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Abstract

P. Arrizabalaga¹, M. Solé², C. Iglesias², G. Escaramís³ and C. Ascaso³

Services of ¹Nephrology and ²Pathology, Hospital Clínic, ³Public Health, University of Barcelona, Biomedical Investigation Institute August Pi i Sunyer, Barcelona, Spain
Background: Antineutrophil cytoplasmic autoantibodies (ANCA) play a role in the expression of adhesion molecules. Differences in ANCA test results in ANCA-associated vasculitis may provide differences in their renal expression. Patients and methods: We assessed the renal expression of ICAM-1 and VCAM-1 with monoclonal antibodies in 19 patients with ANCA-vasculitis: 7 microscopic polyangiitis, 5 Wegener’s granulomatosis, 4 renal-limited vasculitis and 3 Churg-Strauss disease. Immunofluorescence and ELISA for myeloperoxidase (MPO) and proteinase 3 (PR3) were performed for ANCA-testing. 10 normal renal tissues were used as controls. Results: The ANCA staining pattern was perinuclear in 14 patients, with MPO-ANCA 31 – 220 EU/ml, and cytoplasmic in 5, with PR3-ANCA 37 – 144 EU/ml. Abnormal tubular expression of ICAM-1 and VCAM-1 was seen in more than 80% of biopsies and abnormal expression of VCAM-1 in glomerular tuft was seen in 60%. Glomerular tuft stains of ++ or +++ for VCAM-1 were observed in 10% of renal biopsies from MPO-ANCA-GN patients, but in 60% of biopsies from PR3-ANCA-GN patients (Fi = 8.538, p = 0.03). In conclusion: De novo expression of VCAM-1 on glomerular tuft suggests that the endothelial cells play a role in ANCA-GN. De novo glomerular expression of VCAM-1 is associated more with ANCA directed against PR3 than with ANCA directed against MPO. Upregulated glomerular expression of VCAM-1 may reflect a higher histological activity in patients with PR3-ANCA, and supports the existence of specific immune activation mechanisms in the different serologic subgroups in ANCAGN. The de novo tubular expression of ICAM-1 and VCAM-1 suggests that the epithelial cells may participate in adhesive interactions in ANCA-GN. Correspondence to:
P. Arrizabalaga, M.D.
Servei de Nefrologia
Hospital Clínic
Villarroel, 170
08036 Barcelona, Spain
Email: parriza@clinic.ub.es

Abstract

L. Razukeviciene, I.A. Bumblyte, V. Kuzminskis and A. Laurinavicius

¹Department of Nephrology, Kaunas Medical University, Kaunas,
²Lithuanian Pathological Center, Vilnius, Lithuania
Background: In Lithuania renal biopsies (RB) have become routine since 1995. Our study attempted to analyze RB for 5 years in Lithuania. Methods: We analyzed data of adult patients who underwent native kidney biopsies in 6 renal units in the period between 1995 – 1999. It accounted for 62.5% of all kidney biopsies, done throughout Lithuania. All biopsy specimens were examined by the same pathologist using light- and immunofluorescence microscopy. Results: A total of 316 renal biopsies was analyzed; males : females 1.8 : 1. The mean age was 41.4 ± 16.7 years. The most common indications for biopsy was nephrotic syndrome (29.1%) and urinary abnormalities (27.8%). After exclusion of inadequate biopsies in the remaining 280 RB, primary glomerulonephritis (GN) accounted for 68.7% and secondary GN for 19.5%. The most frequent forms of primary GN were membranoproliferative GN and immunoglobulin A nephropathy (17.9% and 15.4%, respectively), followed by membranous nephropathy (7.1%) and focal segmental glomerulosclerosis (6.8%). Conclusions: The main indication for renal biopsy in Lithuania was nephrotic syndrome, which was followed by isolated urinary abnormalities. The leading type of kidney damage was primary glomerulonephritis, which was 2.4 times more frequent in males than in females. The most frequent form of primary glomerulonephritis was membranoproliferative GN, with dominance in males. Immunoglobulin A nephropathy was the second form of primary GN according to the frequency.Correspondence to:
L. Razukeviciene, MD
Nephrological Clinic
Kaunas University of Medicine
Eiveniu 2
Kaunas, 50009, Lithuania
Email: nefrolog@kmu.lt

Abstract

M. Sekkarie

Department of Medicine, Bluefield Regional Medical Center and Nephrology and Hypertension Associates, Bluefield, WV, USA
Background: In addition to the known disturbances in mineral metabolism and vitamin D activation, the majority of patients with chronic kidney disease (CKD) do not have sufficient vitamin D stores. The impact of supplementation with low-dose, nonactive forms of vitamin D (calciferol) on parathyroid hormone (PTH) levels in this population is unknown, however. Methods: A cross-sectional evaluation of vitamin D levels, intact parathyroid hormone (iPTH) and other laboratory results in 108 stage 3 and stage 4 CKD patients according to their intake of over-the-counter vitamin D. Results: 37 patients took 400 IU of vitamin D daily with supplemental calcium and 71 did not. Compared to subjects who did not take it, patients who were on the supplement had higher 25(OH)D (31 ± 15 vs. 17 ± 9) ng/ml, higher 1,25(OH)D (21 ± 12 vs. 16 ± 9) pg/ml, lower iPTH (75 ± 48 vs. 144 ± 100) pg/ml and were more likely to meet K-DOQI PTH guidelines. However, these subjects were more likely to have oversuppressed iPTH values. The groups did not differ with regard to demographics, glomerular filtration rate and calcium and phosphorus levels. Conclusions: Vitamin D supplements may be a valuable tool in the prevention and treatment of hyperparathyroidism in patients with stages 3 and 4 CKD. CKD patients who have oversuppressed PTH need to be asked about their vitamin supplement intake.Correspondence to:
M. Sekkarie, MD, MPH
510 Cherry St., Suite 306
Bluefield, WV 24701, USA
Email: msekkarie@brmcwv.org

Abstract

O. Cetin¹, S. Bekpinar¹, Y. Ünlucerci¹, A. Turkmen², Ç. Bayram³ and T. Ulutin³

¹Department of Biochemistry, ²Department of Nephrology, Istanbul Faculty of Medicine, and ³Genetics and Teratology Research Center, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
Background: A moderate increase in plasma total homocysteine (t-hcy) is considered to be an independent risk factor for cardiovascular disease (CVD) in general population. One of the mechanisms by which hyperhomocysteinemia contributes to cardiovascular risk has been explained to be the increased thrombotic potential. Elevated t-hcy levels were also reported in chronic renal failure patients because the renal function is a major determinant of serum t-hcy levels. Patients and methods: We measured serum hcy and ADP-induced platelet aggregation and plasma tissue factor as a major activator of the coagulation cascade in hemodialysis (HD), peritoneal dialysis (PD) and early stage chronic renal failure (early stage CRF) patients who are not receiving dialysis and compared with those of control. In addition, we also determined serum vitamin B12 and folat levels which are the important factors regulating the metabolism of t-hcy. Results: Hcy levels in all patient groups were significantly higher (HD: 20.42 ± 1.91 µmol/l, PD: 35.47 ± 6.30, early stage CRF: 24.39 ± 3.06) than the normal levels (10.74 ± 0.74) in spite of standard multivitamin supplementation. The highest t-hcy values were found in peritoneal dialysis patients. Vitamin B12 levels in hemodialysis/peritoneal dialysis patients and folat levels in hemodialysis/early stage CRF patients were also significantly above those of control. On the other hand, the significant elevations in plasma tissue factor concentration were found in all patient groups (HD: 331.4 ± 31.3 pg/ml, PD: 306.0 ± 30.0, early stage CRF: 277.2 ± 25.5 and Control: 69.5 ± 13.5). t-hcy levels were positively correlated with creatinine (r: 0.791 p < 0.002) and tissue factor levels (r: 0.526 p < 0.05) in only early stage CRF group. The association between t-hcy and tissue factor persisted after these two parameters were adjusted for creatinine (r: 0.649 p < 0.05). On the other hand the same correlations were not observed in dialysis patient groups. In spite of the high tissue factor levels, ADP-induced platelet aggregations were found to be lower in all patient groups (HD: 102.6 ± 6.7, PD: 98.6 ± 7.6 and Early stage CRF: 84.9 ± 7.6) than controls (154.9 ± 13.7). Conclusion: These results suggest that hyperhomocysteinemia and increased tissue factor level are present in patients with renal failure, despite supplementation with vitamin B6 and B12 and folat. However, elevated levels of these thrombogenic factors are not linked with platelet aggregation. Correspondence to:
Y. Ünlücerci, MD
Department of Biochemistry
Istanbul Faculty of Medicine
Istanbul University
Çapa 34093-Istanbul, Turkey
Email: ymyu@istanbul.edu.tr

Abstract

J. Guitard¹, O. Cointault¹, N. Kamar¹, F. Muscari², L. Lavayssière¹, B. Suc², D. Ribes¹, L. Esposito¹, K. Barange³, D. Durand¹ and L. Rostaing¹

¹Multiorgan Transplant Unit, University Hospital, ²Department of Surgery and Liver Transplantation, CHU Rangueil, ³Department of Hepatology and Gastroenterology, CHU Purpan, Toulouse, France
Aims: To identify the predictive factors for acute renal failure (ARF) in a retrospective study of 100 orthotopic liver transplantations (OLT) performed in 94 patients between 2000 and 2003. Methods: Acute renal failure (ARF) was defined using the RIFLE criteria, i.e. injury when creatinine doubles or GFR halves, and failure when creatinine trebles or GFR decreases by > 75%. Patients on dialysis pre OLT (n = 3) were excluded from the study. Immunosuppression included steroids, calcineurin inhibitors (CNIs), with (n = 32) or without mycophenolate mofetil. A total of 85% of patients also received induction therapy with antithymocyte globulins (29%) or anti-CD25 monoclonal antibodies (56%). Results: 39 patients (41.5%) and 21 (22.3%) patients developed injury, and failure, respectively. Of these, 10 (10.6%) underwent dialysis. Univariate analysis revealed that acute renal dysfunction with a RIFLE score ³ 3 was significantly associated with a pre-operative serum creatinine level of > 100 mmol/l, pre-operative creatinine clearance of < 75 ml/mn, need for a transfusion (> 10 red packed units), post-operative diuresis of < 100 ml/h, use of vasopressive drugs, times to aspartate (AST) and alanine (ALT) aminotransferase peaks of > 20 and > 24 hours, respectively, relaparotomy, CNIs transient discontinuation, and the use of lower daily dosage of CNIs at post-OLT Days 3, 5, 7 and 15. In multivariate analysis, failure was significantly associated with time to AST peak (> 20 h) (OR 6.35 (1.2 – 33.6), p = 0.029), post-operative diuresis (<100 ml/h) (OR 9.8 (2.03 – 47.3), p = 0.004), post-operative use of vasopressive drugs (OR 9.91 (2.02 – 48.7), p = 0.004), and transient CNIs withdrawal (OR 51.08 (7.58 – 344.1), p < 0.0001). Finally, the occurrence of ARF was significantly associated with an increased number of days on mechanical ventilation, on stay-in intensive care unit (ICU), and on overall hospitalization time. Conclusion: ARF is quite common after OLT and significantly increases the post-operative time at the hospital, thereby increasing the OLT cost. Its independent predictive factors are mainly related to perioperative events.Correspondence to:
Prof. L. Rostaing
CHU Rangueil
Service de Néphrologie-Transplantation
1 av. Jean Pouilhès, TSA 50032
31059 Toulouse cedex 9, France
Email: rostaing.l@chu-toulouse.fr

Abstract

S. Turk¹, H. Atalay¹, L. Altintepe¹, I. Güney¹, N. Okudan², H.Z. Tonbul¹, H. Gökbel², R. Kücür³, M. Yeksan¹ and A. Yildiz⁴

¹Division of Nephrology, ²Division of Physiology, Department of Internal Medicine, Faculty of Medicine, ³Department of Psychiatry, Faculty of Medicine, Selcuk University, ⁴Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey
Background: Despite some improvements in dialysis therapies, depression still remains an important problem in chronic hemodialysis (HD) patients. In this study, we aimed to investigate the association of depression and its treatment with quality of life (QOL) in HD patients. Patients and methods: 97 HD patients (52 male, 45 female, mean age 55 ± 16 years) were enrolled. All patients had been dialyzed for more than 6 months. In order to evaluate QOL of the patients, a short form of Medical Outcomes Study (SF-36) was used. Depression was assessed by using Beck Depression Inventory (BDI). Patients who had BDI score ³ 15 were diagnosed as to have depression. Patients with depression received antidepressive treatment (sertralin HCl, 50 mg/day) for an 8-week period. After 8-week antidepressive treatment, all biochemical analysis, SF-36 and BDI were performed again. Results: 40 patients (20 male, 20 female, mean age 56 ± 14 years) had depression. All parameters related to QOL were significantly decreased in patients with depression as compared to patients without depression. Severity of depression was correlated with QOL parameters. After 8 weeks of treatment, as parallel to changes in BDI, QOL parameters improved in patients with depression. Conclusion: Decrease in QOL, associated with depression and antidepressive treatment, improves QOL in HD patients. Hemodialysis patients should be followed-up closely for presence of depression. Treatment of depression with antidepressive drug regimen would lead to relieve the symptoms related to depression and improvement of QOL in these patients. Antidepressive treatment should be required more often than we prescribe in routine clinical practice now.Correspondence to:
A. Yildiz, MD
Istanbul University
Istanbul School of Medicine
Department of Internal Medicine
Division of Nephrology
34390, Topkapi, Istanbul, Turkey
Email: yildiza@istanbul.edu.tr,alaattiny@hotmail.com

Abstract

R. Zoccali¹, G. Bellinghieri², A. Mallamace², M.R.A. Muscatello¹, A. Bruno¹, D. Santoro², D. Mallamace¹, G.P. Barillà¹, P. Scardamaglia¹, D. La Torre¹ and M. Meduri¹

¹Department of Neurosciences, Division of Psychiatry, and ²Department of Medicine and Pharmacology, Division of Nephrology, University of Messina, Italy
Defense mechanisms are automatic psychological processes that protect the individual against anxiety and from the awareness of internal or external dangers or stressors. The influence of defense mechanisms in patients on chronic hemodialysis treatment was studied. There were 53 uremic subjects (37 males and 16 females), aged between 22 and 88 years (mean age 60.11, SD 15.03), on chronic dialysis and 50 healthy subjects as controls have been enrolled in the study. According to the duration of dialysis, uremic patients were divided in two subgroups: 21 patients with less than 5 years and 19 patients with more than 10 years of dialytic treatment. Assessment was conducted using the Defense Mechanisms Inventory DMI. The inventory identifies five defensive styles: turning against the object (TAO), projection (PRO), principalization (PRN), turning against the self (TAS) and reversal (REV). Results showed DMI scores within the normal range both for uremics and controls with significant differences in TAO (t = –3.053, p = 0.003) and REV (t = 5.067, p < 0.0001) between groups. No significant differences in the use of defensive styles related to the duration of dialytic treatment were observed. Besides other psychological features, the assessment of defense mechanisms in patients with chronic and invalidating diseases may contribute to ameliorate the knowledge of the adjustment processes and of the psychological well-being of the patients.Correspondence to:
Dr. D. Santoro
C. da Conte Coop.
Sperone is. 3/c
98122 Messina, Italy
Email: gbellinghieri@hotmail.com

Abstract

Y. Kikuchi, N. Yoshizawa, T. Oda, T. Imakiire, S. Suzuki and S. Miura

¹Second Department of Internal Medicine and ²Department of Public Health, National Defense Medical College, Namiki, Tokorozawa, Saitama, Japan
We report the case of a 25-year-old man with abdominal pain, purpura on the legs and proteinuria occurring 2 weeks after acute tonsillitis, and admitted to our hospital with suspected Henoch-Schönlein purpura nephritis (HSPN). He had increased antistreptolysin O (ASO) titer and hypocomplementemia. A renal biopsy specimen showed endocapillary proliferative changes, which are typical of acute poststreptococcal glomerulonephritis (APSGN). However, immunofluorescence study revealed predominant IgA and C3 deposits in mesangial lesions, indicating a diagnosis of HSPN. Because of massive proteinuria initially, the treatment with a combination of prednisolone, cyclophosphamide, dipyridamole and warfarin was started along with 3 plasma exchanges. Angiotensin-converting enzyme inhibitor was also given. Response to the treatment was favorable. A follow-up biopsy was performed 8 months after the first biopsy. The renal biopsy specimen showed a figure of typical HSPN. To further investigate the cause of glomerular changes in our patient, an immunofluorescent study of nephritogenic nephritis-associated plasmin receptor (NAPlr) of group A, b-hemolytic streptococci was performed. NAPlr was significantly positive in the glomeruli in the first biopsy specimen, but not in the second. His clinical course and pathological findings suggest that NAPlr may be related to the pathogenesis in a part of patients with HSPN, especially in patients with high ASO titer and hypocomplementemia. Correspondence to:
Y. Kikuchi, MD
Second Department of Internal Medicine
National Defense Medical College
3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
Email: grd1615@ndmc.ac.jp

Abstract

T. Tohyama, K. Ikeda and K. Hattori

¹Department of Internal Medicine, Kohryo Clinic, ²Izumigaoka Naika Clinic, ³Department of Dermatology, Takaoka City Hospital, Takaoka, Toyama, Japan
A 15-year-old boy developed a nephrotic syndrome. At that time, autoantibodies related to systemic lupus erythematosus (SLE) had been persistently negative, even on repeated evaluation. C1q was normal, but C4, C3 and CH50 were low. Renal biopsy revealed membranous lupus nephritis (LN) based on the new classification of glomerulonephritis in SLE [Weenig et al. 2004]. We did not establish our diagnosis of SLE on the criteria of the American Rheumatism Association (ARA). The patient showed complete remission of nephrotic syndrome treated with prednisolone and cyclophosphamide. Thereafter, he had no proteinuria and clinical evidence of SLE for 22 years. At the age of 37, however, he developed facial discoid eruption, proteinuria in the nephrotic range, hypocomplementemia and positive reaction to autoantibodies of SLE. Light microscopic findings of renal biopsy indicated mesangial LN, which showed “full-house” immunofluorescence and mesangial dense deposits associated with diffuse epithelial cell foot process effacement in electron microscopy. Steroid therapy was very effective. This case initially showed autoantibody-negative and hypocomplementemic LN with membranous type, and transformed to SLE with mesangial LN after a long interval.Correspondence to:
T. Tohyama, MD
Department of Internal Medicine
Kohryo Clinic
Nomura 23-1, Takaoka, Toyama, 933-0014, Japan
Email: ko-cli@p2332.nsk.ne.jp

Abstract

N.P. Sheth, B. Sennett and J.S. Berns

¹Department of Orthopaedic Surgery and ²Renal, Electrolyte, and Hypertension Division, University of Pennsylvania School of Medicine, Philadelphia, USA
We describe a college football player and weight-lifter who unexpectedly developed rhabdomyolysis and nonoliguric acute renal failure (ARF) following arthroscopic knee surgery. There was swelling and pain without evidence of a compartment syndrome postoperatively. The patient reported that he was an avid weight-lifter and that he was taking up to 10 g/d of a creatine supplement during the 6 weeks prior to this surgery. His ARF resolved over several days, with a peak serum creatinine of 2.3 mg/dl and peak creatine kinase (CK) of 194,000 U/l, following administration of intravenous fluids, mannitol, and sodium bicarbonate. Given the rarity of clinically significant rhabdomyolysis with this type of operation, we suggest that the patient’s use of creatine increased the risk of skeletal muscle injury due to ischemia from intra-operative tourniquet application.Correspondence to:
J.S. Berns, MD
University of Pennsylvania School of Medicine
Renal, Electrolyte, and Hypertension Division
Penn Presbyterian Medical Center
51 N. 39th Street, MOB 240
Philadelphia, PA 19104, USA
Email: bernsj@uphs.upenn.edu

Abstract

L. Meylaerts, V. Ooms, S. Lyra, K. Claes, Y. Vanrenterghem and P. Demaerel

¹Department of Radiology and ²Nephrology, University Hospitals Gasthuisberg, Leuven, Belgium
Hypertensive brain stem encephalopathy is a rare disorder that can be seen in severe hypertensive encephalopathy. Patients with chronic renal failure are more prone to develop this disorder because a mild elevation of the blood pressure can already induce brain changes. It is important to diagnose this entity as soon as possible because the symptoms and brain stem lesions are reversible following treatment and because it is important to exclude brain stem ischemia in the diagnostic work-up. Brain MRI and particularly diffusion weighted images are crucial for this purpose.Correspondence to:
Prof. Dr. Ph. Demaerel Department of Radiology University Hospitals Gasthuisberg Herestraat 49 3000 Leuven, Belgium
Email: philippe.demaerel@uz.kuleuven.ac.be

Abstract

M. Ozeki, T. Fukushima, M. Ohzeki, T. Sasaki and N. Kashihara

Division of Nephrology, Kawasaki Medical School, Kurashiki, Japan
A male patient aged 67 years with chronic renal failure (CRF), who had undergone hemodialysis since June 3, complained of dyspnea while walking on June 23, 1998. Rapidly progressive anemia and severe reticulocytopenia were noted. Serological tests showed that parvovirus B19- (B19) specific IgM antibody, but not IgG antibody, was present in the patient’s serum. B19 DNA was detected in the patient’s serum by the polymerase chain reaction (PCR). Therefore, a definite diagnosis of transient aplastic crisis induced by B19 was made. On June 10, prior to the appearance of this case, a female nurse aged 27 years working in our hemodialysis center, complained of cough, fever and arthralgia. Another female nurse, aged 35 years, developed similar symptoms on July 3. Both nurses had a positive IgM titer against B19, but were negative for IgG, indicating an acute B19 infection. These findings led us to suspect that this series of B19 infection was spread by nosocomial transmission. Although some cases of B19 infection have been reported to occur in laboratory staffs, the B19 nosocomial infection has not been described in the literature. We also suggest that a transient aplastic crisis due to B19 infection could lead to severe anemia in cases of CRF whose erythropoiesis is maintained by a recombinant human erythropoietin.Correspondence to:
Dr. T. Fukushima
Division of Nephrology
Kawasaki Medical School
577 Matsushima, Kurashiki 701-0192 Japan
Email: fuku@tch.or.jp

Abstract

W.-C. Lee, M.-J. Wu, C.-H. Cheng, C.-H. Chen, M.-C. Wen, H.-C. Chen and K.-H. Shu

¹Division of Nephrology, Department of Internal Medicine, ²Department of Pathology, Taichung Veterans General Hospital, ³Chung-Shan Medical University and Department of Life Sciences, National Chung Hsing University, Taichung, Taiwan
Acute pancreatitis is a rare complication following OKT3 therapy, which to our knowledge has never been reported in patients treated with antilymphocyte globulin (ALG). We herein report a case of a kidney transplantation patient who developed acute pancreatitis 2 days after treatment with ALG for grade IIb acute rejection. The symptoms subsided after discontinuing this drug. Resumption of ALG therapy triggered another episode of acute pancreatitis. Therefore, the clinical course strongly suggests that ALG was the etiological factor of acute pancreatitis in this particular patient.Correspondence to:
K.-H. Shu Division of Nephrology Department of Internal Medicine Taichung Veterans General Hospital No. 160, Sec. 3, Chung-Kang Rd., Taichung, Taiwan
Email: khshu@vghtc.gov.tw

Abstract

H. Matsukura, O. Higuchi, M. Arai, Y. Itoh and T. Miyawaki

Abstract

H. Nishi, T. Nii-Kono, K. Ikeda, A. Fujimori and M. Fukagawa

Abstract

H. Matsukura, S. Toyoshima, S. Inaba, M. Arai, T. Miyawaki and M. Miyamoto

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Volume 65, No. 2/2006(February)