Predictive Role Of Neutrophil Gelatinase-Associated Lipocaline As An Early Marker For Kidney Injury In Patients With Diabetes Mellitus

Diabetic kidney disease (DKD) is a chronic complication of diabetes mellitus leading to increased cardiovascular morbidity and mortality, and a risk of developing an end-stage renal disease (ESRD). Diabetic nephropathy is a disease affecting mainly the glomerulus, however, a number of studies indicate the predictive role of tubulo-interstitial lesions in the development and the progression of diabetic nephropathy. Neutrophil gelatinase-associated lipocalin (NGAL) is one of the most promising tubular biomarkers in the diagnosis of kidney disease. The data in the literature determine NGAL as a marker with a good diagnostic profile in the diagnosis of DKD.  Neutrophil gelatinase-associated lipocalin values correlate with the progression of the albumin excretion, with the decrease in the glomerular filtration rate and with the severity of renal impairment.  Neutrophil gelatinase-associated lipocalin is defined as an early marker of DKD, which establishes the development of renal dysfunction before the increase in albumin excretion. The evaluated cut-off values demonstrate good to high efficacy of NGAL in discriminating DKD patients with normal albumin excretion from healthy individuals. Several studies have indicated NGAL as an indicator of DKD progression, stratifying the risk of developing ESRD, patients with diabetes with higher NGAL levels have a faster and earlier decline in renal function. However, NGAL is a modulator of insulin signalling and its levels are elevated in patients with diabetes without DKD. Elevated levels of NGAL may be the result of common concomitant diseases of diabetes—cardiovascular disease and urinary tract infections. Additional studies are needed to assess the clinical applicability of NGAL in the diagnosis of DKD

Tracing and comparing serum, specific, bone biomarkers in patients with secondary hyperparathyroidism

Bone and mineral disorders (BMDs) in chronic kidney disease (CKD) are increasingly being studied, and prophylaxis and treatment are conducted, but they still remain one of the most severe systemic illnesses in patients with CKD.In patients with end-stage CKD and secondary hyperparathyroidism, accompanying metabolic disorders of calcium and phosphorus homeostasis may lead to pathological changes in bone and blood vessels, which increase the risk of bone fractures and cardiovascular (CV) events. High levels of parathyroid hormone (PTH), calcium and phosphorus are associated with increased morbidity and mortality in dialysis patients.Dialysis treatment is a renal replacement method that continues the life of patients with CKD, temporarily improving existing bone pathology, but it more often accelerates its progression. Therefore, the symptoms, developmental and complications of BMD-CKD are demonstrated and manifested in patients with extracorporeal treatment.Treatment of BMD requires constant monitoring of Ca-P exchange, PTH, serum of Vitamin D levels and the protein bone markers - osteocalcin, bone alkaline phosphatase.Despite the systemic use of active metabolites of vitamin D, phosphate binders and calcimimetics, in many patients with secondary hyperparathyroidsm, inadequate biochemical control has been observed.In the Dialysis Clinic at St. Marina University Hospital, Varna, two groups of patients on hemodialysis (HD) and with CKD - 2/3 stage with secondary hyperparathyroidism, were followed and had their serum biomarker levels compared - PTH, bone alkaline phosphatase (BAP), osteocalcin, and vitamin D. The results showed statistically significant differences between the two groups in the investigated serum levels of the indicators

Tuberculosis as a potential pitfall on FDG PET/CT in patients with Hodgkin`s lymphoma - a case report

FDG-PET is an essential diagnostic tool in the management of Hodgkin's lymphoma (HD). However, a lot of benign conditions are well-known to present with high FDG uptake thus mimicking malignant activity. Tuberculosis (TBC) is an infection with known high FDG accumulation and should be suspected in patients with lymphoma and those treated with chemotherapy.CASE REPORT: We present a 19-year old female with mediastinal Hodgkins lymphoma who had discrete lung changes on presentation. After initial chemotherapy, patients status worsened, with CT scan showing complete resolution of the mediastinal mass along with progression in the lung. Patient was restaged and mediastinal and lung involvement was proven. Therapy was escalated with further worsening and newly found liver lesions. TBC was clinically suspected although not objectively proven. FDG PET scan revealed high activity infiltrative lung changes, diffuse pleural activity, active liver lesions and celiac lymph nodes. However, changes could not be addressed as malignant, due to TBC or to both. Pleural biopsy revealed TBC. Patient received anti-TBC treatment only. The follow-up FDG PET scan revealed almost complete resolution of all the changes consistent with complete remission of the lymphoma and good treatment response of TBC.CONCLUSION: Based on initial CT report we consider this case a coexistence of TBC and HD at initial presentation with further worsening rather than a newly-developed TBC on an immunosupressed ground. FDG PET is an excellent tool in HD management, but falsely positive results from TBC should be kept in mind, especially when lung in involved.Scripta Scientifica Medica 2013; 45(1): 82-84

The Comparison Of Automated Urine Analysis With Manual Microscopic Examination For Urinalysis

Увод: Уринният анализ е един от най-често извършваните в клиничната лаборатория. Той дава важна информация за заболявания на отделителната система. Микроскопското изследване на седимент отнема време и няма възможност за стандартизация.Цел: Целта на изследването е да се съпоставят резултатите за уринен седимент от автоматичен анализатор и микроскопски анализ.Материали и методи:Уринни проби (n = 92) бяха изследвани на уринен анализатор за определяне на уринен седимент FUS–100 и на камера на Fuchs-Rosenthal. Сравнени бяха резултатите за еритроцити и левкоцити.Резултати: За изследваната група уринни проби бяха изчислени: средна стойност за левкоцити за автоматичен анализатор 163 ±77/μl, а за левкоцити на микроскоп 201 ± 45/μl. Средната стойност за еритроцити на автоматичен анализатор е 47 ±48,5/μl, а за еритроцити на микроскоп 22 ± 13,5/μl.След статистически анализ на резултатите с T-test на Student (p < 0.05) се установи статистически значима разлика при изброяване на левкоцити (p = 0.04) и еритроцити (p = 0.00081) посредством двата изследвани метода.Обсъждане:Автоматизираните системи имат значение от гледна точка на стандартизация и бързина. Необходимото време за провеждане на микроскопско изследване на патологична проба урина, съдържаща голям брой клетки е около 20 минути. С производителност около 50 урини на час автоматичните анализатори успешно се използват за скрининг на пробите. Засичането на резултатите от тест лента и апаратния седимент е достатъчно на обучения лаборант да определи суспектните за неточен резултат проби, чиито брой клетки да бъде определен с последващо микроскопско изследване. Автоматичният анализатор оптимизира работния процес в клинично-лабораторната практика, като осигурява значително walk-away време за включване в други дейности.Изводи: FUS–100 разполага със софтуер за идентификация и високоспециализираната технология тип „изкуствен интелект“. Системата позволява автоматична калибрация и контрол на качеството. Методът позволява стандартизация и се характеризира с много добра възпроизводимост и точност.Introduction: Urinalysis is one of the most commonly performed tests in the clinical laboratory. It is an indicator of the status of urinary tract. Manual microscopic sediment examination is time-consuming and lacks standardization.Aim: In this study the results from manual microscopic examination and automated urine analysis were compared. Materials and Methods: A total of 94 urine samples were analyzed by Dirui FUS – 100 automatic urine sediment analyzer and by manual microscopic method using Fuchs – Rosenthal’s counting chamber. The results for leucocytes and erythrocytes were compared.Results: Within the tested urine samples the average value for leucocytes counted by the automated analyzer was calculated as 163 ± 77 / microl, for leucocytes counted using counting chamber – 201 ± 45 / microl.For erythrocytes counted by the automated analyzer the average value was calculated as 47 ± 48.5/microl and for the erythrocytes counted using counting chamber - 22 ± 13.5 / microl.Statistical analyses were performed by the T Student’s Test (p < 0.05) and statistically significant difference was determined for the leucocyte count (p = 0.04) and for the erythrocyte count (p = 0.00081) using both methods.Discussion: Automated systems are important in terms of standardization of measurement and speed of the analysis performance. The microscopic analysis of a pathological sample requires approximately 20 min. FUS – 100 Urine Sediment Analyzer is able to analyze 50 samples per hour. The automated analyzers are successfully used for screening urine samples. When combined with urine chemistry analysis the well trained staff can easily recognize the samples suspect for inaccurate result and to analyze them microscopically. The automated analyzers optimize the work process, providing significant amount of walk-away time for the laboratory staff.Conclusion: Dirui FUS – 100 uses artificial intelligence identification technique. The system performs automated calibration, provides standardization of the measurement and repeatability and accuracy of the analysis

Aldosterone And Renin - Indications For Testing And Pre-Analytical Requirements

Въведение: Според данни на СЗО хипертонията е най-често срещаното хронично заболяване, което причинява 7,5 милиона или 12,8% от всички смъртни случаи годишно. Централно място в регулирането на обмяната на соли и течности в организма заема ренин-ангиотензин-алдостероновата система (RAAS).Цели: Ренинът се изследва основно за откриване причината за увеличеното артериално налягане, при недостатъчен отговор на антихипертензивното лечение и ниски нива на калий в кръвта. Измерванията на алдостерон са предназначени за диагностика и лечение на първичен хипералдостеронизъм; резистентна хипертония, хипоалдостеронизъм, едематозни състояния и други състояния на електролитен дисбаланс. За оценка на РААС изследването на алдостерон се съчетава с определянето на плазмена ренинова активност и определяне на съотношението алдостерон/ренин.Материали и методи: Нивата на ренин и алдостерон в клинична лаборатория към УМБАЛ „Св. Марина“ се изследват с автоматичен имунохимичен анализатор LIASON®, DIASORIN, прилагащ технологиятa на хемилуминисцентен имунеоанализ (CLIA). Материал за изследване са ЕДТА плазма и 24-часова диурезна урина.Резултати: Референтните стойности за ренин и алдостерон зависят от положението на тялото при венепункцията, съдържанието на натрий в диетата, прием на медикаменти, физиологичното състояние на пациента – стрес и бременност. На резултатите се отразява приемът на кортикостероиди, естрогени, аспирин, кофеин, бета-блокери, диуретици, ACE-инхибитори. Референтните стойности за алдостерон в плазма са: 0,6-0,98 nmol/l в изправено положение и 0,03-0,65 nmol/l за легнало положение; алдостерон в урина – 1,19-28,1 µg/24 ч. Референтните стойности за ренин в плазма са: 4,4-46,1 u IU/ml в изправено положение, 2,8-39,9 u IU/ml – легнало положение.Заключение: Изследването на ренин и алдостерон се използва като скринингов тест за диагностика на първичен хипералдостеронизъм и високо артериално налягане. Резултатът в референтни граници не изключва наличието на заболяване и трябва да бъде интерпретиран съвместно с клиничната картина на пациента и с други диагностични процедури. За постигане на надеждни резултати е необходима прецизна техника и стриктно спазване на преданалитичните изисквания.Introduction: According to WHO data, high blood pressure is the most common chronic disease that causes 7.5 million or 12.8% of all deaths yearly on a global scale. The renin-angiotensin-aldosterone system (RAAS) plays a significant role in preserving hemodynamic stability in response to the loss of blood volume, salt and water.Aim: A blood renin test is usually ordered to detect the cause of increased blood pressure, insufficient response to antihypertensive therapy and low blood potassium levels. Indications for aldosterone measurements are intended for use in the diagnosis and treatment of primary aldosteronism, hypertension caused by primary aldosteronism, selective hypoaldosteronism, edematous states and other conditions of electrolyte imbalance. Since renin and aldosterone are so closely related, both substances are often tested together as aldosterone-to-renin ratio (ARR).Materials and Methods: The levels of renin and aldosterone are being tested in the Clinical Laboratory at the St. Marina University Hospital, with an automated immunochemical analyzer LIASON®, DIASORIN, which uses chemiluminescent immunoassay (CLIA) technology. For screening renin and aldosterone levels EDTA plasma and 24-hour urine collection are used.Results: Reference ranges of renin and aldosterone tests can be affected by body position when blood is drawn, salt intake, stress, pregnancy,variety of prescribed medications and supplements – corticosteroids, estrogens, caffeine, beta blockers, vasodilators, diuretics, ACE inhibitors. The normal value range for aldosterone in plasma is: 0.6-0.98 nmol/L for upright position, and 0.03-0.65 nmol/L – in a lying down position; aldosterone in the urine - 1.19-28.1 μg/24h. The normal value range for plasma renin is: 4.4-46.1 in IU/mL – upright position and 2.8-39.9 in IU/mL – in a lying down position.Conclusion: Measuring renin and aldosterone levels is used as a screening test for diagnosis and treatment of hyperaldosteronism and hypertension. A score within a reference range does not exclude the presence of a disease and it should be interpreted in conjunction with the patient's clinical picture and other diagnostic procedures. In order to achieve reliable results, precise technique and strict observance of the pre-analytical requirements are required

Serum homocysteine and high-sensitive C-reactive protein levels and cardiovascular disease in patients with diabetes mellitus type 2

PURPOSE: Hyperhomocysteinemia and hs-CRP are non-classical risk factors independently associated to the development of cardiovascular disease. The increased coronary heart disease (CHD) risk in subjects with type 2 diabetes mellitus (DMT2) can be in part explained by the classical risk factors like hypertension, hyperlipidemia and obesity. There is no sufficient data about the importance of homocysteine (Hcy) and hs-CRP levels in DMT2 patients without CHD in predicting the macroangiopathic complications. The aim of this study was to determine the association between plasma homocysteine and hs-CRP concentrations in DMT2 patients with and without CHD.MATERIAL AND METHODS: Fifty patients hospitalized in the Clinic of Endocrinology at St. Marina University Hospital of Varna were divided into three groups: group one, 20 DMT2 patients without any evidence of CHD; group two, 20 DMT2 patients with history of CHD and group three, 10 healthy controls matched to these groups in terms of age and classical risk factors for CHD.RESULTS: Serum hs-CRP concentrations were significantly higher in DMT2 patients than in healthy controls as well as in DMT2 patients with CHD than in CHD-free DMT2 ones. Serum Hcy concentrations were significantly higher in DMT2 patient with CHD than in controls. Both markers were elevated in group two presenting with the highest risk for CHD.Scripta Scientifica Medica 2013; 45(1): 58-61

Which rating system is better – qSOFA or SIRS?

IntroductionThe definitions of sepsis and septic shock were redefined in 2016. This study compares the performance of qSOFA with that of SIRS criteria for the diagnosis of sepsis and prediction of 30-day mortality.AimThe aim of this article is to assess the severity of the infection of patients using SIRS and qSOFA scales and to compare their specificity and predictive value. Materials and MethodsA prospective, non-interventional single-center clinical trial was conducted at St. Marina University Hospital in Varna. The sample included 87 patients with sepsis and septic shock. The criteria for inclusion in the study were laboratory constellation for systemic exposure; over 18 years of age; with or without co-morbidities; no malignancies. Pregnancy, neoplasia and the age of under 18 were the criteria for exclusion. Logistic regression was used to test the predictability of both scales. ROC curve analysis determined the sensitivity and specificity of SIRS and qSOFA.ResultsOur analysis showed that both SIRS and qSOFA are significant predictors of mortality of septic patients. The SIRS scale had a 2.050-fold probability of predicting the death of the patient (p = 0.004, 95% CI 1.255 - 3.349), whereas the qSOFA score was 2.581 times more likely to predict mortality in patients with sepsis and septic shock (p = 0.0001, 95% CI 1.557 - 4.279). Cut-off values for SIRS higher than 2.5 points showed 91% sensitivity and  60% specificity - (AUC 0.80, 95% CI - 0.712 - 0.907), whereas qSOFA scores greater than 1.5 points indicated sensitivity of 82.2% and  specificity of 70.3% (AUC 0.85, 95% CI 0 0.770 - 0.934).Conclusion SIRS and qSOFA criteria for early detection of sepsis are useful clinical tools for mortality reduction and predictability. 

Prognostic value of serum amyloid A protein compared with C-reactive protein in patients with influenza

Introduction: Acute phase response represents an increase in hepatic production of the so-called acute phase proteins (APP). Until now, C-reactive protein (CRP) has routinely been measured as an indication of bacterial infections. Serum amyloid A (SAA) is a novel marker. It is a more conservative protein for viral etiology of the disease. We analyzed the dynamic changes of SAA and CRP during influenza infection and evaluated the role of SAA as a significant marker for viral infections.Materials and Methods: We studied 31 patients with clinically suspected and serologically proved influenza, hospitalized in the Department of Infectious Diseases at St. Marina University Hospital, Varna. Serum levels of SAA and CRP were measured on admission and 4.23±1.03 days later by immunoturbidimetric assays, adapted on Olympus AU 400.Results: The mean serum concentrations of SAA during the acute stage were 168.92 mg/L and those of CRP were 48.08 mg/L. In the group of bacterial complications, such as bronchitis, sinusitis and otitis media, the SAA levels were 5- to 9-fold greater than CRP. Analyses of the second measurement showed a tendency of serum SAA to disappear more quickly than CRP - 52.11 mg/L vs. 16.71 mg/L.  Conclusion: SAA is more sensitive APP than CRP in viral infection settings. In cases of bacterial superinfections, serum SAA is more predominant than CRP, indicating the necessity of an antibiotic therapy. Prompt downgrading of SAA in sera correlates with auspicious prognosis could be used as an effective treatment monitoring.

Changes in the sera levels of amyloid A protein in the course of influenza, chickenpox and infectious mononucleosis

Introduction: Until now, there has been no routinely measured laboratory marker, which indicates acute inflammation from viral origin. According to some authors, the serum amyloid A (SAA) protein is of great importance in such circumstances.Aim: The aim of this article is to establish the clinical significance of SAA as a potential laboratory marker for viral infections.Materials and Methods: Sera samples from 93 subjects with different viral infections, including influenza (n=31), infectious mononucleosis (n=31), and chickenpox (n=31) were analyzed. Levels of SAA were prospectively measured by immunoturbidimetry, adapted on Olympus AU 400. Thirty healthy subjects were included in the control group.Results: In comparison with the control group, the levels of SAA were significantly higher, reaching a mean concentration of up to 180.80±199.87 mg/L. During convalescence, the levels decreased dramatically achieving a level of up to 31.29±83.42 mg/L. The highest concentrations were registered in the cases with different complications, such as secondary bacterial infections. In comparison with erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and leukocytes, SAA levels were statistically significant for minor inflammatory stimuli, such as viral infections are.Conclusion: SAA increases significantly in the course of different viral infections, such as influenza, infectious mononucleosis, and chickenpox. Early normalization of its levels correlates with full recovery, lack of complications and auspicious prognosis of the disease