Thesis (M.Sc. (Medical Sciences)) -- University of Limpopo, 2018 / Microalbuminuria (MA) is considered to be a strong and independent risk factor for cardiovascular disease (CVD), chronic kidney disease (CKD) and end-stage renal disease (ESRD). Cross sectional studies have indicated that microalbuminuria is also associated with cardiovascular risk factors such as dyslipidaemia and low grade inflammation. Hence, the aim of this study was to investigate the association of microalbuminuria with serum lipids [Total cholesterol (TC), Triglycerides (TG), High Density Lipoproteins Cholesterol (HDL-C), Low Density Lipoproteins Cholesterol (LDL-C), Lipoprotein a (Lp (a)] and inflammatory markers [C-reactive protein (CRP) and Interleukin-6 (IL-6)] in a rural black population. Methods: This is a cross-sectional study conducted in Dikgale Health and Demographic Surveillance System (HDSS) site and quantitative methods were used. The present study is part of a study titled “Prevention, control and integrated management of chronic diseases in a rural area, South Africa” conducted in the Department of Medical Sciences, University of Limpopo. In the above study blood samples were collected from 816 people aged 15 years and above. For the present study participants with HIV, macroalbuminuria, creatinine ≥170 μmol/land diabetes mellitus were excluded from the 816 people. Six hundred and two (602) participants fitted the inclusion criteria of the present study. Of the 602 participants 255 were men and 377 were women. From these participants, creatinine and albumin concentrations were measured in a morning spot urine sample and the albumin/creatinine ratio (ACR) was calculated. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured using OMRON M5-I. Serum lipids (TC, TG, HDL-C, and LDL-C) and glucose were determined using ILAB 300 plus. Lp (a) and hs-CRP were determined using IMMAGE 800 Immunochemistry System. Insulin and IL-6 were determined using ACCESS 2 Chemistry System. Data was analysed using SPSS version 22.0. Statistical tests used included Student T-test, ANCOVA, ANOVA, linear regression and logistic regression. Results: The levels of serum lipids and inflammatory markers in this study were similar in participants with and without microalbuminuria. In a linear regression model TG was the only lipid vi | P a g e parameter found to be associated with microalbuminuria (p = 0.018). Inflammatory markers were not associated with microalbuminuria. In a logistic regression model CRP and HDL-C showed negative association with microalbuminuria in men while in women no association was found. However men with a high CRP and a high TG were found to be more likely to have microalbuminuria (p = 0.007). Conclusion: A linear positive association was observed between microalbuminuria and TG in men and in women. The OR of having microalbuminuria was lower in participants with a high CRP, low HDL-C or in women with a high glucose. Women with a low HDL-C had higher OR of having MA and men with a high CRP and a high TG were found to be more likely to have microalbuminuria.

Les anomalies du tractus rénal et les troubles du spectre autistique caractérisent le syndrome 19q12 causé par la délétion hétérozygote du gène TSHZ3. Pour identifier des programmes développementaux TSHZ3-dépendants, nous avons comparé le transcriptome (RNA-seq) d’uretères et de reins mutants Tshz3 (KO) et sauvage (WT) d’embryons de souris au stade E12,5. Nous avons identifié des gènes exprimés de façon différentielle connus pour être impliqués dans le développement de l'uretère et/ou des reins, dont 38 ont des orthologues humains associés à des maladies rénales. Corrélativement, les reins E12,5 KO présentent une arborisation anormale de l’uretère.Dans les reins adultes, TSHZ3 est exprimé dans les cellules endothéliales glomérulaires. L'analyse morphologique de reins Tshz3+/lacZ (HET) révèle une diminution de la densité des glomérules et de l'épaisseur de la membrane basale glomérulaire ainsi qu'un phénotype d'effacement des pieds des podocytes. L’analyse du sang et de l'urine de souris adultes HET a permis d’établir des profils spécifiquement associés au génotype HET. En particulier, le protéome urinaire a identifié 33 biomarqueurs qui pourraient constituer la signature d'un processus pathologique. Par ailleurs, l'analyse du transcriptome des reins HET adultes montre un enrichissement pour des voies liées à l'inflammation.Ces résultats confirment le rôle précoce de Tshz3 dans l'uretère ainsi qu'une fonction de Tshz3 dans les reins embryonnaires. La présence de défauts structurels et fonctionnels dans les reins hétérozygotes adultes Tshz3 renforce l'idée que les souris HET modélisent le syndrome TSHZ3 humain. / Renal tract defects and autism spectrum disorder represent the phenotypic core of the 19q12 syndrome caused by heterozygote deletion of the TSHZ3 gene. To identify TSHZ3-dependent developmental programs, we performed a transcriptome analysis (RNA-seq) on E12.5 Tshz3 mutants (KO) and wild type (WT) control mouse ureters and kidneys. This analysis identified differentially expressed genes known to be involved in ureter and/or kidney development, among which 38 have human orthologues associated to renal tract diseases. Correlatively, we found that E12.5 Tshz3 KO kidneys display an abnormal ureteric branching morphogenesis.In adult kidneys, we showed that TSHZ3 is expressed in glomerular endothelial cells. Histological and transmission electron microscopy analysis showed a decreased glomerular density and thickness of the glomerular basement membrane as well as a foot process effacement phenotype in Tshz3+/lacZ (HET) kidneys. To evaluate renal function, we analysed blood and urine samples from HET and WT adult mice. Both analyses generated profiles that specifically associated with HET genotype. In particular, the urine proteome identified 33 biomarkers that might constitute a signature for a pathological process in HET kidneys. Note that transcriptome analysis of adult HET kidneys showed enrichment for inflammation-related pathways.These results support an early role for Tshz3 in the ureter as well as an unanticipated function for Tshz3 in E12.5 embryonic kidneys. The presence of structural and functional defects in Tshz3 heterozygous adult kidneys reinforces the idea that HET mice model the human TSHZ3 disorder.

Despite best available care, uncontrolled chronic kidney disease (CKD) - a complex disease that impacts millions in the United States, will eventually progress to end stage renal disease which is associated with high morbidity and mortality. New evidence suggests management of earlier stages of CKD is effective in delaying disease progression. This project evaluated the impact of a CKD class, led by a nephrology nurse practitioner, on preventing disease progression in advanced CKD patients with diabetes and hypertension. The purpose of the class was to validate the need for the advanced practice nurse (APN) in the care continuum of CKD. CKD education is a quality improvement project based on the chronic illness trajectory nursing model by Corbin and Strauss. Using a case-control method and a simple descriptive statistic to compare the mean values, retrospective data from 52 patients were analyzed. Twelve non-participating patients had a mean 7% increase in serum creatinine levels at the 1-year mark. Forty participating patients saw a mean decrease of 30% serum creatinine. With significant evidence suggesting that disease progression is delayed and renal function is improved in all study markers for patients who participated in a CKD education class led by a nephrology nurse practitioner and who received usual care - an argument can be made for updating the APN role in the continuum of care for those with CKD. The results may contribute to social change by providing improved access to quality care that addresses the socioeconomic devastation of end stage renal disease.

To see if aggressive diuresis in first twenty four hours is associated with a comparable number of total days in the hospital as compared to non-aggressive diuresis. In this retrospective cohort study, we compared the length of hospital stay of consecutive patients admitted in one year based on their diuresis during the first twenty-four hours of hospitalization: aggressive diuresis (group 1) i.e. > 2400mL versus non-aggressive diuresis (group 2) i.e. ≤ 2400mL urine output. Patients were excluded if in cardiogenic shock, had creatinine level above 3 mg/dL on admission, or on dialysis. A total of 194 patients were enrolled (29 in group 1 and 165 in group 2 respectively). The Kaplan-Meier estimate of the median cumulative proportion of patients still hospitalized for the group 1 was 4 days and in group 2 was 5 days (log-rank test; P=0.67). In univariate analysis, Cox PH regression showed unadjusted hazard rate of discharge from hospital was slightly higher in group 1 than group 2 but was statistically non-significant (HR=1.08; P=0.70). In multivariate Cox model analysis, creatinine at the time of admission when greater than 1.6mg/dL (P=0.75), LVEF (P= 0.14), total twenty-four hours dose of intravenous Furosemide given (P=0.98) and interaction between Furosemide dose and Creatinine level (P=0.79) were not significant predictor of hospital discharge. Adjusted hazard rate for discharge from hospital was 12% higher in group 1 than group 2 but still statistically non-significant (HR=1.12; P=0.60). Since the length of hospital stay is similar between two groups, we suggest the goal of diuresis to be less than 2400mL in first twenty-four hours to prevent excessive dehydration.

Chronic kidney disease (CKD) affects more than 30 million adults in the U.S. and is strongly associated with cardiovascular events and mortality. Venous thromboembolism (VTE) is the third leading vascular disease, affects up to 900,000 Americans each year and contributes to as many as 100,000 deaths annually. The relationship of CKD and VTE has been described in patients receiving dialysis, kidney transplants recipients and in nephrotic syndrome, however, data supporting the association of VTE in mild to moderate CKD is conflicted. The overall goal of this research was to study the association of CKD and VTE and to understand the mechanisms of this association. To accomplish this goal we studied participants of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, a nationally representative cohort of 30,239 blacks and whites in the U.S.. The first chapter provides a review of the state-of-the science on CKD and VTE and potential mechanisms for this association. We focus on factor VIII as a potential mediator of VTE risk in CKD by reviewing the biochemistry and epidemiology linking factor VIII and CKD. In Chapter 2, we use a cohort study design and a competing risk analysis to determine the risk of VTE with albuminuria (ACR) and with various equations for estimated glomerular filtration rate (eGFR). There was no association of ACR and VTE and the risk of VTE was similar among eGFR equations. Compared to a normal eGFR (>90 ml/min/1.73m2), eGFR < 45 ml/min/1.73m2 was associated with a two-fold risk of VTE. The association of eGFR and unprovoked VTE was similar to the association with provoked VTE. The population attributable fraction of CKD (eGFR<60 ml/min/1.73m2) was modest at 5%. In Chapter 3, we utilize a case-cohort study to determine if biomarkers of inflammation (C-reactive protein) and procoagulation (Factor VIII and D-dimer) attenuate the risk of VTE in CKD. These biomarkers were higher in lower kidney function and were also strongly associated with VTE. Adjustment for factor VIII fully attenuated the risk of VTE in CKD, thus factor VIII is a potential mediator of the association of CKD and VTE. We assessed whether lifestyle factors and medications mitigate the risk of VTE in those with and without CKD. Exercise frequency and use of statins were associated with reduced risk of VTE in the presence and absence of CKD, but normal BMI was associated with reduced VTE risk only in those without CKD. We conclude that CKD is a risk factor for VTE, and findings shed light on the mechanisms of this association. Interventions that might lower VTE risk in CKD patients include exercise and statin therapy, but not weight loss. Factor VIII is a potential mediator of VTE in CKD and deserves further study. We suggest several avenues for future research to explore the relationship of Factor VIII and CKD.

Chronic kidney disease (CKD) is a global health problem and efforts are needed to improve the care of individuals affected by the disease. A recent strategy for improving care within the healthcare system is patient engagement. Nurses and other health care clinicians can apply patient engagement into their clinical practice to improve the care they provide to their patients. Therefore, the purpose of this project was to increase the knowledge and awareness of patient engagement among clinicians who work with CKD patients. This quality improvement project used Lewin's force field analysis to analyze driving and restraining forces to help develop and implement strategies to develop an e-learning module. The project used practice-focused questions to determine if knowledge about patient engagement and the Shared End-Stage Renal Patients - Decision Making Tool could improve staff knowledge and awareness about patient engagement. A quantitative pretest, posttest approach was used to compare pretest scores to posttest scores after the e-learning module was viewed. Nine clinicians participated in the project study. Results showed that clinicians' knowledge and awareness about patient engagement increased from a mean pretest score of 5.22 to a mean posttest score of 6.22, (p = 0.08617). The sample of only 9 participants may have contributed to the lack of statistical significance after viewing the educational presentation. The e-learning module will provide positive social change as staff and students of renal programs learn about and apply the principles of patient engagement to their clinical practice.

Orientador: Luciano Tavares Angelo Cintra / Banca: Gustavo Sivieri de Araújo / Banca: Suely Regina Mogami Bomfim / Resumo: Objetivo: Este trabalho teve como objetivo verificar a influência da Insuficiência Renal Aguda (IRA) na severidade da periodontite apical (PA) em Ratos Wistar. Métodos: Foram utilizados sessenta e quatro ratos divididos em 4 grupos e 2 períodos de análise (n=8): Controle (C), IRA, PA e IRA+PA. A IRA foi induzida por meio de uma aplicação diária de Gentamicina (100 mg/Kg/dia) durante 8 dias, via intraperitoneal. A PA foi induzida pela exposição pulpar dos primeiros e segundos molares superiores e inferiores do lado direito. Após 15 e 30 dias da indução da PA, os animais foram anestesiados, a urina foi coletada para a urinálise e sedimentoscopia, e o sangue foi coletado para análise do hemograma, creatinina, proteína sérica e ureia. Em seguida, os animais foram eutanasiados, os rins coletados para análise histológica e as mandíbulas e maxilas removidas e processadas para análise histomorfométrica e imunohistoquímica para IL-6, IL-17, IL-23 e TNF-α. Resultados: Para urinálise, a quantidade de proteínas foi maior nos grupos PA, IRA e IRA+PA quando comparados ao controle, em ambos os períodos experimentais (p<0,05). Na sedimentoscopia, foram encontrados cilindros granulosos, fosfato amorfo e carbonato de cálcio nos grupos IRA e IRA+PA. No hemograma, o número de hemácias, hemoglobina e volume globular foram menores nos grupos IRA e IRA+PA em 15 e 30 dias comparados aos grupos C e PA (p<0,05); já o volume corpuscular médio foi menor no grupo IRA+PA no período de 15 dias, comparado a... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Objective: This study aimed to verify the influence of Acute Renal Failure (ARF) on the severity of apical periodontitis (AP) in Wistar rats. Methods: Sixty-four rats divided into 4 groups and 2 periods of analysis (n = 8) were used: Control (C), ARF, AP and ARF+AP. IRA was induced by daily application of Gentamicin (100 mg/kg/day) for 8 days,intraperitoneal route. AP was induced by the pulp exposure of the upper and lower right and first and second molars. After 15 and 30 days of AP induction, the animals were anesthetized, the urine was collected for urinalysis and sedimentation, and the blood was collected for hemogram, creatinine, serum protein and urea analysis. Afterwards, the animals were euthanized, the kidneys collected for histological analysis and the jaws and jaws removed and processed for histomorphometric and immunohistochemical analysis for IL-6, IL-17, IL-23 and TNF-α. Results: For urinalysis, the amount of protein was higher in the AP, ARF and ARF+AP groups when compared to the control, in both experimental periods (p <0.05). In the sedimentation, granular cylinders, amorphous phosphate and calcium carbonate were found in the ARF and ARF+AP groups. In the hemogram, the number of red blood cells, hemoglobin and globular volume were lower in the ARF and ARF+AP groups at 15 and 30 days compared to the C and AP groups (p <0.05); mean corpuscular volume was lower in the ARF+AP group in the 15-day period, compared to the other groups (p <0.05). Regarding the leukog... (Complete abstract click electronic access below) / Mestre

acase@tulane.edu

C3 glomerulopathy (C3G) encompasses a group of severe renal diseases characterized by “dominant C3” deposition in the renal glomerulus. Patients typically present as nephritic nephrotics, with hematuria, hypertension, heavy proteinuria and edema. Within ten years of diagnosis, 50% of affected patients progress to end-stage renal disease and require dialysis or renal transplantation. No treatment is available to halt disease progression and thus both disease recurrence and allograft loss are common after transplantation. Genetic studies of C3G have firmly implicated dysregulation of the alternative pathway (AP) of complement in disease pathogenesis. In addition to genetic factors, acquired factors like autoantibodies can also exaggerate AP activity in the circulation to cause C3G. Although AP dysregulation in the circulation (i.e. fluid-phase dysregulation) has been well studied in these patients, AP activity in the glomerular microenvironment is not well understood. In this body of work, we used MaxGel, an ex-vivo surrogate for the glomerular extracellular matrix, to study AP activity and regulation. We showed that C3 convertase can be assembled on MaxGel and elucidated the dynamics of its formation and decay in the presence of complement regulators. We confirm that on MaxGel factor H (fH) inhibits C3 convertase formation and accelerates its decay, while properdin has a stabilizing effect. We also show that the complement factor H-related proteins (FHRs) are vital to the regulation of AP activity. Consistent with our MaxGel data, CFHR gene-fusion events have been reported as genetic drivers of disease in a few familial cases of C3G. One such familial case in which we identified and characterized the rearrangement event results from a novel CFHR5-CFHR2 fusion gene. The fusion gene is translated into a circulating FHR-5/-2 protein that consists of the first two SCRs of FHR-5 followed by all four SCRs of FHR-2. The structural repetition of SCR1-2 followed by another SCR1-2 motif facilitates the formation of complex FHR-1, FHR-2 and FHR-5 multimers, which have enhanced affinity for C3b and by out-competing fH, lead to impaired C3 convertase regulation in the glomerular microenvironment. Finally, we tested gene therapy as a tool to rescue the disease phenotype and restore fluid-phase AP complement control in a mouse model of C3G (Cfh-/-/huCR1-Tg mice). Using the piggyBac transposon system, we introduced a construct derived from complement regulator 1 (CR1) into Cfh-/-/huCR1-Tg mice. Delivery of sCR1-AC via hydrodynamic tail vein injection provided constitutive circulatory expression of sCR1-AC, and in animals followed for 6 months, we found that long-term expression of this complement regulator rescued the renal phenotype. These results suggest that sCR1 may be a potential therapy for patients with this disease.

1,25-dihydroxyvitamin D3 (1,25(OH)2D3) has been shown to mediate the rapid, non-nuclear stimulation of calcium and phosphate transport in chick intestine through binding to a receptor localized in the basal lateral membrane. By using an antibody to the N-terminus of the membrane receptor, studies were undertaken to determine whether a comparable protein exists in kidney and brain, and whether it is present in a particular subcellular fraction. The first step was to establish fractionation protocols to separate subcellular organelles as judged by marker enzyme analyses. Differential centrifugation and Percoll gradient fractions were prepared from chick kidney and brain whole homogenates by two methods (method 1 and method 2). Protein and marker enzymes were analyzed in each fraction to determine the distribution of organelles. By method 1, the organelles were not adequately separated. By method 2, chick kidney and brain were found to have the same order of organelle distribution: In the post-nuclear pellet (P2), fraction 1 was found to be enriched for the lysosomal marker acid phosphatase; fractions 2-5 were found to be enriched for the mitochondrial marker succinate dehydrogenase; fraction 8 was found to be enriched for the Golgi marker α-D-mannosidase; and fraction 9 was found to be enriched for the plasma membrane marker Na+,K+ ATPase. In Percoll gradients of microsomal membranes prepared from the 100,000xg pellet (P3), fractions 1-3 contained the endoplasmic reticulum marker enzyme activity glucose-6-phosphatase. Subsequently, sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDSPAGE) and Western blots were performed using the antibody to 1,25(OH)2D3 receptors in chick intestinal basal lateral membrane. The areas of the bands were scanned by computer, and analyzed quantitatively. After establishing a suitable protein concentration for Western analysis, differential centrifugation and Percoll gradient fractions were analyzed. Finally, the specific binding of [3H]1,25(OH)2D3 was determined in Percoll gradient fractions to assess whether the receptor is functional. Plasma membrane 1,25(OH)2D3 receptors were found in both chick kidney and brain cells. Golgi membranes also were found to have receptor activity, perhaps since this organelle packages proteins for delivery to other membranes. In kidney, fraction P27 demonstrated a very high receptor activity, and [3H]1,25(OH)2D3 specific binding assays showed these membrane receptors are functional. Although this fraction lacks traditional marker enzyme activity, it may contain endocytic vesicles. The physiological function and the mechanism of action of plasma membrane receptors in these two tissues remain to be determined.