Volume 57, No. 3/2002(March)
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 Clinical Nephrology
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Originals
Pneumonia-associated acute glomerulonephritis
T. Srivastava, B.A. Warady and U.S. Alon
Abstract
T. Srivastava, B.A. Warady and U.S. Alon
Section of Nephrology, The Children?s Mercy Hospital, University of Missouri at Kansas City, Kansas City, USA
Objective: Post-infectious glomerulonephritis typically occurs 7 – 14 days after an infection. However, in
several children we observed acute glomerulonephritis (AGN) to develop concurrently with pneumonia. The objective of the study was to delineate the clinical course and outcome of pneumonia-associated AGN. Study design: The hospital database was searched from 1984 – 1999 for c+hildren admitted with both acute pneumonia and AGN, each diagnosis having been made within 72 hours of each other. Results: 11 boys, age 3.8 –12.7 years, were identified. Ten children had lobar pneumonia and 1 had an interstitial infiltrate. All responded to antibiotic therapy with resolution of fever and respiratory symptoms. Only 1 child developed an empyema. The mean ± SD hospital stay was 5.9 ± 3.9 days. All patients had an abnormal urinalysis with hematuria (gross hematuria in 5), proteinuria and cellular casts. At presentation, 7 children had a serum creatinine > 1.0 mg/dl and creatinine clearance £ 80 ml/min/1.73 m2; in all, serum creatinine returned to normal and the creatinine clearance was > 80 ml/ min/1.73 m2 on follow-up. Nine of the 11 children had a low serum complement C3, 3 of whom also had low complement C4. Anti-streptolysin-O (ASO) titers were elevated in all 10 children tested.Six children developed hypertension and received anti-hypertensive medications. Only 1
child was severely oliguric requiring peritoneal dialysis for 4 days. He underwent a
kidney biopsy, which showed acute proliferative glomerulonephritis without crescents.Neither a biopsy nor dialysis was performed in the other children. At follow-up, blood pressure, urinalysis and serum complements had normalized in the 9 children in whom follow-up was available. Conclusion: Children with pneumonia who are found to have abnormal urinalysis, hypertension, azotemia or oliguria should be evaluated for concomitant glomerulonephritis. In most children, pneumonia-associated AGN runs a benign course and has a good prognosis, however, in some short-term medical intervention may be necessary.
Originals
Bone involvement in idiopathic hypercalciuria
A.M. Misael da Silva, L.M. dos Reis, R.C. Pereira, E. Futata, C.T. Branco-Martins, I.L. Noronha, B.L. Wajchemberg and V. Jorgetti
Abstract
A.M. Misael da Silva, L.M. dos Reis, R.C. Pereira, E. Futata, C.T. Branco-Martins, I.L. Noronha, B.L. Wajchemberg and V. Jorgetti
1Nephrology Division, 2Immunology Division, and 3Endocrinology Division, University of São Paulo Medical School, São Paulo, Brazil
Background: To evaluate bone involvement in idiopathic hypercalciuria, 40 lithiasic patients and 10 controls were studied. Methods: According to urinary calcium excretion, patients were first classified as hypercalciuric (Hca, n = 22) and normocalciuric (Nca,n = 18). The Hca patients were then subclassified according to bone densitometry (BMD) as osteopenic (HcaO, n = 10) and non-osteopenic(HcaNO,
n = 12). Routine biochemistry, dietary records, bone histomorphometry, and cytokines (IL-1b, IL-6, and TNF) production
by peripheral blood mononuclear cell cultures were studied. Results: There were no differences in routine biochemistry between Hca and Nca groups
except for urinary calcium. Inadequate nutrition was observed in Hca group,showing high protein (80.9% of the patients), carbohydrate (76.2%) and sodium (90%) intake. Calcium intake was low in Hca (57%) and Nca (83%) groups. IL-6 and TNF were not different between the Hca and Nca groups. IL-1b levels were significantly high in both groups when compared to controls. IL-6 and TNF were higher in HcaO than Nca. BMD in femoral neck in HcaO was lower than in HcaNO and Nca groups. Eroded surface (ES/BS) increased in 91% of the Hca group and 36% had a mineralization defect. In the HcaO group serum PTH
correlated negatively with trabecular bone volume (BV/TV) and positively with ES/BS.
1,25(OH)2D3 levels correlated positively with osteoblastic surface.
Calcium intake correlated positively with BV/TV and inversely with ES/BS. A negative
correlation was observed between IL-6 levels and Z score of the femoral neck. Conclusion:Bone involvement was detected in a young population with nephrolithiasis demonstrating that a strict follow-up is necessary in order to control hypercalciuria.
Originals
Hypertension after renal transplantation and polymorphism of genes involved in essential hypertension: ACE, AGT, AT1R and ecNOS
A. Basset El-Essawy, P. Berthoux, S. Cécillon, C.Deprèle, D. Thibaudin, J.-P. De Filippis, E.Alamartine, and F. Berthoux
Abstract
A. Basset El-Essawy1,2, P. Berthoux1,2, S. Cécillon2, C.Deprèle1,2, D. Thibaudin1,2, J.-P. De Filippis1, E.Alamartine1,2 and F. Berthoux1,2
1Nephrology, Dialysis and Renal Transplantation Department, Hôpital Nord, CHU de Saint-Etienne, 2Research Group on Glomerulonephritides and Renal Transplantation, Faculty of Medicine, Saint-Etienne, France
Background: Arterial hypertension (HT), secondary to cyclosporine A (CsA) used as main immunosuppressive treatment in renal transplantation (RTx), is very frequent (70%), usually severe and explained mostly by vasoconstriction of the glomerular afferent arteriole with secondary sodium and water retention. Material and methods: In a retrospective study, we have analyzed 294 consecutive recipients receiving a first renal cadaveric allograft and all treated with CsA (the majority with triple therapy). We studied, by molecular biology, the polymorphism of genes previously implicated in essential HT such as: angiotensin-converting enzyme (ACE: II, ID and DD), angiotensinogen (AGT: MM, MT and TT), angiotensin II type 1 receptor (AT1-R: AA, AC and CC) and endothelial constitutive nitric oxide synthase (ecNOS: aa, ab and bb), and correlated the data to the prevalence and severity of post-Tx HT. This cohort included 195 (66%) males and 99 females with a mean age of 42 years at time of Tx. The presence and severity of post-Tx HT were indicated by initial persistent blood pressure over 140/90 mmHg with the need for at least one anti-hypertensive drug and by the number of anti-HT medications required to achieve its control. Results: The distribution of the specific alleles and genotypes for ACE, AGT, AT1-R, and ecNOS was not different in transplant recipients compared to 181 controls. At 5 years post-Tx, the prevalence of HT was 72% (169 out of 235) among functioning grafts. There was no significant difference for ACE, AGT, AT1R and ecNOS genotypes distribution between hypertensive vs non-HT recipients. The number of anti-hypertensive drugs prescribed was not different among ACE, AGT, and AT1-R genotypes. However, the a allele and the non-bb genotype (aa + ab) for ecNOS were significantly (p = 0.001) associated with a less severe HT, needing fewer anti-HT drugs. At 10 years post-Tx, the HT prevalence remained high 78% (67 out of 86) among functioning Tx. However, the limited numbers did not allow further correlation. Conclusions: This study produced mainly negative results except for ecNOS-a allele, which seems to protect against severe hypertension. The explanation remains speculative but probably relates to the known cyclosporine-induced upregulation of ecNOS gene and enzyme activity.
Originals
Dyspepsia and gastroparesis in chronic renal failure: the role of Helicobacter pylori
R. Schoonjans, B. Van Vlem, W. Vandamme, N. Van Heddeghem, H. Verdievel, R. Vanholder, N. Lameire and M. De Vos
Abstract
R. Schoonjans, B. Van Vlem, W. Vandamme, N. Van Heddeghem, H. Verdievel, R. Vanholder, N. Lameire and M. De Vos
1Department of Internal Medicine, Gastroenterology Division, and
2Department of Internal Medicine, Renal Division, Ghent University Hospital, Ghent, Belgium
Aims: Many patients with chronic renal failure have dyspeptic symptoms. In the present study, we assessed the Helicobacter pylori (Hp) status, dyspeptic symptoms and gastric emptying rates in uremic patients. The present study was undertaken to compare chronic renal failure patients not under dialysis therapy (predialysis), hemodialysis (HD) patients and peritoneal dialysis (PD) patients for these variables and to search for a possible causative role of Hp. Methods: We used a standardized questionnaire to assess dyspeptic symptoms. Gastric emptying rates were determined by the 13C-octanoic acid breath test. HD patients were examined outside a dialysis session, PD patients were examined with a ?full? abdomen. Specific Helicobacter pylori IgG was measured by a second-generation enzyme-linked immunosorbent assay. Results: Sixty-six HD patients, 58 predialytic patients and 28 PD patients were included. Prevalences of Hp infection were highest in HD patients (46.2%) and predialysis patients (42.3%) compared to PD patients (28.6%) (p < 0.02). On the contrary, the prevalence of dysmotility-like dyspepsia was higher in PD patients (67.9%) when compared to HD patients (33.3%) (p < 0.01) and predialytic patients (53.6%) (difference not significant). Neither dyspepsia nor delayed gastric emptying were related to the presence of Helicobacter pylori IgG antibodies. Conclusion: A positive Helicobacter status based on serology was not related to the presence of dyspepsia or gastroparesis in uremic patients, whether on dialysis therapy or not. Dyspeptic complaints as well as gastroparesis are most prevalent in patients on peritoneal dialysis. The physiopathological mechanisms and clinical impact of these findings merit further investigation.
Originals
Polycystic kidney disease at end-stage renal disease in the United States: patient characteristics and survival
K.C. Abbott and L.Y. Agodoa
Abstract
K.C. Abbott and L.Y. Agodoa
1Nephrology Service, Walter Reed Army Medical Center, Washington, D.C., and Uniformed Services University of the Health Sciences, Bethesda, MD, 2NIDDK, NIH, Bethesda, MD, USA
Background: The patient
characteristics and mortality associated with autosomal dominant polycystic kidney disease
have not been characterized for a national sample of end-stage renal disease (ESRD)
patients. Methods: 375,152 patients in the United States Renal Data System were
initiated on ESRD therapy (including patients who eventually received renal transplants)
between January 1, 1992 and June 30, 1997 and analyzed in an historical cohort study of
polycystic kidney disease. Results: Of the study population, 5,799 (1.5%) had
polycystic kidney disease. In logistic regression, polycystic kidney disease was
associated with Caucasian race (odds ratio 3.31, 95% CI, 3.09 – 3.54), women (1.10,
1.04 – 1.16), receipt of renal transplant (4.15, 3.87 – 4.45), peritoneal
dialysis (vs. hemodialysis, 1.37, 1.27 – 1.49), younger age, and more recent year of
first treatment for ESRD. Use of pre-dialysis EPO but not the level of serum hemoglobin at
initiation of ESRD was significantly higher in patients with polycystic kidney disease.
Patients with polycystic kidney disease had lower mortality compared to patients with
other causes of ESRD, but patients with polycystic kidney disease had a higher adjusted
risk of mortality associated with hemodialysis (vs. peritoneal dialysis) compared to
patients with other causes of ESRD (hazard ratio 1.40, 1.13 – 1.75). Conclusions:
Hematocrit at presentation to ESRD was not significantly different in patients with
polycystic kidney disease compared with patients with other causes of ESRD. Peritoneal
dialysis is a more frequent modality than hemodialysis in patients with polycystic kidney
disease, and patients with polycystic kidney disease had an adjusted survival benefit
associated with peritoneal dialysis, compared to patients with other causes of renal
disease.
Originals
Accuracy and clinical utility of dialysis dose measurement using online ionic dialysance
K.P. Katopodis and N.A. Hoenich
Abstract
K.P. Katopodis and N.A. Hoenich
1Department of Nephrology, School of Clinical Medical Sciences, Medical School, University of Newcastle upon Tyne, and Department of Renal Medicine, University Hospital of Ioannina, Greece, and 2Department of Nephrology, School of Clinical Medical Sciences, Medical School, University of Newcastle upon Tyne, Renal Research Laboratory, Renal Research Institute, New York, and Division of Nephrology and Hypertension, Beth Israel Medical Center, New York
Background: Statistical associations
between urea removal and survival have been described in a number of publications. Urea
removal during treatment may be quantified by the delivered dose of dialysis. Methods in
clinical use to measure delivered dose are retrospective and reliant on accurate blood
sampling. The new generation of single patient proportionating systems incorporate the
facility to automatically measure ionic dialysance throughout dialysis. Methods: In
a prospective study on 9 anuric patients with a stable dialysis prescription, we have
compared the agreement of the dose of dialysis determined from ionic dialysance (Dt/V)
with that derived from equilibriated Kt/V (eKt/V) and Kt/V measured by direct dialysis
quantification (Kt/VDDQ) using 2 types of hemodialysis membrane (hemophan and
low-flux polysulfone). The variability of the delivered dose over a 1-month period was
also determined. Results: Ionic dialysance was independent of membrane type. It was
comparable to that established for plasma urea water clearance for hemophan but lower for
polysulfone (p < 0.001). The mean (± SD) delivered dose of dialysis (Dt/V) was similar
for both membranes (1.18 ± 0.15 (hemophan) and 1.18 ± 0.11 (low-flux polysulfone)).
Bland Altman comparisons showed the limits of agreement between Dt/V and Kt/VDDQ
were ± 0.17 and for Dt/V compared with eKt/V ± 0.15. A 1-month measurement of Dt/V
demonstrated considerable treatment to treatment variability indicating that delivered
dose cannot be considered stable. Conclusion: The availability of online
measurement of ionic dialysance provides a step towards monitoring dialysis more closely
at the time of delivery, and its clinical application will ensure that a more constant
dialysis dose is delivered.
Originals
Lymphopenia in dialysis patients: a preliminary study indicating a possible role of apoptosis
M. Bhaskaran, R. Ranjan, H. Shah, J. Siu, R. Colvin, N. Radhakrishnan, K. Reddy, N. Franki, J.D. Wagner and P.C. Singhal
Abstract
M. Bhaskaran, R. Ranjan, H. Shah, J. Siu, R. Colvin, N. Radhakrishnan, K. Reddy, N. Franki, J.D. Wagner and P.C. Singhal
Division of Kidney Diseases and Hypertension, Long Island Jewish Medical Center and North Shore University Hospital, New York, NY, USA
Lymphopenia in dialysis patients
Lymphopenia is a common finding in dialysis patients. Since infection rate and mortality associated with infection are high in dialysis patients, lymphopenia may be one of the contributing factors. In the present study, we evaluated the mechanism responsible for lymphopenia in these patients. Lymphocytes isolated from dialysis patients showed increased apoptosis (p < 0.001) when compared to lymphocytes isolated from healthy subjects (healthy subjects, 0.5 ± 0.2% vs. dialysis patients, 8.8 ± 0.7% apoptotic cells/field). Sera from dialysis patients promoted lymphocyte apoptosis in a time- and dose-dependent manner. These sera also enhanced lymphocyte DNA fragmentation into multiple integers of 180 base pairs in the form of a ladder pattern. Cellulose acetate membranes promoted T cell apoptosis when compared to polysulfone membranes and to control. Cellulose acetate dialysis membranes also appear to promote lymphocyte FasL expression. Similarly, dialysis sera enhanced T cell Fas as well as FasL expression. Neither the cellulose acetate nor polysulfone membranes could induce FasL expression on B cells. Similarly, dialysis sera failed to induce FasL expression on B cells. On the other hand, anti-FasL antibodies attenuated dialysis sera-induced apoptosis in T as well as B cells. Interestingly, dialysis serum showed a 5-fold increase in FasL content when compared with control serum. These results suggest that dialysis-associated factors can induce autocrine death in T cells but the help of activated T cells is required to induce death in B cells.
Originals
Ultrasound changes of the carpal tunnel in patients receiving long-term hemodialysis: a cross-sectional and longitudinal study
T. Takahashi, A. Kato, N. Ikegaya, T. Takita, Y. Maruyama, A. Hishida and M. Takahashi
Abstract
T. Takahashi, A. Kato, N. Ikegaya, T. Takita, Y. Maruyama, A. Hishida and M. Takahashi
1Maruyama Hospital, 2First Department of Medicine and 3Orthopedics Surgery, Hamamatsu University School of Medicine and 4Shizuoka University, Hamamatsu, Shizuoka, Japan
Background: Carpal tunnel syndrome
(CTS) is one of the major problems of long-term hemodialysis (HD), but sometimes difficult
to distinguish from uremic or diabetic neuropathy by clinical symptoms. Patients and
methods: To evaluate the diagnosis of CTS more precisely, we examined the
ultrasonographic alterations of the carpal tunnel and tendons of 90 wrists from 45
patients undergoing HD for more than 5 years. We measured the thickness of the palmar
radiocarpal ligament (PRL), corresponding to the posterior wall of the carpal tunnel (CT),
and the width of the CT, and compared those values with sensory (SCV), motor conduction
velocity (MCV) of the median nerve and clinical symptoms. In addition, we longitudinally
measured CT and PRL in the same patients for 5 years, and compared ultrasonographic
changes and clinical parameters. Results: A linear positive relationship was found
between HD duration and PRL thickness (r = 0.43, p < 0.01) or CT width (r = 0.53, p
< 0.01). CT diameter was negatively correlated with MCV (r = –0.30, p < 0.01)
and SCV (r = –0.33, p < 0.04). PRL thickness was also inversely correlated with
MCV (r = –0.44, p < 0.01) and SCV (r = –0.46, p < 0.01) of the median
nerve, respectively. The wrists with clinical CTS and/or previous CTS surgery had
significantly greater CT and PRL values compared to patients without CTS (CT: 6.1 ± 0.2
vs. 8.0 ± 0.3 mm, p < 0.01; PRL: 1.9 ± 0.1 vs. 3.6 ± 0.2 mm, p < 0.01). There was
a significant increase in CT width from 6.2 ± 0.2 to 7.1 ± 0.2 mm (p < 0.01) and PRL
thickness from 2.4 ± 0.2 to 2.8 ± 0.2 mm (p < 0.01) during the 5-year observation,
respectively. PRL thickness was constantly increased at the rate of 0.4 mm during the
study. However, no significant association was found between the 5-year increases in CT
and PRL distance and age, gender, the prevalence of diabetes, or laboratory parameters
such as blood b2-microglobulin,
pentosidine and Kt/Vurea. Conclusion: Our data suggest that echographic evaluation
of the wrist tissue thickness was useful to assess the progression of CTS. Serial
measurements of the wrist by echography may be helpful to clarify the advance of
subclinical CTS in patients receiving long-term HD.
