Lupus anticoagulant (LA), anticardiolipin (aCL), and/or antiphospholipid (aPL) antibodies are the hallmarks of the antiphospholipid syndrome, characterized by widespread thrombosis. The syndrome has been described as primary or secondary... more
Lupus anticoagulant (LA), anticardiolipin (aCL), and/or antiphospholipid (aPL) antibodies are the hallmarks of the antiphospholipid syndrome, characterized by widespread thrombosis. The syndrome has been described as primary or secondary when aCL/aPL are the only classes of detectable autoantibodies or occur in the context of systemic lupus erythematosus (SLE) or SLE-like disease. However, since LA/aCL/aPL have been extensively looked for, it has become evident that they may also be detected in the absence of any clinical correlation with thrombosis. In particular, among SLE patients, these antibodies mean a high risk of thrombosis only in a small subset, sharing clinical features with primary antiphospholipid syndrome. As laboratory examination is still unable to distinguish between high-risk and non-high-risk antiphospholipid antibodies, it is crucial to have some reasonable criteria able to guide the day-to-day clinical practice. We attempt to trace the following guidelines: (1) distinguish between transient and persistent LA/aCL/aPL results; (2) do not forget the LA phenomenon in the era of aCL/aPL; (3) maintain a strict communication with the laboratory; (4) exclude other causes of primary coagulation abnormalities; (5) look at the time of appearance of LA/aCL/aPL with respect to thrombosis; (6) analyze any possible laboratory clue putatively useful to distinguish between 'rouge' and 'non-rouge' LA/aCL/aPL; (7) look for signs of widespread noninflammatory vasculopathy; (8) do not engage a war to the knife against LA/aCL/aPL by immunosuppressive therapies.
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The objective of this study was to look for the occurrence of catastrophic antiphospholipid syndromes (APS) and to try to detect discriminating factors for predicting a worse prognosis, related to Lupus anticoagulant (LA) and... more
The objective of this study was to look for the occurrence of catastrophic antiphospholipid syndromes (APS) and to try to detect discriminating factors for predicting a worse prognosis, related to Lupus anticoagulant (LA) and antiphospholipid antibodies (aPL), in systemic lupus erythematosus (SLE) with main renal involvement. Regression, recursive partition and logistic regression analyses were applied to our 80 SLE patients prospectively followed up since 1980. Immunologic and other laboratory parameters including beta 2-glycoprotein 1 dependence, resistance to activated protein C caused by a substitution on the coagulation factor V gene, induction of monocyte procoagulant activity. Regression studies demonstrated an overall worse prognosis in term of both thrombosis and death for the group of LA/aPL positive patients (33/80). However, recursive partition analysis was able to isolate a small high risk-subgroup (8/33) characterized by persistent LA/aPL antibodies positive result, widespread signs of noninflammatory vasculopathy (skin, brain, kidney) and renal pathology mimicking that of thrombotic microangiopathy or arteriolosclerosis, also in the absence of classic SLE-nephritis. Only in this subset, three catastrophic APS were recorded, while, in traditional SLE nephritis, even persistent LA/aPL positive results (sometimes after one previous thrombosis) did not seem to imply a particularly severe prognosis. All serologic criteria employed are unable to identify high-risk patients. We conclude that catastrophic APS is a rare event in renal SLE. Before more predictive serologic markers become available, a simple algorithm, dealing with clinical data and renal histologic patterns, may help physicians to identify putatively high risk-LA/aPL antibodies in SLE patients with main renal involvement. This ominous subset does not belong to the group of classic SLE-nephritis.
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Research Interests:
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Research Interests: Physiology, Research Methodology, Reproduction, Case Studies, Biology, and 22 moreBirth, Pregnancy, Humans, Fertility and Sterility, Female, Intracytoplasmic Sperm Injection, Ovulation Induction, Hormones, Male, Karyotyping, Clinical Sciences, Newborn Infant, Developed Countries, Adult, Public health systems and services research, The Endocrine System Function, Cesarean Section, Enzyme Linked Immunosorbent Assay, Estradiol, Follicle stimulating hormone, Live birth, and Oral Contraceptive(Birth, Pregnancy, Humans, Fertility and Sterility, Female, Intracytoplasmic Sperm Injection, Ovulation Induction, Hormones, Male, Karyotyping, Clinical Sciences, Newborn Infant, Developed Countries, Adult, Public health systems and services research, The Endocrine System Function, Cesarean Section, Enzyme Linked Immunosorbent Assay, Estradiol, Follicle stimulating hormone, Live birth, and Oral Contraceptive)
(Birth, Pregnancy, Humans, Fertility and Sterility, Female, Intracytoplasmic Sperm Injection, Ovulation Induction, Hormones, Male, Karyotyping, Clinical Sciences, Newborn Infant, Developed Countries, Adult, Public health systems and services research, The Endocrine System Function, Cesarean Section, Enzyme Linked Immunosorbent Assay, Estradiol, Follicle stimulating hormone, Live birth, and Oral Contraceptive)
Fibrinogen and elevated AER increase cardiovascular mortality, but few data are available in the type 2 diabetic population. We have conducted an 11-year follow-up study of the Casale Monferrato cohort to assess: (1) the long-term... more
Fibrinogen and elevated AER increase cardiovascular mortality, but few data are available in the type 2 diabetic population. We have conducted an 11-year follow-up study of the Casale Monferrato cohort to assess: (1) the long-term predictive role of AER independently of conventional risk factors; (2) the shape of its relationship with cardiovascular mortality; and (3) whether fibrinogen has a predictive effect independent of the increased cardiovascular risk associated with nephropathy. During the follow-up period (1991-2001) a population-based cohort of 1,565 patients was regularly examined, and measurements of HbA1c were centralised. Multivariate Cox proportional hazards modelling was employed to assess the role of fibrinogen and AER as predictors of all-cause and cardiovascular mortality, independently of baseline variables and individual cumulative average values of HbA1c during follow-up. In 10,890.2 person-years of observations, 685 deaths were identified, giving an all-cause mortality rate of 63.4 per 1,000 person-years (95% CI 58.8-68.3). In Cox regression analyses, the strongest predictor of cardiovascular mortality was macroalbuminuria (relative risk 2.18, 95% CI 1.62-2.94), which was mainly associated with a high risk of short-term mortality. No increased risk was evident until the upper microalbuminuric range of AER values. Plasma fibrinogen was also a major independent predictor, and its role was not modified by AER, or by the exclusion of subjects developing chronic renal failure or diabetic nephropathy during follow-up. The results indicate that: (1) AER is the main independent predictor of 11-year cardiovascular mortality; (2) this effect is mainly evident in the upper range of microalbuminuria and in macroalbuminuria; and (3) fibrinogen has an independent effect on cardiovascular mortality, but no synergistic effect with AER, suggesting that both endothelial dysfunction and chronic inflammation are involved in the excess cardiovascular mortality of type 2 diabetic patients.
Research Interests: Risk, Type 2 Diabetes, Cardiovascular Risk, Multivariate Analysis, Italy, and 26 moreFibrinogen, Humans, Cox Regression, Regression Analysis, Follow-up studies, Risk factors, Endothelial dysfunction, Diabetic Nephropathy, Clinical Sciences, Aged, Chronic Renal Failure, Middle Aged, Public health systems and services research, Time Factors, Cardiovascular Diseases, Biological markers, Risk Factors, Chronic Inflammation, Albuminuria, Type 2 Diabetes Mellitus, Proportional Hazards Models, Mortality rate, Cohort Studies, Cumulant, Relative Risk, and Synergistic effect(Fibrinogen, Humans, Cox Regression, Regression Analysis, Follow-up studies, Risk factors, Endothelial dysfunction, Diabetic Nephropathy, Clinical Sciences, Aged, Chronic Renal Failure, Middle Aged, Public health systems and services research, Time Factors, Cardiovascular Diseases, Biological markers, Risk Factors, Chronic Inflammation, Albuminuria, Type 2 Diabetes Mellitus, Proportional Hazards Models, Mortality rate, Cohort Studies, Cumulant, Relative Risk, and Synergistic effect)
(Fibrinogen, Humans, Cox Regression, Regression Analysis, Follow-up studies, Risk factors, Endothelial dysfunction, Diabetic Nephropathy, Clinical Sciences, Aged, Chronic Renal Failure, Middle Aged, Public health systems and services research, Time Factors, Cardiovascular Diseases, Biological markers, Risk Factors, Chronic Inflammation, Albuminuria, Type 2 Diabetes Mellitus, Proportional Hazards Models, Mortality rate, Cohort Studies, Cumulant, Relative Risk, and Synergistic effect)
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The aim of this study was to assess in an 11-year survival follow-up of a population-based cohort of type 2 diabetes the predictive role of World Health Organization-defined metabolic syndrome, independent of conventional cardiovascular... more
The aim of this study was to assess in an 11-year survival follow-up of a population-based cohort of type 2 diabetes the predictive role of World Health Organization-defined metabolic syndrome, independent of conventional cardiovascular risk factors. During the follow-up (1991-2001), 1,565 patients were regularly examined with centralized measurements of HbA(1c). The independent role of the metabolic syndrome as a predictor of all-cause and cardiovascular mortality was assessed with multivariate Cox proportional hazards modeling. At baseline, the prevalence of the metabolic syndrome was 75.6% (95% CI 73.6-77.9). Results are based on 685 deaths (520 with the metabolic syndrome and 165 without it) in 10,890.2 person-years of observations. With respect to subjects without the metabolic syndrome, those with the metabolic syndrome had a similar hazard ratio (HR) of cardiovascular mortality after adjustment for age, sex, smoking, total cholesterol level, and coronary heart disease. In contrast, relative to subjects with diabetes only, the HR of subjects with only one component of the syndrome was 2.92 (1.16-7.33), independent of other risk factors. We found that 1) the prevalence of the metabolic syndrome in a population-based cohort of type 2 diabetes is high (75.6%); 2) the metabolic syndrome is not a predictor of 11-year all-cause and cardiovascular mortality; and 3) more than twofold higher cardiovascular risk, independent of conventional risk factors, is evident in diabetic subjects with only one component of the syndrome compared with those with diabetes only. Categorizing type 2 diabetic subjects as having or not having the metabolic syndrome does not provide further prediction compared with the knowledge of its single components.
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The first sign of diabetic nephropathy is microalbuminuria, but its predictive role of progression to overt nephropathy in type 2 diabetes has not yet been clarified. The aims of this study were to assess during 7 years of follow-up the... more
The first sign of diabetic nephropathy is microalbuminuria, but its predictive role of progression to overt nephropathy in type 2 diabetes has not yet been clarified. The aims of this study were to assess during 7 years of follow-up the incidence rate of overt nephropathy and the predictive role of microalbuminuria and other baseline variables (blood pressure, lipids, fibrinogen, uric acid, smoking, and HbA(1c) cumulative average during follow-up). A prospective population-based study was performed in Casale Monferrato, Italy, including 1,253 type 2 diabetic patients recruited at baseline (1991-1992), 765 with normoalbuminuria (albumin excretion rate [AER] <20 microg/min) and 488 with microalbuminuria (AER 20-200 microg/min). All measurements were centralized. A nested case-control study within the cohort was performed, selecting four control subjects, frequency matched for age and attained individual time of follow-up with each case. Conditional regression analysis was performed to assess variables independently associated with risk of progression to overt nephropathy. Of 1,253 total patients, 1,103 (88.0%) were included in the follow-up examination (median 5.33 years); their age and duration of disease at baseline were 68.4 +/- 10.5 years and 10.4 +/- 6.6 years, respectively. Cases of overt nephropathy were 202, giving an incidence rate of 37.0/1,000 person-years (95% CI 32.3-42.6). In conditional logistic regression analyses, microalbuminuria provided a 42% increased risk with respect to normoalbuminuria (95% CI 0.98-2.06), independently of duration of diabetes, hypertension, and systolic blood pressure. Other variables independently associated with progression to overt nephropathy were HbA(1c) cumulative average (P = 0.002), apolipoprotein B (P = 0.013), fibrinogen (P = 0.02), and HDL cholesterol (P = 0.03). Of type 2 diabetic patients, 3.7% progress every year to overt nephropathy. Microalbuminuria is associated with a 42% increased risk of progression to overt nephropathy. Other independent predictors are HbA(1c), HDL cholesterol, apolipoprotein B, and fibrinogen.
Research Interests: Diabetes, Type 2 Diabetes, Fibrinogen, Prospective studies, Humans, and 15 moreHypertension, Smoking, Female, Male, Regression Analysis, Follow-up studies, Risk factors, Aged, Time Factors, Biological markers, Disease Progression, Risk Factors, Albuminuria, Type 2 Diabetes Mellitus, and Diabetes Care
Data on the incidence of end-stage renal disease (ESRD) and chronic renal failure from population-based studies in Caucasian type 2 diabetic patients are lacking. To provide such data, a population-based cohort of type 2 diabetic patients... more
Data on the incidence of end-stage renal disease (ESRD) and chronic renal failure from population-based studies in Caucasian type 2 diabetic patients are lacking. To provide such data, a population-based cohort of type 2 diabetic patients was identified in Casale Monferrato, Italy, and prospectively examined from 1991 to 2001. During the follow-up period, patients were regularly examined with centralized measurements of plasma creatinine and HbA(1c). Independent predictors of progression to renal events were identified with multivariate Cox proportional hazards modeling, with sex, age, and individual follow-up time as confounders. We followed 1,408 of 1,540 (91.4%) patients (average follow-up time 6.7 years, range 0.011-11.1); 10 new cases of ESRD and 72 of chronic renal failure (plasma values of creatinine >or=2.0 mg/dl) were identified, giving incidence rates/1,000 person-years of 1.04 (95% CI 0.56-1.94) and 7.63 (6.06-9.61), respectively. Cumulative risks for chronic renal failure adjusted for competing mortality were 6.1 and 9.3% after 20 and 30 years from diagnosis of diabetes, respectively. Incidence rates and cumulative risks of chronic renal failure defined by plasma creatinine values >1.5 mg/dl increased to 13.1/1,000 person-years, 8.6 and 14.8%, respectively. In Cox regression analysis, predictors of progression (after adjustment for confounders) were hypertension (P = 0.078), diastolic blood pressure (P = 0.034), BMI (P = 0.03), and albumin excretion rate (AER) (P < 0.0001). We provide evidence that the individual risk of ESRD and chronic renal failure is low. AER and diastolic blood pressure are independent predictors of progression. These findings underline the relevance of primary prevention to reduce the number of diabetic patients with ESRD.