EUROMEDICA  Hanover 23-24  Mai 2011	Advanced methods of diagnosis, treatment and prophylactics
	European Academy of Natural Sciences, Hanover European Scientific Society, Hanover

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Research objective. To establish peculiarities of kidney affection clinical and morphological pictures of patients suffering from cryoglobulinemia along with chronic hepatitis C (CH-C) in order to facilitate diagnosing and assessment of prognosis and optimize treatment methods.

Materials and methods. Two groups of patients were examined: a group of 64 patients suffering from cryoglobulinemia and a group of 62 patients without cryoglobulinemia. Patients of both groups are comparable in terms of sex, age and disease duration. Liver biopsy was done to 63 patients, histologic activity index (HAI) and histologic sclerosis index (HSI) were determined according to the METAVIR scale.

Clinical pictures of 48 patients with cryoglobulinemic kidney affection were analyzed, 15 of these patients underwent morphological examination of kidney tissue which included semiquantitative estimation of activity (histologic activity index) and fibrosis degree (histologic sclerosis index) according to H.A. Austin (1983).

Results. The patients suffering from CH-C along with cryoglobulinemia had a wider range of systemic affections than the patients without cryoglobulinemia. More severe forms of skin affections (ulceronecrotic changes), joint affections (arthritis development), kidney affections (nephrotic syndrome, acute nephrotic syndrome, fast-evolving renal insufficiency) and nervous system affections (neuropathy with motor disturbances) were present only in patients with cryoglobulinemia, which allows to regard cryoglobulinemia as an indicator of poor prognosis. We have discovered an evidential direct correlation between cryocrit value (> 5%) and such phenomena as severity of systemic manifestations (of purpura), Meltzer triad, neuropathy, Raynaud’s phenomenon, kidney affections, which is correspondingly as follows: р < 0,01; р < 0,01; р < 0,01; р < 0,001; р < 0,001.

Analysis of liver biopsy material showed that patients with cryoglobulinemia had a more marked fibrosis (3 to 6 points) than patients without cryoglobulinemia; the difference has been proven (p < 0,01); most of the patients of the second group (80%) had a milder form of fibrosis (0 to 2 points).

Average age of 48 patients suffering from cryoglobulinemic glomerulonephritis (GN) was 43,9±12,2 years old, while duration of chronic hepatitis C from supposed contamination to beginning of kidney affection made up 197,05±18,5 (from 50 to 324) months.

15 patients underwent kidney biopsy, most of them (13 patients) were diagnosed with cryoglobulinemic mesangiocapillary glomerulonephritis, 2 of them – with mesangioproliferative glomerulonephritis.

Morphologic assessment of kidney affection severity showed that most patients with HCV-infection suffered from a more severe proliferative form of nephritis, i.e. mesangiocapillary glomerulonephritis (high degree of fibrosis - histologic sclerosis index equal to 17±1,02).

29 out of 48 patients (60,4%) suffering from GN with HCV-infection and cryoglobulinemia had a latent form of GN with a moderate uretic syndrome, 9 of them (18,6%) had a nephritic syndrome (NS), 10 of them (21,0%) – an acute nephritic syndrome.

Most of the patients were diagnosed with arterial hypertension – 29 out of 48 patients with a moderate uretic syndrome (average systolic blood pressure/diastolic blood pressure - 165,6±5,3/108,9±5,4 mm of mercury column), 9 patients with NS (systolic blood pressure/diastolic blood pressure - 162,5±13,15/97,5±7,5 mm of mercury column). 13 patients were diagnosed with creatinenemia (3,02±0,55 mg/dl), while 4 of them had a fast-evolving GN.

Conclusion. Treatment results analysis showed that in case of cryoglobulinemic vasculitis with severe kidney affection it is necessary to prescribe immunosuppressive therapy in combination with plasmapheresis or cryopheresis and afterwards – viricides. A new approach which implies use of rituximab may be preferable according to the results obtained so far, but for final conclusion further clinical testing is needed.

Persisting cryoglobulinemia should be viewed as a criterion for a serious diagnosis in patients with CH-C and an indication for antiviral therapy to prevent possible severe affections of organs, first of all kidney affections.