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Role of Metabolomics in Biomarker Identification and Pattern Recognition Metabolomics research has increased significantly over recent years due to advances in analytical measurement technology and the advances in pattern recognition soft- ware enabling one to visualize changes in levels of hundreds or even thousands of Universal Free E-Book Store 174 7 Role of Metabolomics in Personalized Medicine chemicals simultaneously kemadrin 5mg lowest price medicine dosage chart. Multivariate metabolomic and proteomic data and time- series measurements can be combined to reveal protein-metabolite correlations generic 5mg kemadrin mastercard medications 10325. Different methods of multivariate statistical analysis can be explored for the inter- pretation of these data generic kemadrin 5mg online medicine 6 clinic. Biomarkers that are responsible for these different biological characteristics can easily be classified because of the optimized separation using independent compo- nents analysis and an integrated metabolite-protein dataset kemadrin 5mg otc medicine 6mp medication. Evidently, this kind of analysis depends strongly on the comprehensiveness and accuracy of the profiling method, in this case metabolite and protein detection. Assuming that the techniques will improve, more proteins and metabolites can be identified and accurately quanti- fied, the integrated analysis will have great promise. Validation of Biomarkers in Large-Scale Human Metabolomics Studies A strategy for data processing and biomarker validation has been described in a large metabolomics study that was performed on 600 plasma samples taken at four time points before and after a single intake of a high fat test meal by obese and lean subjects (Bijlsma et al. Such metabolomics studies require a careful ana- lytical and statistical protocol. A method combining several well-established statis- tical methods was developed for processing this large data set in order to detect small differences in metabolic profiles in combination with a large biological varia- tion. The strategy included data preprocessing, data analysis, and validation of sta- tistical models. Univariate plots of potential biomarkers were used to obtain insight in up- or down-regulation. Pharmacometabonomics A major factor underlying inter-individual variation in drug effects is variation in metabolic phenotype, which is influenced not only by genotype but also by environ- mental factors such as nutritional status, the gut microbiota, age, disease and the co- or pre-administration of other drugs. Thus, although genetic variation is clearly important, it seems unlikely that personalized drug therapy will be enabled for a wide range of major diseases using genomic knowledge alone. Metabolite patterns Universal Free E-Book Store Metabonomic Technologies for Toxicology Studies 175 that are characteristic of the individual can be used to diagnose diseases, predict an individual’s future illnesses, and their responses to treatments. The principle of pharmacometabonomics has been demonstrated in humans by showing a clear connection between an individual’s metabolic phenotype, in the form of a predose urinary metabolite profile, and the metabolic fate of a standard dose of the widely used analgesic acetaminophen (Clayton et al. The predose spectra were statistically analyzed in relation to drug metabolite excre- tion to detect predose biomarkers of drug fate and a human-gut microbiome come- tabolite predictor was identified. Thus, the investigators found that individuals having high predose urinary levels of p-cresol sulfate had low postdose urinary ratios of acetaminophen sulfate to acetaminophen glucuronide. They conclude that, in individuals with high bacterially mediated p-cresol generation, competitive O-sulfonation of p-cresol reduces the effective systemic capacity to sulfonate acet- aminophen. Given that acetaminophen is such a widely used and seemingly well- understood drug, this finding provides a clear demonstration of the immense potential and power of the pharmacometabonomic approach. However, many other sulfonation reactions are expected to be similarly affected by competition with p-cresol and these finding also has important implications for certain diseases as well as for the variable responses induced by many different drugs and xenobiotics. It is proposed that assessing the effects of microbiome activity should be an integral part of pharmaceutical development and of personalized health care. Furthermore, gut bacterial populations might be deliberately manipulated to improve drug effi- cacy and to reduce adverse drug reactions. Pharmacometabonomics could be used to preselect volunteers at key stages of the clinical trials. This would enable stratifi- cation of subjects into cohorts, which could minimize the risk of adverse events, or focus on those individuals with a characteristic disease phenotype for assessment of efficacy. Metabonomic Technologies for Toxicology Studies Metabonomics studies demonstrate its potential impact in the drug discovery pro- cess by enabling the incorporation of safety endpoints much earlier in the drug discovery process, reducing the likelihood (and cost) of later stage attrition. Global metabolic profiling (metabonomics/metabolomics) has shown particular promise in the area of toxicology and drug development. A metabolic profile need not be a comprehensive survey of composition, nor need it be completely resolved and assigned, although these are all desirable attributes. For the profile to be useful across a range of problems, however, it must be amenable to quantitative interpreta- tion and it should be relatively unbiased in its scope. A further requirement for the Universal Free E-Book Store 176 7 Role of Metabolomics in Personalized Medicine platform used to generate profiles is that the analytical variation introduced postcol- lection be less than the typical variation in the normal population of interest, so as not to reduce significantly the opportunity to detect treatment/group-related differ- ences. Fulfilling this condition is very dependent on the actual system and question in hand and is probably best tested in each new application. In both preclinical screening and mechanistic exploration, metabolic profiling can offer rapid, noninvasive toxicological information that is robust and reproduc- ible, with little or no added technical resources to existing studies in drug metabo- lism and toxicity. Extended into the assessment of efficacy and toxicity in the clinic, metabonomics may prove crucial in making personalized therapy and pharmacoge- nomics a reality. The company believes that it is possible to profile metabolic diseases before symptoms appear. Metabonomic testing is important in obesity/metabolic syndromes, in which several metabolic pathways interact to produce symptoms and could be an important guide to select diets and exercise programs tailored to metabolic states. It is considered desirable to establish a human “metabonome” parallel to human genome and proteome but it will be a formidable undertaking requiring analysis of at least half a million people. Some projects are examining metabonomic patterns in series of patients with metabolic syndromes and comparing them with normal peo- ple. Other studies are examining how a person’s unique metabonomic profile can be used as a guide to personalize diet and exercise regimens for obesity. It is now possible to measure hundreds or thousands of metabolites in small samples of biological fluids or tissues. This enables assessment of the metabolic component of nutritional phenotypes and will enable individualized dietary recom- mendations. The relation between diet and metabolomic profiles as well as between those profiles and health and disease needs to be established. Appropriate technolo- gies should be developed and that metabolic databases are constructed with the right inputs and organization. Moreover, social implications of these advances and plan for their appropriate utilization should be considered. Large-scale human metabolomics studies: a strategy for data (pre-) processing and validation. Pharmacometabonomic identification of a significant host-microbiome metabolic interaction affecting human drug metabolism. Universal Free E-Book Store References 177 Gieger C, Geistlinger L, Altmaier E, et al. Genetics meets metabolomics: a genome-wide associa- tion study of metabolite profiles in human serum. Universal Free E-Book Store Chapter 8 Non-genomic Factors in the Development of Personalized Medicine Introduction Besides genomics other omics, epigenomic and non-genomic factors and biotechnologies have contributed to the development of personalized medicine. Although personalized medicine is considered to be mostly based on pharma- cogenomics, a number of other factors that vary among individuals and should be considered are: • Identification of subpopulation of patients best suited for an existing drug • New drug design for a specific sub-population of patients • Use of an individual patient’s cells or tissues for biological therapies • Cytomics: analysis of disease at single cell level. Among biotechnologies, nanobiotechnology has made important contributions to the development of personalized medicine. They are attributed to circadian rhythms, which are endogenous self-sustained oscillations with a period of ~24 h. These rhythms persist under constant environmental conditions, demonstrating their endogenous nature.

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Mycobacterium tuberculosis infection in solid-organ transplant recipients: impact and implications for management kemadrin 5 mg online medicine pill identification. Trimethoprim-sulfamethoxazole as toxoplasmosis prophylaxis for heart transplant recipients purchase generic kemadrin on line in treatment. Nosocomial infections with vancomycin-resistant Enterococcus faecium in liver transplant recipients: risk factors for acquisition and mortality discount kemadrin 5mg on-line medicine used for uti. Vaccinations for adult solid-organ transplant recipients: current recommendations and protocols purchase kemadrin with amex symptoms 1dp5dt. Pretransplant renal dysfunction predicts poorer outcome in´ liver transplantation. Early allograft dysfunction after liver transplantation: a definition and predictors of outcome. National Institute of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database. Nutritional support after liver transplantation: a randomized prospective study [see comments]. Intraoperative hypothermia is an independent risk factor for early cytomegalovirus infection in liver transplant recipients. Leukocyte reduction during orthotopic liver trans- plantation and postoperative outcome: a pilot study. Kidney failure associated with liver transplantation or liver failure: the impact of continuous veno-venous hemofiltration. Role of epicardial pacing wire cultures in the diagnosis of poststernotomy mediastinitis. A blinded, long-term, randomized multicenter study of mycophenolate mofetil in cadaveric renal transplantation: results at three years. A prospective search for ocular lesions in hospitalized patients with significant bacteremia. Characteristics of discrepancies between clinical and autopsy diagnoses in the intensive care unit: a 5-year review. Staphylococcus aureus nasal colonization and association with infections in liver transplant recipients. The diagnosis of pneumonia in renal transplant recipients using invasive and noninvasive procedures. Legionellosis in a lung transplant recipient obscured by cytomegalovirus infection and Clostridium difficile colitis. Impact of bacterial and fungal donor organ contamination in lung, heart-lung, heart and liver transplantation. Infections caused by Legionella micdadei and Legionella pneumophila among renal transplant recipients. Isolation of Legionella pneumophila by centrifugation of shell vial cell cultures from multiple liver and lung abscesses. Use of terminal tap water filter systems for prevention of nosocomial legionellosis. Clinical presentation and outcome of tuberculosis in kidney, liver, and heart transplant recipients in Spain. Rhodococcus equi infection in transplant recipients: case report and review of the literature. Successful medical treatment of multiple brain abscesses due to Nocardia farcinica in a paediatric renal transplant recipient. Challenges in the diagnosis and management of Nocardia infections in lung transplant recipients. Nebulized amphotericin B prophylaxis for Aspergillus infection in lung transplantation: study of risk factors. Risk factors of invasive aspergillosis after heart transplantation: protective role of oral itraconazole prophylaxis. Invasive fungal infections in liver transplant recipients receiving tacrolimus as the primary immunosuppressive agent. Environmental surveillance and other control measures in the prevention of nosocomial fungal infections. Risk factors for invasive aspergillosis in solid-organ transplant recipients: a case-control study. Treatment of solid organ transplant patients with invasive fungal infections: should a combination of antifungal drugs be used? Opportunistic mycelial fungal infections in organ transplant recipients: emerging importance of non-Aspergillus mycelial fungi. Infections due to Scedosporium apiospermum and Scedosporium prolificans in transplant recipients: clinical characteristics and impact of antifungal agent therapy on outcome. Antifungal management practices and evolution of infection in organ transplant recipients with Cryptococcus neoformans infection. Allograft loss in renal transplant recipients with Cryptococcus neoformans associated immune reconstitution syndrome. Significance of the isolation of Candida species from respiratory samples in critically ill, non-neutropenic patients. Candida infection in a stent inserted for tracheal stenosis after heart lung transplantation. Candidal anastomotic infection in lung transplant recipients: successful treatment with a combination of systemic and inhaled antifungal agents. Prevalence and outcome of invasive fungal infections in 1,963 thoracic organ transplant recipients: a multicenter retrospective study. Management of herpes simplex virus type 1 pneumonia following liver transplantation. Acute adenoviral infection of a graft by serotype 35 following renal transplantation. Treatment of parainfluenza virus 3 pneumonia in a cardiac transplant recipient with intravenous ribavirin and methylprednisolone. Clinical impact of community-acquired respiratory viruses on bronchiolitis obliterans after lung transplant. Cell-mediated immune response to influenza vaccination in lung transplant recipients. Viral infections in immunocompromised patients: what’s new with respiratory viruses? Human metapneumovirus in lung transplant recipients and comparison to respiratory syncytial virus. Lower respiratory viral illnesses: improved diagnosis by molecular methods and clinical impact. Incidence and management of abdominal closure-related complications in adult intestinal transplantation. Effect of antibiotic prophylaxis on the risk of surgical site infection in orthotopic liver transplant. Surgical site infection in liver transplant recipients: impact of the type of perioperative prophylaxis.

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The patients had been seizure free for at least 24 h purchase 5 mg kemadrin with amex chi royal treatment, except in seven cases where the seizures were too frequent (seizure free for 4-20 h cheap kemadrin 5mg overnight delivery treatment definition, with a mean time of 10 h) kemadrin 5 mg otc medications on a plane. The patients were all closely observed for 10 min after tracer administration with no evidence of seizure during this time buy 5 mg kemadrin with visa treatment of shingles. The mean delay from seizure end to injection of the tracer was 86 ± 19 s (range 0-400 s). Sixty-four images were acquired with an acquisition time of 30 s per frame and an average of 70 000 counts per frame on a 64 x 64 matrix. Transaxial images were primarily obtained parallel to the long axis of the temporal lobe. The analysis was qualitative and an area was reported as abnormal if the increase or decrease of the tracer uptake was observed in at least two adjacent slices in comparison with the opposite temporal lobe. In two of them, lateralization differed from that obtained by the other methods and eventually the side of surgery. In two patients the hypoperfusion extended to the adjacent cortical areas, and in one case there was a contralateral cerebellar hypoper­ fusion. Another two cases demonstrated hypoperfusion of the temporal lobe extending to the adjacent cortical area, which corresponded to the eventual side of surgery (delay from seizure to injection was 70 and 400 s). Interictal hypoperfusion and ictal hyperperfusion in the temporal lobe corresponding to the eventual site of surgery was observed in six patients. In one of them, the interictal temporal hypoperfusion was associated with decreased ipsilateral parietal perfusion. The positive predictive value of combined ictal hyperperfusion and interictal hypoperfusion was 6/6 (100%). Ictal study reveals a markedly increased perfusion of the entire left temporal lobe. Ten patients were seizure free, four had nearly complete control of the seizure frequency (greater than 90% reduction in seizure frequency) and four had occasional simple partial seizures. For the successful excision of the epileptogenic focus, it is essential to obtain accurate pre-operative localization. It is therefore important to develop accurate, non-invasive methods of seizure focus localization. The reasons for these wide discrepancies may include the different popula­ tions of patients studied, the radiopharmaceutical used and the spatial resolution of the acquisition system. The degree of hypoperfusion seems to correlate inversely with the age of seizure onset [9]. When the tracer is administered in the post-ictal period, the sensitivity is lower, but seems to be higher than for interictal scans [9]. Consequently, better localization is obtained with ictal than with post-ictal studies and its sensitivity decreases with the time lag between seizure end and tracer injection [15]. During the seizure, it shows hyper- perfusion of the whole temporal lobe, up to 2 min post-ictally mesial hyperperfusion associated with ipsilateral lateral temporal lobe hypoperfusion, and hypoperfusion of the whole temporal lobe for the first few minutes after seizure onset [15]. Interictal hypoperfusion represents an area of dysfunction which may or may not be epileptogenic. However, when there is ictal hyperperfusion in the same focal area, it is highly suggestive of a seizure focus [15, 16]. It consists of two stages: initially it performs rotational and centring corrections in the coronal and transverse planes by maximizing two indices of bilateral hemispheric sym­ metry, and later it performs rotational correction in the sagittal plane from the automatic determination of the inclination angle of images in the sagittal plane. This is computed performing a line fit of the set of points of a curve that was defined by the inferior border of the encephalous in the image of the total sum of the sagittal planes. Using this value, and determining the orbito-meatal (O-M) position by a previous calibration study, the rotational correction in the sagittal plane is performed. In order to evaluate the algorithm, 20 patients were studied and a set of simulated symmetrical brain images with single and multiple lesions (software phantom) were examined. The relationship between the inclination angle of the volume and the O-M plane, computed in the calibration study, had a value of -8. The rotational and centring corrections showed satisfactory results, the rotational correction errors being less than 1. Este consta de dos etapas: en la primera se realiza la corrección de la orientación y centrado de los cortes en los planos coronal y transversal a partir de la maximización de dos índices de simetría inter­ hemisférica, y en la segunda se corrige la orientación en el plano sagital a partir de la deter­ minación automática del ángulo de inclinación de las imágenes en el plano sagital, calculado por el ajuste lineal de los puntos de una curva, que es definida por el borde inferior del encéfalo en la imagen formada por la superposición de los cortes en el plano sagital. Con este valor, y conociendo la posición del plano órbito meatal (O-M) a partir de un estudio de calibra­ ción realizado previamente, se hace la corrección por rotación en el plano sagital. Para la valoración de este método se estudió a 20 pacientes, y se examinó un juego de imágenes simuladas con lesiones únicas y múltiples (software phantom). La reorientación y centrado de las imágenes en los tres planos arrojó resultados satisfactorios, presentando un error menor que 1,4° en la reorientación, y menor que 0,5 pixeles en el centrado. La orientación y centrado de estos estudios tienen una importancia preponderante ya que permiten obtener niveles de cortes predeterminados que son comparados con patrones conocidos de perfusión, los cuales son utilizados como referencia para evaluar los resultados. La exactitud en el cálculo de índices relativos de perfusión interhemisférica a través de regiones de interés, también requiere de un adecuado centrado y alineamiento de las imágenes. Existen varios métodos empleados para garantizar una adecuada orientación y centrado de estas imágenes. Algunos de estos procedimientos consisten en posicionar la cabeza del paciente de tal forma que el plano orbito-meatal sea perpendicular al plano del detector y, otros, en reorientar las imágenes después de procesadas por “ software” de forma interactiva. Estos métodos son muy inexactos y tienen una gran dependencia de las habilidades y experiencias del operador, aunque en la actualidad se emplean sistemas con posicionamiento por láser con los que se logra una gran exactitud. Se adquireron 128 proyecciones de 15 s cada una, en formato de 64 X 64 y zoom de 1,14. La reconstrucción de los cortes transversales se realizó empleando el método de la retroproyección filtrada (filtro Butterworth 4/16) y fueron recons­ truidos cortes sagitales y coronales en un volumen de 64 x 64 x 64. Confección de los program as Para la reorientación y centrado de las imágenes se utilizó un conjunto de programas que ejecutan el realineamiento total del volumen. Orientación y centrado en los planos transversal y coronal En primer lugar se realiza el centrado del volumen y la reorientación en los planos transversal y coronal. El centrado inicial se efectúa tomando como base el centro geométrico del volumen. Posteriormente, el algoritmo asume una simetría grosera entre ambos hemisferios para determinar los valores óptimos de corrección de traslación y rotación a partir de la maximización de dos índices de similitud interhemisférica obtenidos empleando dos criterios. Este consiste en maximizar la suma de los cambios de signo en la imagen creada por la substrac­ ción de las imágenes que son comparadas. Calculando el número de cambios de signos de la resta de estas imágenes, se obtiene un índice de similitud entre ambos hemis­ ferios cuyo valor máximo se obtendrá cuando el volumen esté adecuadamente centrado y orientado en los planos sagital y coronal. El índice de similitud calculado estará en correspondencia con el número de pares de puntos simétricos que presentan diferencias no significativas. Este será máximo cuando el plano sagital medio coincida con el plano sagital medio del cerebro. Para la busqueda de este plano, empleando los dos criterios anteriormente expuestos, se calculan los máximos de estos índices de similitud entre diversas com­ binaciones de traslación y rotación de las imágenes. Orientación de las imágenes en el plano sagital La reorientación de las imágenes en el plano sagital se basa en calcular el ángulo de inclinación del volumen en este plano. Esto se logra a partir de una curva que se ajusta al borde inferior del encéfalo en el plano sagital, calculada de la imagen formada por la superposición de los cortes en este plano (Fig.

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First exclude haemoglobinuria and myoglobinuria since both of them can also cause positive dipstick test for haematuria kemadrin 5 mg discount symptoms pregnancy. In case of myoglobinuria buy kemadrin without prescription symptoms lymphoma, clinical examination may show manifestations of muscle disease and the examination of urine by immunoelectrophoresis may show myoglobin cheap 5mg kemadrin visa treatment plantar fasciitis. Examination of urine for proteinuria and casts (to diagnose glomerular disease) purchase genuine kemadrin online oxygenating treatment, pus cells and urine culture (for diagnosis of infection), Zeil-Nelson stain and specific media (for diagnosis of T. How to examine urine: We have to comment on the following items: - Volume/24 h - Specific gravity (osmolality) - Colour of urine - Dip stick examination of urine - Microscopic examination. Volume of urine: Changes in urine volume may be oliguria or polyuria: Polyuria: (Urine volume > 2500 ml/day) may occur with: - Diuretics - Excessive water intake (within the normal range). Oliguria with intrinsic renal disease: - Oliguric phase of acute tubular necrosis. Specific gravity: Specific gravity represents the amount of solids in urine: - Specific gravity is measured by urinometer or by another special complicated apparatus which is more perfect (osmometer). Colour: - Normal: umber yellow - Examples of colour changes of urine: • Red urine: with hematuria, myoglobinuria and haemoglobulinuria (with haemoglobinuria the colour is red brown). Dip stick examination of urine: - Dip stick is a plastic strip with squares of paper impregnated with enzymes which change in colour on exposure to target chemicals. It is mainly albumin and Tamm Horsfall protein which is synthesized by renal tubules. Haemoglobinuria: - Haemoglobin may be present in urine in haemoglubinuria or haematuria (differentiated by presence of R. Bacteruria: • To collect a urine sample one of the following methods should be used: - Cleaning of the area around the urethra and a midstream urine is collected. False low count may occur with high urine flow, antibiotic treatment or contaminated container. At the same time someone may wrongly give hypoglycaemic drugs which are dangerous in such cases so caution should be taken on diet and treatment of glycosuria. This is largely due to the following: 1- The fact that multiple environmental factors could be working together, 2- Difficulty in confirming and quantifying the exposure to a certain environmental toxin; and 3- The lack of specific clinical or pathologic presentation of different environmental toxin. The kidney is more prone to environmental toxins for the following reasons: 1- The kidney is the principal organ for excretion of different toxins; 2- High renal blood flow; 3- Extensive surface of endothelial contact with toxins; 4- Positive intraglomerular hydrostatic pressure; 5- The medullary counter-current multiplier system leading to more accumulation of toxic agents and their metabolites in the renal medulla. The environmentally-induced renal injury may be tubulo- interstitial, glomerular or combined. Tubulo-interstitial lesions may be in the form of acute tubular necrosis (such as exposure to high concentration of mercury) or chronic tubulointerstitial nephritis (such as chronic exposure to low doses of lead). Glomerular lesions may be due to direct toxicity (such as deposition of gold in basement membrane and silica in the mesangium) or immunologically-induced (for example immune complex disease in chronic exposure to hydrocarbons). Environmental chemicals with nephrotoxicity includes solvents, hydrocarbons, heavy metals and fungal toxins. Volatile Hydrocarbons (Organic Solvents) As Environmental Nephrotoxins Types of exposure include: • Ingestion or inhalation of carbon tetrachloride; • Intentional sniffing of cleaning fluid (toluene-containing glues, trichlorethylene, 1,1,1,-trichloroethane); • Suicide attempts by ingestion of tetralin; • Occupational exposure (inhalation of trichloroethylene, diesel fuel and toluene, paints, glue, degreasing solvents); • Washing hands and hair with diesel fuel; • Domestic solvent inhalation. Heavy Metals As Environmental Nephrotoxins These include lead, cadmium, mercury, uranium and arsenic. Moreover, therapeutic forms of gold, bismuth and platinum can cause nephrotoxicity. Silicon, beryllium, lithium, barium and selenium are not heavy metals (specific gravity <5) but may cause nephrotoxicity. Lead nephrotoxicity: Prior to the industrial revolution the normal total body burden of lead was 2mg. Exposure: a) Occupational: metal smelting workers, miners, storage battery workers, pottery makers, automanufacturers, ship builders, paint manufacturers and painting industry. Acute lead nephropathy: This may manifest as acute renal failure with Fanconi syndrome and systemic disease including abdominal colic, anorexia, vomiting, constipation, anaemia, peripheral neuropathy and encephalopathy. Lead containing inclusion bodies will be detected in renal tubular cells, urine, liver, neural tissue and osteoblasts. Chronic lead nephropathy: Histologically, it will appear as a slowly progressive tubulointerstitial nephritis. Clinically, this manifests as chronic renal failure, hypertension, hyperuricaemia and gout. These manifestations are associated with others, including gastrointestinal, haematologic and neurologic. In the hypertensive gouty patient with chronic renal failure and without stone disease, chelation test may detect an unrecognized lead exposure. Chronic lead nephropathy, especially if diagnosed and treated early could be arrested or its progression is retarded. Cadmium nephropathy: Source of exposure: Cadmium is a component of metal alloys, in the manufacture of electrical conductors, electroplating storage batteries, aircraft industries, as a by-product of iron smelting, as a pigment, in ceramics, glass, in plastic stabilizer, in photographic developer, rubber or dental prosthetics. Cadmium toxicity: The acute absorption of as little as 10 mg of dust or fumes will cause severe gastrointestinal symptoms; and 12 hours later, pulmonary oedema. Early renal manifestations are those of adult Fanconi syndrome, tubular proteinuria and renal tubular acidosis. Vitamin D and calcium may be of help for bone disease, but may aggravate renal disease (by more stone formation). Mercury nephrotoxicity: Mercury toxicity depends on its chemical form and route of administration. Elemental mercury is harmless when ingested but when its vapour is inhaled will be very toxic. Toxicity is usually caused by methyl, ethyl, or phenoxyethyl organic salts and the chloride salt. Acute mercury nephrotoxicity will manifest as acute renal failure due to acute tubular necrosis associated with erosive gastritis, haematemesis and melena. Arsenic nephrotoxicity: Elemental arsenic is not toxic, but the pentavalent, trivalent salts and arsine gas (Arsine) are very toxic. Radiation injury It may be defined as any somatic or genetic disruption of function or form caused by electromagnetic waves or accelerated particles. These could be ultraviolet radiation, microwave radiation, high intensity ultrasound and ionized radiation from natural or man made sources. Exposure: a) Medical: Staff or the public may be affected by a malfunction or during repair of machinery in radiotherapy departments. Patients subjected to radiotherapy may be affected and can be a source of irradiation to others. This could be through ingestion or inhalation of long-lived isotopes (such as radium and plutonium). Radiation Nephrotoxicity: a) Immediate: decreased renal blood flow and glomerular filtration rate. Infective (biological) environmental risk factors a) Parasitic: for example malaria, schistosoma and hydatid disease. Ochratoxins arise from fungus Aspergillus ochraceus, discovered in the mid 1960s during a search for new toxic substances from moulds.

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