially in patients who have had previous thrombosis and/or clinical manifestations of atherosclerotic cardiovascular diseases.</p>

<p>Endotelin-1 je najpotentniji vazokontstriktorni peptid koji značajno doprinosi funkcionalnim i strukturnim bubrežnim promenama i poslednjih godina se izdvojio kao značajan faktor u razvoju i progresiji dijabetesne nefropatije. Cilj ovog istraživanja bio je odrediti nivo plazmatskog endotelina-1 kod bolesnika sa tipom 2 &scaron;ećerne bolesti u odnosu na zdravu populaciju kao i ispitati odnos plazmatskog endotelina-1 i funkcionog statusa bubrega kod bolesnika sa &scaron;ećernom bolesti tip 2 i dijabetesnom nefropatijom. U istraživanje je uključeno sto dvadeset ispitanika sa tipom 2 dijabetesa i sekundarno inzulin zavisni, koji&nbsp; su podeljeni u dve grupe u odnosu na izmerenu jačinu glomerulske filtracije: Grupa I (n=60) ispitanici sa jačinom glomerulske filtracije većom od 60 ml/min/1.73m2 i grupa II (n=60) ispitanici sa jačinom glomerulske filtracije manjom od 60 ml/min/1.73m2. Kod svih ispitanika izmerena je plazmatska vrednost endotelina-1 i izvr&scaron;ena procena funkcionog statusa bubrega merenjem jačine glomerulske filtracije, efektivnog bubrežnog protoka plazme i ostalih parametara bubrežne funkcije: serumske koncentracije cistatina C, uree, kreatinina, mokraćne kiseline kao i određivanje 24h albuminurije i proteinurije. Dobijeni rezultati upoređivani su sa rezultatima kontrolne grupe ispitanika (n= 30). Postoji statistički značajna razlika u medijanama vrednosti endotelina-1 između ispitivanih grupa (p&lt;0.001). Značajno niže vrednosti plazmatske koncentracije endotelina-1 su imali ispitanici kontrolne grupe (0.80 &plusmn;0.3) u odnosu na ispitanike sa &scaron;ećernom bolesti i JGF&gt;60 ml/min (1.4&plusmn;0.4) kao i u odnosu na dijabetesne bolesnike sa JGF&lt;60ml/min (2.5 &plusmn;0.8). Značajno vi&scaron;e vrednosti endotelina-1 su&nbsp; imali bolesnici sa &scaron;ećernom bolesti i većim stepenom redukcije jačine glomerulske filtracije u odnosu na bolesnike sa manjim stepenom redukcije jačine glomerulske filtracije (p&lt;0.001). U grupi bolesnika sa tipom 2 &scaron;ećerne bolesti postoji statistički značajna inverzna korelacija između plazmatskog nivoa endotelina-1 i izmerene vrednosti jačine glomerulske filtracije i efektivnog bubrežnog protoka plazme (r= -0,75; p=0,000; r= -0,74; p=0,000) odnosno bolesnici sa &scaron;ećernom bolesti kod kojih postoje povi&scaron;ene vrednosti plazmatskog endotelina-1 imaju veći stepen redukcije jačine glomerulske filtracije i efektivnog bubrežnog protoka plazme. Kod bolesnika sa tipom 2 dijabetes melitusa i različitim stepenom bubrežne hipofunkcije endotelin-1 u značajnoj meri utiče na vrednosti jačine glomerulske filtracije i efektivnog bubrežnog protoka plazme ali i druge funkcijske parametre bubrega i samim tim može imati važnu ulogu u nastanku i razvoju dijabetesne nefropatije.</p> / <p>Endothelin-1, potent vasoconstrictor peptide may contribute to the functional and structural renal changes and in recent years emerged as a significant factor in the development&nbsp; and progression of diabetic nephropathy. The aim of&nbsp; this study was to determine the level of plasma endothelin-1 levels in patients with type 2 diabetes and compared to healthy&nbsp; population as well as to examine the relationship of plasma endothelin-1 and the functional status of the kidneys in patients with type 2 diabetes. The study included one hundred&nbsp; and&nbsp; twenty patients&nbsp; with type 2 diabetes and insulin-dependent secondary, which are divided into two groups with respect to the measured GFR: Group I (n = 60) subjects with by glomerular filtration rate greater than 60 ml /min/1.73m2 and group II (n&nbsp; =&nbsp; 60) subjects with by glomerular filtration rate of less than 60ml/min/1.73m2 . Plasma levels of endothelin-1, glomerular filtration rate and effective renal plasma flow were determined using appropriate methods in all subjects. Other renal function parameters such as serum&nbsp; concentrations of cystatin C, urea, creatinine, uric acid, 24h albuminuria and proteinuria were measured additionaly. The results were compared with control groups of subjects (n= 30). There was a statistically significant difference in median values of endothelin-1 between the groups (p&lt;0.001). Significantly lower plasma concentrations of endothelin-1 had control subjects (0.80&nbsp; &plusmn;&nbsp; 0.3) compared to subjects with diabetes and GFR&gt;60 ml/min (1.4 &plusmn; 0.4) and in relation to diabetic patients with GFR &lt;60 ml/min (2.5 &plusmn; 0.8). Significantly higher values of endothelin-1 had patients with diabetes and a higher degree of reduction of glomerular filtration rate compared with patients with a lower degree of&nbsp; reduction of glomerular filtration rate (p &lt;0.001). In the group of patients with type 2 diabetes, there was a statistically significant inverse correlation between plasma levels endothelin-1 and the measured values of glomerular filtration rate and effective renal plasma flow (r= -0.75; p=0.000; r= -0.74; p=0.000) and patients with diabetes who have the higher values of&nbsp; plasma endothelin-1 have a higher degree of reduction of glomerular filtration rate and effective renal plasma flow. In patients with type 2 diabetes mellitus and various degrees of renal hypofunction endothelin-1 significantly affects the value of the glomerular filtration rate and effective renal plasma flow or other parameters of renal function and thus can play an important role in thedevelopment of diabetic nephropathy.</p>

Heat shock proteins increase their gene expression after exposure of cells or organisms to some forms of stress, which may be high temperature, infection, inflammation, hypoxia, lack of nutrients and water. Stressful situations for the body are also pregnancy-related complications associated with placental insufficiency - preeclampsia and IUGR, as well as other pregnancy-related complications such as fetal growth restriction and gestational hypertension. Therefore, I examined whether the occurrence of pregnancy-related complications (preeclampsia, fetal growth retardation, gestational hypertension) affect the gene expression of heat shock proteins. Five hsp systems was detected, namely Hsp27, Hsp60, Hsp70, Hsp90 and HspBP1 in placental tissue samples and whole maternal peripheral blood. Samples came from women with physiological pregnancy and from women with certain pregnancy-related complications (PE, FGR, GH). RNA was isolated from the samples. Detection of hsp expression was performed by using real-time RT-PCR and the comparative Ct method. Changes in gene expression between the test samples and reference sample were examined. To assess the difference between physiological pregnancies and pregnancies with selected pregnancy- related complications, an analysis of variance (ANOVA) was used....

Introdução: O istmo aórtico (IAo) fetal é um pequeno segmento vascular localizado entre a origem da artéria subclávia esquerda e a extremidade aórtica do canal arterial, que reflete o equilíbrio entre a impedância ao fluxo no território cerebral e na circulação fetal periférica. Considerado o único shunt arterial verdadeiro entre os sistemas vasculares direito e esquerdo, seu fluxo alterado se associa a resultados perinatais adversos, incluindo aumento da mortalidade fetal e morbidade neurológica, especialmente em fetos com insuficiência placentária e restrição de crescimento. Justificativa: Não há protocolo mundial estabelecido definindo conduta clínica baseada na avaliação Doppler do istmo aórtico fetal, havendo espaço para que sua análise seja incorporada como justificativa para indicação do parto e proteção contra injúrias perinatais. Entretanto, implementar novas medidas à prática clínica requer a demonstração de quão confiáveis e reprodutíveis são os resultados obtidos, o que contribui para a garantia de qualidade em sua utilização. Objetivos: Estimar a reprodutibilidade intra e interobservador do índice de pulsatilidade do istmo da aorta fetal (IAo-IP) no terceiro trimestre de gestação (32 a 36+6 semanas), e determinar qual das aquisições, longitudinal ou transversal, produz medidas com melhores confiabilidade e concordância. Métodos: Estudo observacional (transversal) para o qual foram convidadas a participar gestantes no terceiro trimestre de gestação (32 a 36+6 semanas) que preenchiam os critérios de elegibilidade. O IAo-IP foi obtido por dois observadores, que utilizaram os planos longitudinal e transversal para as aquisições, realizadas de forma completamente independente, sem que tivessem conhecimento dos valores das próprias medidas, tampouco das medidas do outro observador. Os dados foram apresentados como média ± DP (desvio-padrão), mediana, mínimo e máximo; A reprodutibilidade foi avaliada pelo coeficiente de correlação intraclasse (ICC). Resultados: As principais características das 49 gestantes foram: média de idade de 26.3 ± 4.7 anos, variando entre 18 e 40 anos, com média da idade gestacional de 33.6 ± 1.5 semanas e índice de massa corporal de 27.9 ± 4.5 Kg/m2. Os resultados dos IP obtidos do estudo Doppler espectral do istmo aórtico fetal pela via longitudinal, demonstraram uma média de 2.75 ± 0.46 para o observador A, 2.53 ± 0.38 para o observador B, e 2.74 ± 0.58 para a segunda medida do observador A. Para a via transversal, as médias foram de 2.75 ± 0.46 para o observador A, 2.53 ± 0.38 para o observador B, e 2.74 ± 0.58 para a segunda medida do observador A. A avaliação Doppler do istmo aórtico fetal no plano longitudinal apresentou ICC de 0.25 na comparação entre os observadores (interobservador), e de 0.42 para a análise intraobservador. No plano transversal, os coeficientes obtidos foram de 0.18 e 0.43 respectivamente para as análises inter-observador e intraobservador. Conclusões: Embora o papel do istmo aórtico na hemodinâmica fetal esteja bem estabelecido, o presente estudo demonstrou que sua reprodutibilidade no terceirotrimestre (32 a 36+6 semanas) é fraca, logo, a medida do IAo-IP deve ser interpretada com cautela, desencorajando seu emprego na prática clínica. Os estudos que examinam aperfeiçoamentos técnicos para melhorar a sua reprodutibilidade devem ser incentivados / Introduction: The fetal aortic isthmus (AoI) is a small vessel located between the origin of the left subclavian artery and the aortic extremity of the arterial ductus, which reflects the balance between the impedance of the brain and systemic circulation of the fetus. Known as the only arterial shunt regarding both right and left vascular systems, its abnormal flow is associated to adverse perinatal outcomes, including high fetal mortality and neurological morbidity, especially among placental insufficiency and growth-restricted fetuses. Rationale: There is no established global protocol defining clinical management based on the Doppler evaluation of the fetal aortic isthmus, allowing its analysis to be incorporated as a reason to indicate delivery and protection against perinatal injury. However, implementation of new methods to clinical practice requires demonstration of how reliable and reproducible the results are, which contributes to quality assurance in their use. Objectives: To estimate the intra and interobserver reproducibility of the fetal aortic isthmus pulsatility index (IAo-PI) in the third trimester of gestation (32 to 36+6 weeks), and to determine which of both longitudinal and transversal acquisitions show better reliability and agreement. Methods: Observational (cross-sectional) study in which were invited to participate pregnant women in the third trimester of gestation (32 to 36+6 weeks) who met the eligibility criteria. The AoI-PI was obtained by two observers, who used the longitudinal and transverse plans for the acquisitions, performing independent acquisitions and blinded analysis. Data were presented as mean ± SD (standard deviation), median, minimum and maximum. The reproducibility was evaluated by the intraclass correlation coefficient (ICC). Results: The main characteristics of the 49 pregnant women were: mean age of 26.3 ± 4.7 years, ranging from 18 to 40 years, with mean gestational age of 33.6 ± 1.5 weeks and body mass index of 27.9 ± 4.5 kg/m2. The results of the PI obtained from the spectral Doppler evaluation of the fetal aortic isthmus, regarding the longitudinal plane, have demonstrated an average of 2.75 ± 0.46 for observer A, 2.53 ± 0.38 for observer B, and 2.74 ± 0.58 for the second measurement of observer A. For the transversal plane the mean values were 2.75 ± 0.46 for the observer A, 2.53 ± 0.38 for the observer B, and 2.74 ± 0.58 for the second measurement of the observer A. The Doppler evaluation of the fetal aortic isthmus in the longitudinal plane has shown a ICC of 0.25 in the comparison between the observers (interobserver), and 0.42 for the intraobserver analysis. In the transversal plane, the coefficients obtained were 0.18 and 0.43 respectively for the interobserver and intraobserver analysis. Conclusions: Although the role of the aortic isthmus in fetal hemodynamics is well established, the present study have reported that its reproducibility in the third trimester (32 to 36+6 weeks) is very poor, so the measurement of the AoI-PI should be interpreted with caution, discouraging its use in clinical practice. Studiesexamining technical amendments to improve its reproducibility should be encouraged

Le retard de croissance intra-utérin par altérations vasculaires placentaires affecte 4% des grossesses actuelles. Ses mécanismes d’installation encore inconnus ont un impact pédiatrique important responsable d’une mortalité non négligeable. La combinaison d’un retard de croissance intra-utérin et de modifications vasculaires placentaires sur un modèle animal est nécessaire pour comprendre ces mécanismes et envisager une étude thérapeutique ultérieure. Le but de ce projet est de mettre au point dans un premier temps un modèle animal qui associe au retard de croissance intra-utérin les modifications vasculaires placentaires retrouvées dans la physiopathologie humaine. Pour cela, deux modèles animaux murins ont été étudiés : l'hyperthermie en fin de gestation et l’anémie par carence martiale pré et péri-gestationnelle. Une étude qualitative et quantitative par échographie (échographie Doppler et échographie de contraste) associée à une étude anatomopathologique. immuno-histochimiques et spectroscopique des placentas a été réalisée. L’optimisation du modèle animal définitif a requis dans un premier temps la mise au point de repères anatomiques inexistants à l'heure actuelle permettant la reproductivité des mesures échographiques ainsi que la mise en évidence de l’innocuité du produit de contraste échographique utilisé. Une étude placentaire globale nous a permis d’enregistrer des modifications structurelles liées au modèle analysé. L’étude de ces deux modèles animaux nous a permis d’établir un protocole de mesure standardisé et de mettre en évidence l’absence d’effet de l’utilisation du produit de contraste échographique sur la gestation. L’hyperthermie tout comme la carence martiale sont responsables d'un retard de croissance intra-utérin avec un effet dose dépendant. Les modifications vasculaires placentaires retrouvées dans le modèle hyperthermie à type d'ischémie-hémorragique n’apparaissent pas consécutives à des modifications vasculaires installées mais séquellaires de cet incident aigu. Les modifications hémodynamiques enregistrées dans le cadre de la carence martiale sont plutôt en faveur de modifications vasculaires en accord avec la pathologie humaine. L’étude spectroscopique ne met pas en évidence de changement métabolomique particulier. Ces deux modèles permettent donc l’installation d’un retard de croissance intra-utérin corrélé positivement à l’intensité du protocole. Le modèle anémie tend à se rapprocher au mieux de la pathologie humaine ; son étude reste à approfondir sur des effectifs plus conséquents. / The intra-uterin growth restriction by placental vascular modifications affects 4% of the current pregnancies. lt’s still unknown installation mechanism has an important pediatric impact with a significant mortality. The association of intra-uterin growth restriction and placental vascular defects on an animal model is necessary to understand this mechanism and envisage a therapeutic study later. The aim of Ibis project is to establish at first an animal model which associates intra-uterin growth restriction and vascular placental modifications found in the human physiopathology For that purpose, two murine models were studied : hyperthermia at the end of the gestation and anaemia by iron deficiency before and during the gestation. A qualitative and quantitative study by ultrasonography (Doppler ultrasonography and contrast ultrasonography) associated with anatomopathological, immune-histochemical and spectroscopic studies of the placentas was realized. The optimization of the definitive animal model required at first anatomical marks development, allowing reproduction of the ultrasonographic measures as well as revelation of the ultrasound contrast product harmlessness. A global placental study allowed us to note structural modifications connected to the analyzed model. The study of these two animals models allowed us to establish a standard measuring protocol and show that ultrasonographic contrast product use had no effect on the gestation. The hyperthermia, as the iron deficiency, is responsible of an intra-uterin growth restriction with a positive effect dose related. The vascular placental modifications found in the hyperthermia model as hemorrhage and ischaemia areas do not appear as the result of vascular modifications but after-effects of this acute incident. The hemodynamical modifications registered within the framework of the iron deficiency are rather in favour of vascular modifications in agreement with the human pathology. The spectroscopic study does not show metabolomic modifications. These two models allow the installation of an intra-uterin growth restriction positively correlated with the protocol intensity. The anaemia model gets closer to the human pathology; its study remains b he continued with more consequent numbers.

INTRODUÇÃO: A ecoescleroterapia com espuma (EEE) é um método minimamente invasivo de tratamento das varizes dos membros inferiores. Suas principais vantagens são a indicação para pacientes com alto risco cirúrgico, recuperação precoce pós-intervenção e menor custo inicial em relação aos outros métodos endovenosos. Porém, a taxa de oclusão venosa é variável, especialmente para o eixo venoso troncular com diâmetro maior que 6 mm. OBJETIVO: Comparar duas técnicas de EEE de polidocanol a 3% em veia safena magna (VSM) insuficiente, tendo como desfecho primário a taxa de sucesso completo com uma sessão terapêutica e desfechos secundários a avaliação da qualidade de vida e a taxa de complicações. PACIENTES E MÉTODOS: Seleção de 50 pacientes com varizes primárias superficiais em membro inferior (CEAP - classificação clínica, etiológica, anatômica, patofisiológica - C3) e insuficiência da VSM (6 - 10 mm de diâmetro) medida a 3 cm da junção safenofemoral. Trata-se de um estudo prospectivo, controlado e randomizado realizado no ambulatório do Serviço de Cirurgia Vascular e Endovascular do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Os participantes foram submetidos à EEE preparada pelo método de Tessari. No grupo controle, a injeção foi realizada com uma agulha 18G enquanto que, no grupo alvo, foi utilizado um cateter angiográfico multipurpose 4 Fr., precedendo-se à tumescência salina anestésica no compartimento da VSM, e irrigação contínua do cateter com solução salina antes da injeção da espuma esclerosante. A flebectomia das tributárias varicosas foi realizada em todos os pacientes em nível ambulatorial sob anestesia local tumescente. RESULTADOS: A EEE com cateter angiográfico, precedida de tumescência salina anestésica, com uma única sessão terapêutica, apresentou taxa de sucesso completo superior ao grupo controle (80% versus 36%) com significância estatística (p = 0,012). Houve melhora na qualidade de vida em ambos os grupos. (p < 0,001). Não houve diferença estatística entre os grupos na taxa de complicações (p = 0,584). CONCLUSÕES: A EEE com cateter longo em VSM, precedida de tumescência ecoguiada é um método seguro e eficaz. Apresenta maior taxa de sucesso completo da veia alvo com uma sessão terapêutica em comparação à técnica com cateter curto / INTRODUCTION: Foam echoesclerotherapy is a minimally invasive method to treat varicose veins of the legs. Its main advantages are indication for patients with high surgical risk, early recovery after intervention and lower initial cost in comparison to other endovenous methods. However, the vein occlusion rate is variable, notably for the truncal venous axis with diameter greater than 6 mm. OBJECTIVES: To compare two techniques of echoesclerotherapy with 3% polidocanol foam for the incompetent great saphenous vein (GSV), having as primary outcome the full success rate with one treatment session and secondary outcomes the quality of life and the complication rates. PATIENTS AND METHODS: Selection of 50 patients with primary superficial varicose veins of the leg (clinical, etiologic, anatomic, pathophysiologic - CEAP - classification C3) and GSV incompetence (6-10 mm diameter) measured at 3 cm distal from the saphenofemoral junction. This was a prospective, controlled and randomized trial conducted on the outpatient clinic, Division of Vascular and Endovascular Surgery, University of São Paulo. Patients underwent foam echoesclerotherapy prepared according to the Tessari method. In control group, the injection was performed with an 18G needle whereas in target group, a multipurpose angiographic catheter 4 Fr. was used, preceded by saline anaesthetic tumescence in the GSV compartment, and continuous catheter flush with saline solution before the sclerosing foam delivery. Phlebectomy of the varicose tributaries was performed under local tumescent anaesthesia on outpatient setting. RESULTS: Foam echoesclerotherapy with the angiographic catheter, preceded by saline anaesthetic tumescence yielded complete success rate with a single treatment session higher than the control group (80% versus 36%) with statistical significance (p = 0.012). There was improvement in quality of life in both groups (p < 0.001). There was no statistical difference between the groups in complication rates (p=0.584). CONCLUSIONS: Sclerotherapy with the long catheter, preceded of ultrasound-guided tumescence in the GSV compartment, is a safe and effective method. It yielded higher full success rate of the target vein with a single treatment session in comparison to the short catheter technique

Objetivo: Comparar o desempenho de diferentes curvas de referência de crescimento fetal em gestações gemelares com insuficiência placentária grave. Método: Estudo retrospectivo envolvendo gestações gemelares (n=47), com fluxo diastólico zero ou reverso, no estudo dopplervelocimétrico da artéria umbilical de um dos fetos, e ambos os fetos vivos no momento do diagnóstico. Não foram incluídas gestações com anomalia fetal \"major\", síndrome de transfusão feto-fetal, ou de ordem maior. Em ambos os fetos (acometido, FA; e cogemelar, CG), as estimativas de peso fetal foram convertidas em escore zeta de acordo com os critérios de Hadlock, Liao e Araújo. As medidas de circunferência abdominal foram convertidas de acordo com as curvas de Hadlock, Liao, Araújo, Ong e STORK. A análise estatística foi realizada segundo modelos de equações de estimação generalizada. Resultados: A idade materna média foi 27,8 ± 7,4 anos, 24 (51%) pacientes eram primigestas, 12 (25,5%) apresentavam antecedentes clínicos significativos e 61,7% (n=29) eram monocoriônicas. A idade gestacional média no momento do diagnóstico da diástole zero ou reversa foi de 27,4 ± 4,7 semanas. A idade gestacional média do parto foi de 32,9 ± 2,9 semanas e o peso médio ao nascimento dos fetos acometidos foi de 1075 ± 469 g, e dos cogemelares, 1749 ± 544 g. No modelo investigado, foram preditores significativos do escore-zeta: sexo fetal (p < 0,001) e a interação sub-grupo (feto acometido/cogemelar) e critério (p < 0,001). As estimativas do escore zeta médio (erro padrão) para o peso fetal estimado segundo cada critério examinado foram Hadlock FA: -2.98 (0,18), CG: -1,16 (0,15), Liao FA: -2,89 (0,24), CG: -0,58 (0,19), Araújo FA: -3,05 (0,29), CG: - 0,75 (0,18). Para circunferência abdominal, Hadlock FA: -3,14 (0,26), CG: - 1,13 (0,19), Liao FA: -2,63 (0,27), CG: -0,42 (0,19), Araújo FA: -2,44 (0,22), CG: -0,71 (0,14), Ong FA: -3,36 (0,34), CG: -1,48 (0,23) e STORK FA: -2,36 (0,14), CG: -1,18 (0,10). Conclusão: Em gestações gemelares, com diástole zero ou reversa em um dos fetos, as curvas que melhor diferenciaram os fetos acometidos de seus cogemelares foram as curvas nacionais, publicadas por Liao et al. e Araújo et al / Objectives: To compare the performance of different fetal growth reference curves in twin pregnancies with severe placental insufficiency. Methods: Retrospective analysis of 47 twin pregnancies with absent or reverse end diastolic flow in the umbilical artery in one fetus, and both twins alive at diagnosis. Pregnancies with major fetal abnormality, twin-twin transfusion and higher order were not included. At each ultrasound evaluation, estimated fetal weight zeta-scores were calculated for both fetuses (abnormal Doppler, AD; co-twin, CT) according to the following criteria: Hadlock, Liao and Araújo. Abdominal circumference zeta-scores were calculated according to Hadlock, Liao, Araújo, Ong and STORK. Statistical analysis was performed with generalized estimating equation regression. Results: Mean maternal age was 27.8 ± 7.4 years, 24 (51%) women were primigravida, 12 (25.5%) had a previous clinical history and 29 (61.7%) were monochorionic. Gestational age at abnormal Doppler diagnosis was 27.4 ± 4.7 weeks. Gestational age at delivery was 32.9 ± 2.9 weeks and mean birthweight was 1075 ± 469 g for AD twin, and 1749 ± 544 g in CT group. Zeta-score values were significantly related to fetal sex (p < 0.001) and subgroup (abnormal Doppler/co-twin) versus criteria interaction (p < 0.001). Estimated fetal weight mean zeta-score (standard error) according to each criteria were: Hadlock AD: -2.98 (0.18), CT: -1.16 (0.15), Liao AD: -2.89 (0.24), CT: -0.58 (0.19), Araújo AD: -3.05 (0.29), CT: -0.75 (0.18). Values for abdominal circumference were: Hadlock AD: -3.14 (0.26), CT: -1.13 (0.19), Liao AD: -2.63 (0.27), CT: -0.42 (0.19), Araújo AD: -2.44 (0.22), CT: -0.71 (0.14), Ong AD: -3.36 (0.34), CT: -1.48 (0.23) and STORK AD: -2.36 (0.14), CT: -1.18 (0.10). Conclusion: In twin pregnancies with absent or reversed end diastolic flow in the umbilical artery of one fetus, affected fetuses and their co-twins are best differentiated by Liao et al. and Araújo et al. reference ranges