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__NOTOC__
* Mixed Cryoglobulinemia is a combination of both types II and III.
* Mixed CGs is associated with following conditions:
** '''SLE (systemic lupus erythematous)'''
**  '''Sjögren's syndrome,'''
** '''HCV'''
** '''Lymphoproliferative disorders'''
* Al the above mentioned disorders can cause excessive production of B-cell which can further lead to selective expansion of Cryoglobulinemia producing B-cell clones.
* In HCV infected patients the HCV complexes such as HCV-IgG, HCV-lipoprotein cause B-cell hyper-proliferation through the CD81 leading to expansion of specific B-cell clones such as WA idiotype or V(H)1-69.
* HCV particles are often found in such patients' serum CG complexes, but, at the same time, CG development in hepatitis C infection does not directly require the HCV virion or its components [38]. In this sense, CG development may, in fact, reflect a normal, expected response to regulate immune complexes in states of chronic immune activation.
* Among patients with HCV infection, the number of circulating T cells with surface markers compatible with a suppressor phenotype may be a feature that differs between patients with cryoglobulinemic vasculitis and those with asymptomatic CG.
* This was illustrated in a study that compared the percentage of "regulatory" T cells in 69 patients with HCV infection who had symptomatic CG with others with asymptomatic HCV infection [39].
* The mean levels of regulatory T cells were significantly lower in those with symptomatic HCV-associated CG than asymptomatic subjects (2.6 versus 7.4 percent, respectively).
* Whether the diminished proportion of regulatory T cells plays a role in causing vasculitis is uncertain but warrants further exploration.


{{CMG}}; {{AE}} {{FT}}




==Overview==
=== Differentiating uremia from other diseases ===
 
Uremia and uremic encephalopathy must be differentiated from other diseases that cause [[personality changes]], altered level of [[consciousness]] and hand [[tremors]] ([[asterixis]]). The differentials include the following:<nowiki/><ref name="pmid20495225">{{cite journal| author=Meparidze MM, Kodua TE, Lashkhi KS| title=[Speech impairment predisposes to cognitive deterioration in hepatic encephalopathy]. | journal=Georgian Med News | year= 2010 | volume=  | issue= 181 | pages= 43-9 | pmid=20495225 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20495225  }} </ref><ref name="pmid25013309">{{cite journal| author=Kattimani S, Bharadwaj B| title=Clinical management of alcohol withdrawal: A systematic review. | journal=Ind Psychiatry J | year= 2013 | volume= 22 | issue= 2 | pages= 100-8 | pmid=25013309 | doi=10.4103/0972-6748.132914 | pmc=4085800 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25013309  }} </ref><ref name="pmid12813481">{{cite journal| author=Roldán J, Frauca C, Dueñas A| title=[Alcohol intoxication]. | journal=An Sist Sanit Navar | year= 2003 | volume= 26 Suppl 1 | issue=  | pages= 129-39 | pmid=12813481 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12813481  }} </ref><ref name="pmid21590619">{{cite journal| author=Seifter JL, Samuels MA| title=Uremic encephalopathy and other brain disorders associated with renal failure. | journal=Semin Neurol | year= 2011 | volume= 31 | issue= 2 | pages= 139-43 | pmid=21590619 | doi=10.1055/s-0031-1277984 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21590619  }} </ref><ref name="pmid6864698">{{cite journal| author=Handler CE, Perkin GD| title=Wernicke's encephalopathy. | journal=J R Soc Med | year= 1983 | volume= 76 | issue= 5 | pages= 339-42 | pmid=6864698 | doi= | pmc=1439130 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6864698  }} </ref><ref name="pmid23251840">{{cite journal| author=Kim Y, Kim JW| title=Toxic encephalopathy. | journal=Saf Health Work | year= 2012 | volume= 3 | issue= 4 | pages= 243-56 | pmid=23251840 | doi=10.5491/SHAW.2012.3.4.243 | pmc=3521923 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23251840 }} </ref><ref name="pmid2497395">{{cite journal| author=Hartmann A, Buttinger C, Rommel T, Czernicki Z, Trtinjiak F| title=Alteration of intracranial pressure, cerebral blood flow, autoregulation and carbondioxide-reactivity by hypotensive agents in baboons with intracranial hypertension. | journal=Neurochirurgia (Stuttg) | year= 1989 | volume= 32 | issue= 2 | pages= 37-43 | pmid=2497395 | doi=10.1055/s-2008-1053998 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2497395  }} </ref><ref name="pmid21590622">{{cite journal| author=Kumar N| title=Acute and subacute encephalopathies: deficiency states (nutritional). | journal=Semin Neurol | year= 2011 | volume= 31 | issue= 2 | pages= 169-83 | pmid=21590622 | doi=10.1055/s-0031-1277986 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21590622  }} </ref><ref name="pmid23035103">{{cite journal| author=Chiu GS, Chatterjee D, Darmody PT, Walsh JP, Meling DD, Johnson RW et al.| title=Hypoxia/reoxygenation impairs memory formation via adenosine-dependent activation of caspase 1. | journal=J Neurosci | year= 2012 | volume= 32 | issue= 40 | pages= 13945-55 | pmid=23035103 | doi=10.1523/JNEUROSCI.0704-12.2012 | pmc=3476834 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23035103  }} </ref><ref name="pmid15284663">{{cite journal| author=Peate I| title=An overview of meningitis: signs, symptoms, treatment and support. | journal=Br J Nurs | year= 2004 | volume= 13 | issue= 13 | pages= 796-801 | pmid=15284663 | doi=10.12968/bjon.2004.13.13.13501 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15284663  }} </ref><ref name="pmid25821643">{{cite journal| author=Abdelhafiz AH, Rodríguez-Mañas L, Morley JE, Sinclair AJ| title=Hypoglycemia in older people - a less well recognized risk factor for frailty. | journal=Aging Dis | year= 2015 | volume= 6 | issue= 2 | pages= 156-67 | pmid=25821643 | doi=10.14336/AD.2014.0330 | pmc=4365959 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25821643  }} </ref>
Mesenteric ischemia is a type of intestinal ischemia primarily affecting the small intestine. It is one of the life-threatening gastrointestinal vascular emergencies which requires prompt surgical/medical intervention depending upon the underlying cause.
{|
 
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
Common causes in the development of mesenteric ischemia can be divided into occlusive/non-occlusive, arterial or venous, localized/generalized and superficial or transmural.<ref name="pmid24160929">{{cite journal| author=Corcos O, Nuzzo A| title=Gastro-intestinal vascular emergencies. | journal=Best Pract Res Clin Gastroenterol | year= 2013 | volume= 27 | issue= 5 | pages= 709-25 | pmid=24160929 | doi=10.1016/j.bpg.2013.08.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24160929 }} </ref>
! rowspan="2" |Diseases
 
! colspan="3" |History and Symptoms
==Risk Factors==
! colspan="4" |Physical Examination
*Mesenteric ischemia can be caused by any factor that can compromise the blood supply to the affected organ; either by reducing the perfusion( low blood pressure or vasoconstriction) or by promoting the formation of thromboemboli(blood clots). It can be broadly classified as modifiable and non-modifiable.  
! colspan="3" |Laboratory Findings
===Common Risk Factors===
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
{| class="wikitable"
!Personality changes
!Risk factors
!Altered level of consciousness
!
!Hand tremors (asterixis)
!
!Slurred speech
|-
!Writing disturbances
| rowspan="13" |Occlusive
!Voice monotonous
| rowspan="7" |Embolic
!Impaired '''memory'''
|[[Atrial fibrillation]]
!Elevated blood ammonia
|-
!Hyponatremia
|[[Cardiac arrhythmia]]
!hypokalemia
|-
|[[Valvular heart disease]]
|-
|[[Infective endocarditis]]
|-
|Recent [[myocardial infarction]]
|-
|[[Ventricular aneurysm]]
|-
|Aortic atherosclerosis
|-
| rowspan="6" |Thrombotic
|Advanced age
|-
|Low cardiac output states
|-
|[[Peripheral arterial disease]]
|-
|-
|Traumatic injury
|'''Hepatic encephalopathy'''
| ++
| ++
| ++
|<nowiki>++</nowiki>
|<nowiki>++</nowiki>
|<nowiki>++</nowiki>
|<nowiki>++</nowiki>
|<nowiki>++</nowiki>
|<nowiki>++</nowiki>
|<nowiki>++</nowiki>
|-
|-
|Inherited thrombophilia-  
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Alcohol intoxication]]'''
* [[Factor V Leiden mutation|Factor V Leidin mutation]]
| style="background: #F5F5F5; padding: 5px;" | +
* [[Prothrombin G20210A mutation]]
| style="background: #F5F5F5; padding: 5px;" | +
* [[Protein S deficiency]]
| style="background: #F5F5F5; padding: 5px;" | -/+
 
| style="background: #F5F5F5; padding: 5px;" | ++
* [[Antithrombin III deficiency]]
| style="background: #F5F5F5; padding: 5px;" | +
* [[Activated protein C resistance]]
| style="background: #F5F5F5; padding: 5px;" | -
* Anti-phospholipid syndrome
| style="background: #F5F5F5; padding: 5px;" | +
* [[Myeloproliferative neoplasm|Myeloproliferative disorders(JAK2 V617F) mutation.]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -/+
|-
|-
|Acquired thrombophilia- malignancy, oral contraceptives intake.
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Alcohol withdrawal]]'''
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | ++
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -/+
|-
|-
| colspan="2" rowspan="6" |Non-occlusive
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Uremia]]'''
|Heart failure
| style="background: #F5F5F5; padding: 5px;" | ++
| style="background: #F5F5F5; padding: 5px;" | ++
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | ++
| style="background: #F5F5F5; padding: 5px;" |[[Hyperkalemia]]
|-
|-
|[[Aortic insufficiency]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Wernicke encephalopathy]]'''
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | ++
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
|-
|-
|[[Septic shock]]  
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Toxic encephalopathy]] from drugs'''
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | +
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -/+
|-
|-
|Vasoconstrictive drugs:
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Altered [[intracranial pressure]]'''
* [[Digoxin]]
| style="background: #F5F5F5; padding: 5px;" | +
* [[Alpha-adrenergic agonist|Alpha-adrenergic agonists]]
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
|-
|-
|Cocaine abuse or ergot poisoning
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Intoxication by chemical agents'''
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -/+
|-
|-
|[[Hemodialysis]]
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Malnutrition]]'''
|}
| style="background: #F5F5F5; padding: 5px;" | -/+
*Common risk factors in the development of mesenteric ischemia include:
| style="background: #F5F5F5; padding: 5px;" | -
**'''Non-modifiable causes'''**
| style="background: #F5F5F5; padding: 5px;" | -
***Age >60 years
| style="background: #F5F5F5; padding: 5px;" | -
***High cholesterol levels
| style="background: #F5F5F5; padding: 5px;" | -/+
***History of smoking
| style="background: #F5F5F5; padding: 5px;" | -
**'''Occlusive causes'''
| style="background: #F5F5F5; padding: 5px;" | -/+
***'''Embolic causes''':<ref name="pmid10917470">{{cite journal| author=Fitzgerald T, Kim D, Karakozis S, Alam H, Provido H, Kirkpatrick J| title=Visceral ischemia after cardiopulmonary bypass. | journal=Am Surg | year= 2000 | volume= 66 | issue= 7 | pages= 623-6 | pmid=10917470 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10917470  }} </ref>
| style="background: #F5F5F5; padding: 5px;" | -
***Atrial fibrillation
| style="background: #F5F5F5; padding: 5px;" | -/+
***Cardiac arrhythmias
| style="background: #F5F5F5; padding: 5px;" | -/+
***Valvular heart diseases
***Infective endocarditis
***Recent myocardial infarction
***Ventricular aneurysm
***Aortic atherosclerosis 
***Aortic aneurysm
**'''Thrombotic causes''':<ref name="pmid9746774">{{cite journal| author=Martinelli I, Mannucci PM, De Stefano V, Taioli E, Rossi V, Crosti F et al.| title=Different risks of thrombosis in four coagulation defects associated with inherited thrombophilia: a study of 150 families. | journal=Blood | year= 1998 | volume= 92 | issue= 7 | pages= 2353-8 | pmid=9746774 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9746774  }} </ref>
***Advanced age
***Low cardiac output states
***Traumatic injury
***Peripheral artery disease
*'''Non-occlusive causes:'''<ref name="pmid16476108">{{cite journal| author=Acosta S, Ogren M, Sternby NH, Bergqvist D, Björck M| title=Fatal nonocclusive mesenteric ischaemia: population-based incidence and risk factors. | journal=J Intern Med | year= 2006 | volume= 259 | issue= 3 | pages= 305-13 | pmid=16476108 | doi=10.1111/j.1365-2796.2006.01613.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16476108  }} </ref>
**[[Heart failure]]
**[[Aortic insufficiency]]
**[[Septic shock]]
**Vasoconstrictive drugs(e.g. [[Digoxin]], [[Alpha-adrenergic agonist|alpha-adrenergic agonists)]]
 
**[[Cocaine abuse]] or ergot poisoning
 
**[[Hemodialysis]]
 
===Less Common Risk Factors===
*Less common risk factors in the development of [disease name] include:
**[Risk factor 1]
**[Risk factor 2]
**[Risk factor 3]
 
===Causes===
Mesenteric ischemia may be caused by the processes that compromise the blood flow to the small intestines. Any factor that can compromise the blood supply to the affected organ; either by reducing the perfusion( low blood pressure or vasoconstriction) or by promoting the formation of thromboemboli(blood clots). It can be broadly classified as modifiable and non-modifiable.It can be classified according to the time course of onset, quality of symptoms and the degree to which the blood flow is compromised. The most commom cause of mesenteric ischemia is superior mesneteric artery occlusion.
*[[Arterial thrombosis]]
*[[Arterial embolism]]
*[[Venous thrombosis]]
*[[Non-occlusive ischemia]]
 
{| class="wikitable"
!Cause
!Incidence
!Risk factors
|-
|-
|Aterial embolism
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Hypoxic brain injury]]'''
|50-70%
| style="background: #F5F5F5; padding: 5px;" | -
|
| style="background: #F5F5F5; padding: 5px;" | -/+
* Arrhythmia
| style="background: #F5F5F5; padding: 5px;" | -
* Myocardial infarction
| style="background: #F5F5F5; padding: 5px;" | -/+
* Infective endocarditis
| style="background: #F5F5F5; padding: 5px;" | -/+
* Valvular heart diseases
| style="background: #F5F5F5; padding: 5px;" | -/+
* Ventricular aneurysms
| style="background: #F5F5F5; padding: 5px;" | -/+
* History of embolic events
| style="background: #F5F5F5; padding: 5px;" | -
* Recent angiography
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
|-
|-
|Arterial thrombosis
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Meningitis]] and [[encephalitis]]'''
|15-25%
| style="background: #F5F5F5; padding: 5px;" | -/+
|
| style="background: #F5F5F5; padding: 5px;" | -/+
* Advnaced age
| style="background: #F5F5F5; padding: 5px;" | -
* Prlonged hypotension
| style="background: #F5F5F5; padding: 5px;" | -/+
* Hypercoagulabilty states
| style="background: #F5F5F5; padding: 5px;" | +
* Estrogen
| style="background: #F5F5F5; padding: 5px;" | -
* Peripheral arterial disease
| style="background: #F5F5F5; padding: 5px;" | -
* Traumatic injury
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -/+
| style="background: #F5F5F5; padding: 5px;" | -
|-
|-
|Venous thrombosis
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''[[Hypoglycemia]]'''
|5%
| style="background: #F5F5F5; padding: 5px;" | -/+
|
| style="background: #F5F5F5; padding: 5px;" | -/+
* Right-sided heart failure
| style="background: #F5F5F5; padding: 5px;" | -
* Previous deep venous thrombosis
| style="background: #F5F5F5; padding: 5px;" | -/+
* Primary clotting disorder
| style="background: #F5F5F5; padding: 5px;" | -/+
* Pancreatitis
| style="background: #F5F5F5; padding: 5px;" | -
* Polycythemia
| style="background: #F5F5F5; padding: 5px;" | -
* Sickle cell anemia
| style="background: #F5F5F5; padding: 5px;" | -
* Recent abdominal surgery or infection
| style="background: #F5F5F5; padding: 5px;" | -/+
|-
| style="background: #F5F5F5; padding: 5px;" | -/+
|Non-occlusive ischemia
|20-30%
|
* Hypovolemia
* Low cardiac output states
* Vasoconstrictive drugs (Digoxin, alpha-adrernergic agonists)
* Septic schock
* Aortic insufficiency
* Cocaine abuse or ergot poisoning
|}
|}
Life-threatening Causes[edit | edit source]
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. There are no life-threatening causes of disease name, however complications resulting from untreated disease name is common.
Life-threatening causes of [symptom/manifestation] include [cause1], [cause2], and [cause3].
[Cause] is a life-threatening cause of [disease].
Common Causes[edit | edit source]
[Disease name] may be caused by:
==References==
{{Reflist|2}}
{{WH}}
{{WS}}
[[Category: (name of the system)]]
==References==

Latest revision as of 19:56, 1 June 2018

  • Mixed Cryoglobulinemia is a combination of both types II and III.
  • Mixed CGs is associated with following conditions:
    • SLE (systemic lupus erythematous)
    • Sjögren's syndrome,
    • HCV
    • Lymphoproliferative disorders
  • Al the above mentioned disorders can cause excessive production of B-cell which can further lead to selective expansion of Cryoglobulinemia producing B-cell clones.
  • In HCV infected patients the HCV complexes such as HCV-IgG, HCV-lipoprotein cause B-cell hyper-proliferation through the CD81 leading to expansion of specific B-cell clones such as WA idiotype or V(H)1-69.
  • HCV particles are often found in such patients' serum CG complexes, but, at the same time, CG development in hepatitis C infection does not directly require the HCV virion or its components [38]. In this sense, CG development may, in fact, reflect a normal, expected response to regulate immune complexes in states of chronic immune activation.
  • Among patients with HCV infection, the number of circulating T cells with surface markers compatible with a suppressor phenotype may be a feature that differs between patients with cryoglobulinemic vasculitis and those with asymptomatic CG.
  • This was illustrated in a study that compared the percentage of "regulatory" T cells in 69 patients with HCV infection who had symptomatic CG with others with asymptomatic HCV infection [39].
  • The mean levels of regulatory T cells were significantly lower in those with symptomatic HCV-associated CG than asymptomatic subjects (2.6 versus 7.4 percent, respectively).
  • Whether the diminished proportion of regulatory T cells plays a role in causing vasculitis is uncertain but warrants further exploration.


Differentiating uremia from other diseases

Uremia and uremic encephalopathy must be differentiated from other diseases that cause personality changes, altered level of consciousness and hand tremors (asterixis). The differentials include the following:[1][2][3][4][5][6][7][8][9][10][11]

Diseases History and Symptoms Physical Examination Laboratory Findings
Personality changes Altered level of consciousness Hand tremors (asterixis) Slurred speech Writing disturbances Voice monotonous Impaired memory Elevated blood ammonia Hyponatremia hypokalemia
Hepatic encephalopathy ++ ++ ++ ++ ++ ++ ++ ++ ++ ++
Alcohol intoxication + + -/+ ++ + - + - -/+ -/+
Alcohol withdrawal + + - ++ + - + - -/+ -/+
Uremia ++ ++ + -/+ -/+ -/+ - ++ Hyperkalemia
Wernicke encephalopathy + + -/+ + + + ++ - - -
Toxic encephalopathy from drugs + + -/+ -/+ + -/+ + + -/+ -/+
Altered intracranial pressure + -/+ - -/+ -/+ - -/+ - - -
Intoxication by chemical agents -/+ -/+ -/+ -/+ -/+ - - - -/+ -/+
Malnutrition -/+ - - - -/+ - -/+ - -/+ -/+
Hypoxic brain injury - -/+ - -/+ -/+ -/+ -/+ - - -
Meningitis and encephalitis -/+ -/+ - -/+ + - - - -/+ -
Hypoglycemia -/+ -/+ - -/+ -/+ - - - -/+ -/+
  1. ↑ Meparidze MM, Kodua TE, Lashkhi KS (2010). "[Speech impairment predisposes to cognitive deterioration in hepatic encephalopathy]". Georgian Med News (181): 43–9. PMID 20495225.
  2. ↑ Kattimani S, Bharadwaj B (2013). "Clinical management of alcohol withdrawal: A systematic review". Ind Psychiatry J. 22 (2): 100–8. doi:10.4103/0972-6748.132914. PMC 4085800. PMID 25013309.
  3. ↑ Roldán J, Frauca C, Dueñas A (2003). "[Alcohol intoxication]". An Sist Sanit Navar. 26 Suppl 1: 129–39. PMID 12813481.
  4. ↑ Seifter JL, Samuels MA (2011). "Uremic encephalopathy and other brain disorders associated with renal failure". Semin Neurol. 31 (2): 139–43. doi:10.1055/s-0031-1277984. PMID 21590619.
  5. ↑ Handler CE, Perkin GD (1983). "Wernicke's encephalopathy". J R Soc Med. 76 (5): 339–42. PMC 1439130. PMID 6864698.
  6. ↑ Kim Y, Kim JW (2012). "Toxic encephalopathy". Saf Health Work. 3 (4): 243–56. doi:10.5491/SHAW.2012.3.4.243. PMC 3521923. PMID 23251840.
  7. ↑ Hartmann A, Buttinger C, Rommel T, Czernicki Z, Trtinjiak F (1989). "Alteration of intracranial pressure, cerebral blood flow, autoregulation and carbondioxide-reactivity by hypotensive agents in baboons with intracranial hypertension". Neurochirurgia (Stuttg). 32 (2): 37–43. doi:10.1055/s-2008-1053998. PMID 2497395.
  8. ↑ Kumar N (2011). "Acute and subacute encephalopathies: deficiency states (nutritional)". Semin Neurol. 31 (2): 169–83. doi:10.1055/s-0031-1277986. PMID 21590622.
  9. ↑ Chiu GS, Chatterjee D, Darmody PT, Walsh JP, Meling DD, Johnson RW; et al. (2012). "Hypoxia/reoxygenation impairs memory formation via adenosine-dependent activation of caspase 1". J Neurosci. 32 (40): 13945–55. doi:10.1523/JNEUROSCI.0704-12.2012. PMC 3476834. PMID 23035103.
  10. ↑ Peate I (2004). "An overview of meningitis: signs, symptoms, treatment and support". Br J Nurs. 13 (13): 796–801. doi:10.12968/bjon.2004.13.13.13501. PMID 15284663.
  11. ↑ Abdelhafiz AH, Rodríguez-Mañas L, Morley JE, Sinclair AJ (2015). "Hypoglycemia in older people - a less well recognized risk factor for frailty". Aging Dis. 6 (2): 156–67. doi:10.14336/AD.2014.0330. PMC 4365959. PMID 25821643.
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