Volume 58, No. 1/2002(July)
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 Clinical Nephrology
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Original
Henoch-Schoenlein nephritis in adults – clinical features and outcomes in Finnish patients
V. Rauta, T. Törnroth and C. Grönhagen-Riska
Abstract
V. Rauta, T. Törnroth and C. Grönhagen-Riska
Department of Medicine, Division of Nephrology, Helsinki University Central Hospital, Helsinki, Finland
Background: Henoch-Schoenlein purpura (HSP) is a small vessel vasculitis that often involves the kidneys. It affects many more children than adults. Few studies on HSP nephritis (HSN) in adult patients have been reported. One aim of the study described here was to determine clinical features in adults diagnosed at a single center as suffering from HSN. Other aims were to record outcomes of the disease and factors associated with its progression. Methods: Between 1980 and 1995, 42 adults attending our clinic were diagnosed consecutively, by means of renal biopsy, as suffering from HSN. Data on 38 patients with a follow-up period of at least a year were subsequently analyzed to determine whether any clinical, laboratory or histopathological variable was associated with the progression of HSN. Results: The mean age of the patients on biopsy was 42.0 years (SD 16.5). Eighteen of the 38 patients were male. Eleven of the 38 patients had isolated hematuria as an indication for renal biopsy and 25 had Ccr ³ 85 ml/min on diagnosis. Eight patients exhibited progression of HSN, 3 to end-stage renal failure (ESRF), during a mean follow-up time of 6.1 years (SD 4.3). Renal survival 10 years after renal biopsy was 91%. No histopathological findings were associated with poor outcome. The only factor statistically significantly related to the progression of HSN was a level of proteinuria greater than 1.0 g/24 h (p < 0.05). Hypertension and level of renal function were not significant prognostic factors either, except in a subgroup of 25 patients with initially normal renal function on diagnosis (p < 0.05 in both). In this subgroup, lower serum albumin levels were also found to be predictive for the progression of HSN. Conclusions: HSN is rare in adults and outcomes are unpredictable. However, any adult with purpura and persistent urinary abnormalities should undergo renal biopsy to determine a diagnosis; all patients suffering from HSN should be carefully monitored to determine whether the condition progresses. Attention should be paid especially to the degree of proteinuria, and also to hypertension in early stages of the disease.Correspondence to:
Dr. C. Grönhagen-Riska, Huch, PB 341, FIN-00029, Finland
Email: carola.gronhagen-riska@hus.fi
Original
Sickle cell nephropathy at end-stage renal disease in the United States: patient characteristics and survival
K.C. Abbott, I.O. Hypolite and L.Y. Agodoa
Abstract
K.C. Abbott1, I.O. Hypolite2 and L.Y. Agodoa3
1Nephrology Service, Walter Reed Army Medical Center, Washington, DC, Uniformed Services University of the Health Sciences, Bethesda, MD, 2Office of Minority Health Research Coordination, NIDDK, NIH, Bethesda, MD, and 3National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, USA
Background: The patient characteristics, including age at presentation to end-stage renal disease (ESRD) and mortality associated with sickle cell nephropathy (SCN) have not been characterized for a national sample of patients. Methods: 375,152 patients in the United States Renal Data System were initiated on ESRD therapy between January 1, 1992 and June 30, 1997 and analyzed in an historical cohort study of SCN. Results: Of the study population, 397 (0.11%) had SCN, of whom 93% were African-American. The mean age at presentation to ESRD was 40.68 ± 14.00 years. SCN patients also had an independently increased risk of mortality (hazard ratio 1.52, 95% CI: 1.27 – 1.82) even after adjustment for placement on the renal transplant waiting list, diabetes, hematocrit, creatinine, and body mass index. However, when receipt of renal transplantation was also included in the model, SCN was no longer significant (p = 0.51, HR = 1.10, 95% CI: 0.82 – 1.48). SCN patients were much less likely to be placed on the renal transplant waiting list or receive renal transplants in comparison to age and race matched controls, and results of survival analysis were similar in this model. Conclusions: SCN patients were much less likely to be listed for or receive renal transplantation than other comparable patients with ESRD. SCN patients were at independently increased of mortality compared with other patients with ESRD, including those with diabetes, but this increased risk did not persist when models adjusted for their low rates of renal transplantation.Correspondence to:
K.C. Abbott, LTC, MC; Nephrology Service, Walter Reed Army Medical Center, Washington, DC 20307-5001, USA
Email: kevin.abbott@ na.amedd.army.mil
Original
Clinical aspects of renal transplantation in polycystic kidney disease
B. Stiasny, D. Ziebell, S. Graf, I.A. Hauser and B.D. Schulze
Abstract
B. Stiasny1, D. Ziebell1, S. Graf1, I.A. Hauser2 and B.D. Schulze1
1Department of Medicine 4, Nephrology, University Erlangen-Nürnberg, Nürnberg, and 2Department of Nephrology, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
Background: Autosomal dominant polycystic kidney disease (ADPKD) as a systemic disorder represents a special subgroup among patients with end-stage renal disease (ESRD). The different organ manifestations are potential risk factors for cardiovascular events or infections in the course after renal transplantation. Therefore, a long-term evaluation of ADPKD patients and of a control group was done. Patients and methods: 80 ADPKD patients were compared with 88 non-diabetic patients in a retrospective follow-up after renal transplantation. Patient and graft survival (1, 5 and 10 years after transplantation) as well as complications such as infections and cardiovascular events were evaluated. Results: A comparable overall transplant (1 year, 5 years, 10 years: 83%, 73%, 67% ADPKD vs. 84%, 70%, 51% controls) and patient survival rate (1 year, 5 years, 10 years: 96%, 84%, 73% ADPKD vs. 91%, 79%, 58% controls) was found in both groups. Infectious complications with the exception of urinary tract infections (UTIs: ADPKD 42.5% vs. 26%) were diagnosed in similar frequency in the graft recipients. ADPKD patients were significantly more affected by UTIs than their control group (p < 0.05) and tended to suffer more often from lethal infections (ADPKD 7 vs. controls 3), but without statistical significance. Cardiovascular events were not observed to be significantly different between both groups (ADPKD 3 vs. controls 4). An obvious difference was found in patient (p < 0.01) and transplant survival rates (p < 0.05) of male and female ADPKD patients. The female group showed a significantly better outcome. Conclusions: The overall patient and graft survival rates did not differ between the ADPKD and control groups. The better outcome of female ADPKD graft recipients compared to the male group may be related to a gender-dependent disease severity, possibly due to hormonal effects. As UTIs and lethal septicemia were the leading complications in ADPKD patients, a careful monitoring for infections is important in the post-transplant follow-up.Correspondence to:
Prof. Dr. B.D. Schulze; Medizinische Klinik 4, Universität Erlangen-Nürnberg, Breslauer Straße 201, D-90471 Nürnberg, Germany
Original
Association of b-fibrinogen and factor VII polymorphism with plasma fibrinogen and factor VII levels, and no association of PAI-1 polymorphism with plasma PAI-1 levels in hemodialysis patients
R. Ando, M. Doi, K. Yamauchi, Y. Chida, T. Ida, K. Endo, H. Yanagi and S. Tomura
Abstract
R. Ando1, M. Doi1, K. Yamauchi1, Y. Chida1, T. Ida1, K. Endo2, H. Yanagi2 and S. Tomura2
1Department of Internal Medicine, Nakano General Hospital, Tokyo, Japan, and 2Department of Medical Science and Welfare, University of Tsukuba, Tsukuba, Japan
Aims: Recent studies have stressed the roles of genetic factors on the plasma levels of hemostatic markers and on cardiovascular complications. We investigated the association of DNA polymorphisms for b-fibrinogen, factor VII, and PAI-1 with plasma levels of these factors and with ischemic heart disease (IHD) and cerebral infarction (CI) in patients undergoing hemodialysis (HD). Methods: b-fibrinogen G/A-455, factor VII R353Q and PAI-1 4G/5G polymorphisms were determined by PCR-RFLP in 149 HD patients and in 100 controls. The plasma levels of fibrinogen, factor VII and PAI-1 were also measured. Results: The allele frequencies and the genotype frequencies of these 3 polymorphisms were not different between HD patients and controls. In HD patients, plasma fibrinogen levels were significantly lower in the GG genotype than in the GA genotype, and plasma factor VII activity was significantly higher in the RR genotype than in the RQ genotype. Multiple regression analysis disclosed that CRP and b-fibrinogen polymorphism were the significant determinants of fibrinogen levels. Plasma PAI-1 levels were not different among the 3 genotypes. The frequency of the A-455 allele was significantly higher in HD patients with CI than in those without CI, and the genotype distribution for b-fibrinogen differed significantly between the 2 groups. Between the same 2 groups, however, significant differences were found neither in the frequency of the 353Q or 4G allele nor in the genotype distribution for factor VII and PAI-1. No significant differences in the frequency of the G-455, 353Q or 4G alleles, or in the genotype distribution for b-fibrinogen, factor VII and PAI-1 were observed between patients with IHD and those without IHD. Multiple logistic regression analysis demonstrated that neither polymorphism was associated with CI or IHD. Conclusions: In HD patients, b-fibrinogen and factor VII polymorphisms affected plasma levels of fibrinogen and factor VII, respectively. b-fibrinogen polymorphism was not an independent but a possible risk factor for CI in HD patients. Further study will be needed to confirm the precise role of b-fibrinogen polymorphisms in the pathogenesis of CI in HD patients.Correspondence to:
Dr. R. Ando; Department of Internal Medicine, Nakano General Hospital, 4-59-16, Chuo, Nakano-ku, Tokyo 164-8607, Japan
Email: rando@bd.mbn.or.jp
Original
Oxidized low density lipoprotein (Ox-LDL) as a marker of atherosclerosis in hemodialysis (HD) patients
T. Takenaka, K. Takahashi, T. Kobayashi, E. Oshima, S. Iwasaki and H. Suzuki
Abstract
T. Takenaka1, K. Takahashi1, T. Kobayashi1, E. Oshima1, S. Iwasaki1 and H. Suzuki2
1Shinjuku Suimei Clinic, Shinjuku, Tokyo, and 2Department of Medicine, Saitama Medical College, Iruma, Saitama, Japan
Aim: To characterize the relationship between oxidative stress and atherosclerosis in HD patients. Methods: Seventy-five HD patients were entered into the study. Ox-LDL was measured as a probe for peroxidation and compared to clinical atherosclerotic parameters. Prospective studies were also performed to assess the effects of vitamin E-bonded membrane on oxidative stress. Results: Elderly patients tended to show elevated Ox-LDL (a = 0.060 ± 0.021 ng/mg LDL protein/year, r = 0.35, p < 0.05). Levels of Ox-LDL in the patients with positive history for atherosclerotic diseases (3.1 ± 0.4 ng/mg LDL protein, n = 36) were higher than those with a negative history (1.6 ± 0.2, n = 39, p < 0.01). Furthermore, ankle/brachial pressure index was negatively correlated to Ox-LDL (a = –0.052 ± 0.012/ng/mg LDL protein, r = 0.42, p < 0.01). Application of vitamin E-bonded membrane for 10 months (–38 ± 11%, n = 14, p < 0.05), but not synthetic membrane, ameliorated Ox-LDL. Conclusions: Our results indicate that Ox-LDL is elevated in aged HD patients. In addition, the present data provide evidence that vitamin E-bonded dialyzers attenuate oxidative stress. Finally, our findings suggest that Ox-LDL correlates to the magnitude of peripheral arterial diseases in HD patients.Correspondence to:
Dr. H. Suzuki; Department of Medicine, Saitama Medical College, 38 Moro-hongo Moroyama, Iruma, Saitama 350-0495 Japan
Email: iromichi@ saitama-med.ac.jp
Original
The effects of nandrolone decanoate on nutritional parameters in hemodialysis patients
A. Barton Pai, C. Chretien and A.H. Lau
Abstract
A. Barton Pai1, C. Chretien2 and A.H. Lau1
1Department of Pharmacy Practice, and 2Section of Nephrology, University of Illinois at Chicago, Chicago, IL, USA
Aims: Malnutrition with hypoalbuminemia is an independent predictor of mortality in end-stage renal disease patients. Anabolic steroids reduce protein catabolism and therefore may improve nutritional parameters. This study was undertaken to determine the effects of the anabolic steroid nandrolone decanoate on the nutritional status of hemodialysis patients. Secondary endpoints were to examine the effects of androgen therapy on hematocrit and erythropoietin (EPO) dose. Patients and methods: Medical records of chronic hemodialysis patients who received nandrolone decanoate for greater than 30 days were reviewed. Data collected included: demographics, dose, frequency, duration of treatment and cumulative dose of nandrolone. Baseline albumin, transferrin, dry weight, phosphorus, creatinine, hematocrit and erythropoietin dose were obtained for comparison with values after treatment. Results: Of the 9 patients evaluated (mean ± SD: age 55 ± 28 years, 4/9 male), 2 patients received nandrolone doses of 25 mg intramuscularly (i.m.) every week, while the remaining 7 patients received 100 mg i.m. every 2 weeks. The mean ± SD duration of treatment was 96 ± 43 days, with a mean ± SD cumulative dose of 656 ± 371 mg. The mean ± SD baseline albumin was 2.9 ± 0.6 mg/dl which increased to 3.3 ± 0.4 mg/dl after treatment (p = 0.045). Dry weight increased from a mean ± SD of 64.4 ± 11.7 kg to 66.0 ± 10.9 kg after nandrolone therapy (p = 0.028). Mean ± SD hematocrit at baseline was 28.2 ± 4.5% and increased to 33.2 ± 5.1% (p = 0.033). The dose of EPO was reduced in 4 patients (44%) during nandrolone therapy. Conclusions: Nandrolone significantly improved markers of nutritional status in our hemodialysis patients. This therapy may also enhance the hematopoietic effects of EPO.Correspondence to:
Prof. Dr. A. Lau; University of Illinois at Chicago, College of Pharmacy, 833 South Wood Street, Chicago, IL 60612, USA
Email: alanlau@uic.edu
Original
Skeletal deposition of clodronate is related to parathyroid function and bone turnover in dialysis patients
H. Saha, I. Ala-Houhala, P. Ylitalo, T. Kleimola and A. Pasternack
Abstract
H. Saha1,2, I. Ala-Houhala2, P. Ylitalo1,2, T. Kleimola3 and A. Pasternack1,2
1Medical School, University of Tampere, 2Tampere University Hospital, Tampere, and 3Leiras Oy, Biomedical Research Center, Turku, Finland
Aims: Bisphosphonates inhibit osteoclastic bone resorption, and in the future, they may also have a role in the therapy of renal osteodystrophy. Our aim was to study whether the severity of hyperparathyroidism has an effect on the clearance of clodronate via routes other than dialysis or kidneys (non- renal, non-dialysis clearance, CLNRD), which most likely represents the deposition of the drug in the skeleton. Methods: We studied 31 dialysis patients (9 female/22 male, aged 28 – 79, median 58 years), 18 on hemodialyis (HD) and 13 on peritoneal dialysis (PD). HD patients were studied on a non-dialysis day. An intravenous infusion of 300 mg clodronate was given during 60 min at 8:00 a.m. Blood, urine and PD fluid samples were collected for 1 + 24 h, and pharmacokinetic parameters were calculated. Results: In PD patients, 7% of the infused drug was excreted into PD fluid within 24 h, and in those HD or PD patients with residual diuresis 11% was excreted via the kidneys. The highest CLNRD was seen in patients with the most severe hyperparathyroidism. There was a positive correlation between CLNRD and plasma intact PTH (r = 0.79, p < 0.001). CLNRD was also related to the serum levels of bone markers PINP (procollagen type I N-terminal propeptide, r = 0.81, p < 0.001), osteocalcin (r = 0.65, p < 0.001) and ICTP (type I collagen cross-linked telopeptide, r = 0.68, p < 0.001). However, even in the patients with normal PTH, more than one-third of the infused drug was taken up by bone. Conclusion: In dialysis patients, the skeletal deposition of clodronate is related to bone turnover being highest in severe hyperparathyroidism. However, even in the case of low turnover, the uptake of the drug in bone takes place in amounts that might be clinically significant.Correspondence to:
Dr. H. Saha; Medical School, University of Tampere, FIN-33014 Tampere, Finland
Email: heikki.saha@uta.fi
Original
Esophagogastroduodenoscopy in chronic hemodialysis patients: 2-year clinical experience in a renal unit
F. Fabbian, C. Catalano, V. Bordin, T. Balbi and D. Di Landro
Abstract
F. Fabbian1, C. Catalano1, V. Bordin1, T. Balbi2 and D. Di Landro1
1Renal and 2Pathology Unit, Monselice Hospital, Monselice, Padua, Italy
Introduction: Upper gastrointestinal (UGI) disorders are frequent in uremic patients and esophagogastroduodenoscopy (OGD) is an important investigation for their management. Subjects and methods: From January 1, 1997 to December 31, 1998, 57 endoscopies were performed in 96 hemodialysis patients (aged 65 ± 12 years, 68 M, 28 F, dialysis duration 51 ± 58 months) chronically treated in our unit in that period. The reasons for prescribing OGD were: anemia, after exclusion of poor response to EPO, in 26 patients (mean decrease in hemoglobin (Hb) levels 2.6 ± 1.3 g/dl: the reference Hb level was the mean value measured before Hb decrease), dyspepsia in 11 and in preparation for renal transplantation in 20 patients. Twelve patients were diabetics, 24 smokers, 41 alcohol drinkers, 13 had hepatitis B or C, 6 were non-steroidal anti-inflammatory drugs (NSAIDs) abusers for bone pain and 21 were taking H2 receptor antagonists or proton-pump inhibitors chronically. Multiple biopsies of gastric mucosa were performed in 38 patients. Results: Endoscopy revealed normal mucosa in 17.5% of cases, whilst chronic gastritis was diagnosed in 30%. Chronic gastritis was also the commonest microscopic abnormality diagnosed in 71.5% of biopsies. Anemic and non-anemic patients were matched and the 2 groups did not show significant differences in endoscopic findings and histological appearance. Thirteen patients had Helicobacter pylori (HP) infection demonstrated by biopsy specimen examination and were treated by metronidazole, clarithromycin and omeprazole. A logistic regression analysis was carried out in all subjects, considering the decrement in Hb as a dependent variable and demographic and clinical characteristics as independent variables. The analysis demonstrates that age (odds ratio 1.05; p < 0.05), NSAIDs abuse (odds ratio 15.6; p < 0.05) and HP infection (odds ratio 16.7; p < 0.01) were independently related to Hb decrease. Conclusions: In our experience, non-EPO-related anemia and dyspepsia are frequent features in hemodialysis patients. OGD is frequently requested (30% of patients/year) and 83% of patients investigated had abnormal UGI mucosa. Underlying mucosal inflammation might promote UGI bleeding but is not likely to be the cause, making it a necessary superimposed factor such as NSAIDs or HP infection.Correspondence to:
Dr. F. Fabbian; Renal Unit, Monselice Hospital, Via Marconi 19, I-35043 Monselice, Padua, Italy
Email: hrfabbia@tin.it
Case Report
A late complication of spousal kidney donation
S.A. Jayawardene, A. Mohsin, J.E. Scoble and R.M. Hilton
Abstract
S.A. Jayawardene1, A. Mohsin2, J.E. Scoble1 and R.M. Hilton1
1Department of Nephrology and Transplantation, Guy’s Hospital, London, UK, and 2Department of Elderly Medicine, Medway Maritime Hospital, Gillingham, UK
An 83-year-old female who had previously (32 years ago) donated a kidney to her husband presented with loin pain, confusion and oliguria. Acute renal failure and pulmonary edema necessitated emergency hemodialysis. The history and findings were thought to be consistent with acute renal artery occlusion on a background of atherosclerosis and severe renal artery stenosis. We present this case, not to imply that renal donation is a hazardous procedure, but rather as an illustration of a complication of donor nephrectomy that in a very large series has proved to be extremely rare. This case illustrates the point that even very rare events become more likely as the period of follow-up increases.Correspondence to:
Dr. R. Hilton; Department of Nephrology and Transplantation, 4th floor Thomas Guy House, Guy’s Hospital, St. Thomas’ Street, London SE1 9RT, United Kingdom
Email: Rachel.Hilton@ gstt.sthames.nhs.uk
Case Report
Epsilon-aminocaproic acid and renal complications: case report and review of the literature
G. Manjunath, A. Fozailoff, D. Mitcheson and M.J. Sarnak
Abstract
G. Manjunath1, A. Fozailoff1, D. Mitcheson2 and M.J. Sarnak1
1Division of Nephrology, Department of Medicine, New England Medical Center, Boston, MA, 2Department of Urology, St. Elizabeth’s Medical Center, Brighton, MA, USA 1,2Tufts University School of Medicine
Epsilon-aminocaproic acid (EACA) is a potent anti-fibrinolytic agent that is used in the treatment of excessive bleeding resulting from a systemic fibrinolytic state. It can also be used to treat hematuria through its action on decreasing urinary fibrinolysis. A broad range of renal complications has been ascribed to EACA. Although they are rare, they may be life-threatening and should therefore be immediately recognized.Correspondence to:
M.J. Sarnak, MD; Box 391, New England Medical Center, 750 Washington Street, Boston, MA 02111, USA
Email: msarnak@lifespan.org
Case Report
Minimal change nephrotic syndrome, lymphadenopathy and hyperimmunoglobulinemia after immunization with a pneumococcal vaccine
Y. Kikuchi, T. Imakiire, T. Hyodo, K. Higashi, N. Henmi, S. Suzuki and S. Miura
Abstract
Y. Kikuchi, T. Imakiire, T. Hyodo, K. Higashi, N. Henmi, S. Suzuki and S. Miura
Second Department of Internal Medicine, National Defense Medical College, Saitama, Japan
A 67-year-old female was admitted to our hospital with eruption and cervical lymphadenopathy which occurred one week after pneumococcal vaccination. Polyclonal hyperimmunoglobulinemia (IgG 6,620 mg/dl) and mild plasma cell proliferation (6.4%) in a bone marrow specimen were found, but a lymph node aspiration biopsy showed no specific findings. Normochromic and normocytic anemia with a positive direct Coombs test were also confirmed. Short-term intensive steroid therapy was given, but the systemic eruption and lymphadenopathy continued. About 4 months after vaccination, she suffered from edema in her face and legs and visual disturbance. When massive proteinuria (10.4 g/day) was found, she was admitted to our ward. A renal biopsy specimen showed a minor glomerular abnormality with mild interstitial plasmacytic infiltration. An abdominal CT scan showed hepatosplenomegaly and para-aortic lymphadenopathy. Uveitis was also found by ophthalmoscopy. These abnormalities completely disappeared after intensive steroid therapy including pulse therapy. On the basis of her clinical course and laboratory findings, it was suggested that minimal change nephrotic syndrome might be induced after vaccination, possibly due to hypersensitivity syndrome.Correspondence to:
Yuichi Kikuchi, MD; Second Department of Internal Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513 Japan
Case Report
Successful treatment by cyclooxyenase-2 inhibitor of refractory hypokalemia in a patient with Gitelman’s syndrome
H. Mayan, O. Gurevitz and Z. Farfel
Abstract
H. Mayan, O. Gurevitz and Z. Farfel
Department of Medicine E, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Israel
Gitelman’s syndrome is manifested by hypokalemic alkalosis, hypomagnesemia, hypocalciuria, normotensive hyperreninemia and hyperaldosteronism. Hypokalemia can at times be refractory to treatment. We present a patient refractory to a variety of drugs including indomethacin, the nonspecific COX inhibitor. Rofecoxib, a specific COX 2 inhibitor, promptly elevated serum potassium concentration with normalization of plasma aldosterone and near normalization of renin without a change in serum magnesium. Our patient also had rhabdomyolysis, a rarely reported complication, which was also ameliorated by COX 2 inhibition.Correspondence to:
Haim Mayan, MD; Department of Medicine E, Sheba Medical Center, Tel-Hashomer 52621, Israel
Email: mayan@post.tau.ac.il
Letter to the Editor
Successful treatment of tacrolimus-associated thrombotic microangiopathy with sirolimus conversion and plasma exchange
A. Yango, P. Morrissey, A. Monaco, J. Butera and R.Y. Gohh
Abstract
A. Yango, P. Morrissey, A. Monaco, J. Butera and R.Y. Gohh
Letter to the Editor
Fractional excretion of sodium – a simple test for the differential diagnosis of acute renal failure
S. Bhargava, A. Jain, V. Gupta
Abstract
S. Bhargava1, A. Jain2, V. Gupta2
Letter to the Editor
A case of Gitelman’s syndrome with premature ovarian failure
A. Akalin, T. Kasifoglu, B. Efe
Letter to the Editor
Deaths due to dialyzer repair: a new syndrome
S. Shaldon
