Volume 58, No. 2/2002(August)
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 Clinical Nephrology
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Originals
Factors associated with progression of IgA nephropathy are related to renal function – A model for estimating risk of progression in mild disease
Abstract
V. Rauta, P. Finne, J. Fagerudd, K. Rosenlöf, T. Törnroth and C. Grönhagen-Riska
Helsinki University Central Hospital, Department of Medicine,
Division of Nephrology Helsinki, Finland
Background: A number of factors are linked to the outcome of IgA nephropathy (IgAN). However, it has been difficult to compare results of studies since patient populations have varied greatly. There were 3 aims in the study reported here, namely to compare factors associated with renal outcome in IgAN patients with different levels of renal function on diagnosis; to determine factors which were independently associated with progression of renal disease in initially mild IgAN; and to create a model for the estimation of the risk of progression in individual IgAN patients with normal renal function on diagnosis. Methods: Two hundred and fifty-nine IgAN patients who had been followed on average for 9.1 (SD 4.5) after diagnosis were divided into 2 groups on the basis of renal function on diagnosis. In group 1 (98 patients), Ccr (creatinine clearance, estimated by the Cockcroft-Gault formula) was < 85 ml/min, in group 2 (161 patients) ³ 85 ml/min. Univariate analyses were used to find significant differences between progressors and non-progressors in both groups. Logistic regression analysis was used to determine factors independently associated with progression in group 2. Results: Several factors were found to be associated with outcome in both groups, such as hypertension, level of Ccr, serum cholesterol, proteinuria, and also histopathological changes. Factors associated with progression in patients with initially decreased renal function (group 1), were predictable, such as male sex, absence of episodes of macroscopic hematuria, serum urate level and degree of tubular atrophy. Surprisingly, in patients with initially normal renal function (group 2), numbers of urinary erythrocytes were associated with outcome. The factors independently associated with progression in this group were number of urinary erythrocytes, existence of hypertension and in histopathology arteriolosclerosis and the level of glomerular score. A model for estimating risk of progression on the basis of various combinations of factors found to be independently associated with outcome is presented. Conclusions: We concluded that association between variable and outcome in IgAN depends partly on renal function at the time of assessment of the factor. Since there are factors which are independently associated with the outcome of early and apparently mild disease, early diagnosis of IgAN is desirable: outcome in mild IgAN can be predicted reliably on the basis of factors found to be independently associated with outcome.
Originals
Nephropathy of cyanotic congenital heart disease: clinical characteristics and effectiveness of an angiotensin-converting enzyme inhibitor
Abstract
Y. Fujimoto, M. Matsushima, K. Tsuzuki, M. Okada, M. Shibata, Y. Yanase, K. Usui and M. Nagashima
1Department of Pediatrics and 2Pediatric Cardiology, Chukyo Hospital, Nagoya, and 3Aichi Children?s Health and Medical Center, Obu, Japan
Aims: Nephropathy has long been recognized as a potential complication of cyanotic congenital heart disease (CCHD). There have been few large-scale studies or clinical reports on renal impairment in patients with CCHD; similarly, very few studies have examined the drug treatment of nephropathy in CCHD. We examined the clinical characteristics and effectiveness of enalapril, an angiotensin-converting enzyme inhibitor (ACE-I), in patients with CCHD complicated with significant proteinuria. Materials and methods: The clinical records of 37 patients with CCHD were evaluated; all were older than 10 years of age (median 19, range from 10 to 27) and had regular check-ups, including urinalysis. The treatment criteria for enalapril administration included significant proteinuria (urinary excretion > 1.0 g/24 h), stable cardiac condition and blood pressure within the normal range. Results: Eleven patients (29.7%) had persistent proteinuria, 6 patients met the enalapril treatment criteria and 5 patients were treated for more than 12 months. Enalapril apparently reduced the urinary protein excretion in 4 of the 5 patients (80%). No consistent improvement of renal function, as evidenced in the glomerular filtration rate (GFR), renal plasma flow (RPF) or filtration fraction (FF) was found in these patients, but neither were any significant adverse effects noted. Conclusion: The incidence of nephropathy among patients with CCHD was about 30%, which was consistent with previous studies. It is worth considering the use of ACE-I when nephropathy accompanies CCHD.
Originals
Oxidative stress and TGFb in kidney- transplanted patients with cyclosporin-induced hypertension. Effect of carvedilol and nifedipine
Abstract
L. Calò1, B. Giacon2, P.A. Davis3, E. Pagnin1, A. Piccin1, P. Riegler2, W. Huber2, A. Antonello4 and A. Semplicini1
1Department of Clinical and Experimental Medicine, Clinica Medica 4 and 2Nephrology, University of Padua, 3Department of Internal Medicine, University of California, Davis, USA, and 4Division of Nephrology Bolzano Hospital, Italy
Cyclosporin is a powerful stimulator of oxidative stress signaling, leading to TGFb production, NO degradation, endothelial dysfunction, hypertension and post-transplant nephropathy. Carvedilol, a1-b-blocker with strong antioxidant activity, may interfere with this chain of events. Therefore, we measured monocyte ecNOS, TGFb and heme oxygenase-1 (HO-1) mRNA level and plasma nitrite/nitrate, 3-nitrotyrosine, an estimate of peroxynitrite, and total plasma antioxidant power in kidney-transplanted patients with post-transplant hypertension, before and after treatment with carvedilol, 25 – 50 mg o.d. orally for 4 months (n = 15). The dihydropyridine calcium channel blocker nifedipine (n = 10) was used as comparator antihypertensive drug. Blood pressure fell to a similar extent with both drugs. Carvedilol increased plasma antioxidant power and HO-1 mRNA and reduced 3-nitrotyrosine and TGFb mRNA levels, while the same was not observed with nifedipine. Monocyte ec NOS mRNA levels and plasma nitrite/nitrate were higher in the patients than in a normotensive healthy control group and were unaffected by either treatment. In conclusion, carvedilol reduces the oxidative stress and corrects the altered cellular signaling mediated by oxidative stress in CsA-induced post-transplant hypertension. Therefore, it may prevent long-term complications, such as endothelial dysfunction, fibrogenesis and post-transplant nephropathy by decreasing NO degradation and production of TGFb, a key fibrogenic cytokine, and by activating HO-1 production.
Originals
Contrast-enhanced MR urography in the evaluation of renal transplants with urological complications
Abstract
M. Cohnen1, M. Brause2, P. May1, G. Hetzel2, A. Saleh1, B. Grabensee2 and U. Mödder1
1Institute of Diagnostic Radiology, and 2Department of Nephrology, Düsseldorf, Germany MR urography in renal transplantation
Aim: The diagnostic work-up of renal transplants with impaired function due to urological problems can be difficult. This study was performed to assess sensitivity and specificity of non-invasive contrast-enhanced MR urography (MRU). Methods and materials: Thirty-five patients with renal transplants (25 – 71 years, mean: 53.4 years) with sonographically diagnosed hydronephrosis or perirenal fluid collections were assessed by MR urography. MR examinations were carried out at a 1.5 T clinical scanner (Vision, Siemens, Erlangen, Germany) with a 512 matrix contrast-enhanced fat-suppressed T1-weighted FLASH 3D sequence in breath-hold technique. MIP reconstructions were used to produce MR urography. MRU diagnoses were compared to operative results. Results: In all patients, images with sufficient contrast in the renal collecting system were obtained. Hydronephrosis was confirmed in 20 patients, 8 patients showed a different pathology while 7 had normal findings. Compared to operative results, sensitivity of MRU was 100% with a specificity of 78%, respectively. One ureteral stone was misdiagnosed as a stricture, and 2 suspected ureteral stenoses could not be found upon operation. Conclusions: Contrast-enhanced MR urography is a highly sensitive and specific non-invasive method to evaluate patients suspected of having typical post-transplant urological complications. It may replace invasive procedures such as antegrade pyelography in the pre-operative work-up.
Originals
Simultaneous bilateral quadriceps tendon rupture in renal patients
Abstract
M.K. Shah
Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital/Harvard Medical School, Boston, MA, USA
Aims: Simultaneous bilateral quadriceps tendon rupture occurs in patients with renal disease. It has been hypothesized that the length of renal disease and the length of dialysis may correlate with the development of tendon ruptures. This study aims to characterize the factors involved in patients with renal disease and simultaneous bilateral quadriceps tendon rupture. Methods: All reported cases of simultaneous bilateral quadriceps tendon rupture were identified using MEDLINE. Each case was reviewed for information regarding this injury. Results: Of the 65 cases reviewed, 24 cases involved patients with renal disease. Males were more often affected than females, almost a 2 : 1 ratio. The mean age of injury was 36 years. Most patients (63%) had signs of secondary hyperparathyroidism. The average length of renal disease was 13 years while the average length on dialysis was 6.5 years. Age, gender, mechanism of injury, time before diagnosis, location of rupture, method of repair, presence of hyperparathyroidism, length of renal disease or length on dialysis were not related to functional outcome. However, length on dialysis was related to mechanism of injury. Conclusions: Most patients with renal disease and simultaneous bilateral quadriceps tendon rupture have good functional recovery. Duration of dialysis is related to spontaneous tendon rupture and should be considered a complication of chronic renal failure.
Originals
Utility of ultrasonographic venous assessment prior to forearm arteriovenous fistula creation
Abstract
K.S. Brimble, Ch.G. Rabbat, D.J. Treleaven and A.J. Ingram
Department of Medicine, McMaster University, Hamilton, Ontario, Canada
Aim: The purpose of this study was to evaluate the clinical utility of Doppler ultrasound (US) prior to native forearm arteriovenous fistula (AVF) creation. Materials and methods: US mapping was carried out pre-operatively to evaluate the major veins and arteries in the appropriate arm. One hundred and 6 patients were identified retrospectively over 2 years with complete clinical and US data. A failed fistula was defined as an inability to provide blood flow to meet adequacy targets by 6 months (urea reduction ratio ³ 65%). Results: Twenty-nine patients (27.4%) had successful forearm AVFs. The mean minimum forearm cephalic vein diameter (CVD) was 2.51 ± 0.14 and 2.23 ± 0.06 mm in successful and failed fistulae, respectively (p = 0.04). This result was primarily due to differences observed in women. A receiver operator curve analysis showed that a cutpoint of 2.6 mm for minimum forearm CVD had the greatest predictive value with a likelihood ratio of 3.94 (95% CI: 1.97 – 7.84) for fistula failure. Multivariate logistic regression analysis determined that male gender and minimum forearm CVD were the only significant predictors for fistula success with odds ratios of 3.90 (95% CI: 1.30 – 11.68) and 2.31 (95% CI: 1.00 – 5.43), respectively. The study is limited by the possibility that US results in patients may have lead to an alternative type of access being attempted. Conclusions: US mapping prior to forearm AVF creation is of modest benefit. Only male gender and minimum forearm CVD were predictive of AVF success.
Originals
Use of the Tesio catheter for hemodialysis in patients with end-stage renal failure: a 2-year prospective study
Abstract
A. Webb, M. Abdalla, P.N. Harden and G.I. Russell
St. Lukes Hospital, Bradford, UK The Tesio catheter system for hemodialysis access
Background: The Tesio catheter system has been proposed to be a reliable source of vascular access for the dialysis patient with low rates of infection and other complications. Whether such catheters provide reliable short- and long-term access remains undetermined. Methods: This study prospectively examined all Tesio lines inserted over a 2-year period in patients with end-stage failure with careful recording of all catheter complications and reasons for catheter loss. Results: 100 catheters were inserted in 82 patients giving a total experience of 13,749 catheter days; 74 catheters were inserted into the jugular veins, the remainder into the femoral veins; 82 insertions were covered with antibiotics. At the end of the study, 29 catheters remained in situ. Of the remaining 71 catheters, 27 catheters were removed because of fashioning of definitive access. Nine catheters were lost due to infection and 10 were lost due to non-function; 19 patients died with a functioning catheter. Episodes of non-function were the major complications, although catheter patency was restored in 90% of cases utilizing urokinase and warfarin. Overall 80% of femoral and 16% of jugular catheters required anticoagulation. Conclusions: Tesio catheters inserted into the jugular or femoral veins can provide excellent access whilst awaiting definitive dialysis access. They are well-tolerated with a low complication rate compared to standard temporary central venous catheters. Non-function remains a significant problem, especially in femoral catheters, which should be anti-coagulated following insertion. Because of our results we suggest that these catheters be used as part of the co-ordinated approach to the management of vascular access in end-stage renal failure patients without definitive access.
Originals
Impact of iron dextran on polymorphonuclear cell function
among hemodialysis patients
Abstract
D. Guo, B.L. Jaber, S. Lee, M.C. Perianayagam, A.J. King, B.J.G. Pereira and V.S. Balakrishnan
Division of Nephrology, Department of Medicine, New England Medical Center Hospitals, Boston, MA, USA
Background: Polymorphonuclear cell (PMN) dysfunction and the increased use of parenteral iron may be important contributory factors to bacterial infections among patients with end-stage renal disease (ESRD) on maintenance hemodialysis (HD). We compared the in vitro impact of a commonly used parenteral iron preparation, iron dextran, on PMN function and viability between a group of HD patients with normal iron indices and healthy subjects. Methods: Eleven patients with ESRD on HD and 10 healthy subjects were studied. PMN harvested from heparinized blood were incubated with iron dextran (0 – 20 mM) in culture medium (RPMI) for 24 hours at 37 °C with 5% CO2 following which function and viability were assessed by flow cytometry using appropriate fluorescent labels. Results: Unstimulated, S. aureus and N-formyl-methionyl-leucyl-phenylalanine (fMLP)-stimulated hydrogen peroxide (H2O2) production was significantly higher in PMN unexposed to iron dextran from HD patients compared to those from healthy subjects. Iron dextran had no impact on unstimulated PMN H2O2 production in either group. In the healthy group, the only significant change occurred with 4-b-phorbol 12-b-myristate 13-a-acetate (PMA) stimulation, where cells exposed to 0.2 and 2.0 mM iron dextran produced less H2O2 relative to PMN unexposed to iron dextran (p < 0.05). In the HD group, all concentrations of iron dextran significantly attenuated H2O2 production stimulated by S. aureus, fMLP and PMA compared to PMN unexposed to iron dextran. Although PMN phagocytosis decreased with exposure to increasing concentration of iron dextran in both healthy subjects and HD patients, these changes did not achieve statistical significance. No significant changes in PMN viability or apoptosis were seen in either group after exposure to iron dextran. Conclusions: These results indicate that iron dextran, a standard parenteral iron preparation, attenuates PMN function in HD patients with normal iron indices at clinically relevant concentrations. Further studies are required to evaluate and compare the impact of newer preparations of parenteral iron, such as iron sucrose and ferric gluconate, on PMN function.
Originals
Natural history of acute HCV infection in hemodialysis patients
Abstract
M. Espinosa, A. Martin-Malo, M.A. Alvarez de Lara, R. Gonzalez, M. Rodriguez and P. Aljama
1Servicios de Nefrologia and 2Immunologia, Hospital Universitario Reina Sofia, Cordoba, Spain Acute hepatitis C in HD patients
Aims: Chronic liver disease develops in the majority of non-uremic patients with hepatitis C virus (HCV) infection. The aim of this study was to analyze the evolution towards chronic hepatopathy in 19 cases of acute hepatitis C observed in hemodialysis patients from 1990 to 2001. Methods: A prospective follow-up study on HCV infection was conducted in 3 HD units from April 1990 to June 2001 to study clinical outcomes after acute hepatitis C. A total of 781 patients were tested monthly for alanine aminotransferase and anti-HCV in serum. In this period, 19 patients suffered from acute hepatitis C. Evolution to chronic liver disease in the follow-up was evaluated by means of biochemical (increased ALT) and virological criteria (HCV-RNA+). The transmission mechanism, the apparition of anti-HCV, clinical manifestations and mortality were also investigated. Results: In 15 (78.9%) of the 19 patients, the viremia remained positive (chronic viremia) and 11 patients (57.8%) evolved to chronic liver disease (chronic viremia and high transaminase levels) with a median follow-up of 3 years (range 1 – 6). Five of them who underwent liver biopsies had histologic signs of chronic active hepatitis. One of them (5.2%) evolved to liver cirrhosis in the follow-up. In 4 out of 19 patients (21%) the HCV infection resolved. Although 7 (36.8%) of them died in the follow-up, acute hepatitis C infection was not a short-term independent risk factor of death. Conclusions: Three years after acute hepatitis C, 87.5% of the hemodialysis patients remained HCV-RNA positive and 56.2% evolved to chronic liver disease. It is important to stress that HCV infection spontaneously cleared in 4 out of 19 patients (21%).
Case reports
Acute interstitial nephritis secondary to infectious mononucleosis
Abstract
N. Verma, S. Arunabh, T.M. Brady and C. Charytan
1Department of Internal Medicine & Nephrology, The New York Hospital Medical Center of Queens, Flushing, NY, and
2Department of Endocrinology, Winthrop-University Hospital, Mineola, NY, USA
Renal involvement in infectious mononucleosis (IM) is infrequent. In most cases it is self-limited and is rarely associated with loss of renal function. The purpose of this case report is to document a case of acute interstitial nephritis (AIN) leading to acute renal failure (ARF) in a patient with Epstein-Barr virus (EBV) infection and to review literature of EBV infection and its renal manifestation. The patient was managed with hemodialysis and steroids and made an uneventful recovery. Renal involvement in IM may be more common than generally appreciated and may occasionally lead to ARF. Therapy with corticosteroids may have role in the management of IM-induced ARF and may shorten the duration of renal failure.
Case reports
Oral doxercalciferol therapy for
secondary hyperparathyroidism
in a peritoneal dialysis patient
Abstract
S.M. Sprague and L.T. Ho
Department of Medicine, Evanston Northwestern Healthcare, Northwestern University Medical School, Evanston, Illinois, USA
Control of hyperphosphatemia and the administration of vitamin D are the primary treatment modalities for the prevention and management of secondary hyperparathyroidism. Vitamin D therapy for secondary hyperparathyroidism has been limited by the development of hypercalcemia and/or hyperphosphatemia due to increased intestinal absorption of these minerals. Recently, selective vitamin D analogs specifically designed to suppress parathyroid hormone (PTH) without causing hypercalcemia or hyperphosphatemia have shown promise for the treatment of secondary hyperparathyroidism in uremia. This case report describes the successful use of doxercalciferol to treat severe secondary hyperparathyroidism in an adult male patient undergoing chronic peritoneal dialysis, with a follow-up period of 9 months. During this period, the patient?s hyperparathyroidism was rapidly and easily controlled. Treatment was complicated by a single incident of over suppression of PTH, with concomitant hypercalcemia. This quickly resolved upon temporary discontinuation of doxercalciferol therapy, after which therapy was resumed without further incident.
Case reports
A case of lupus nephritis with alteration of the glomerular basement membrane associated with Takayasu’s arteritis
Abstract
N. Sano, K. Kitazawa, D. Totsuka,K. Kobayashi, H. Honda, Y. Makino,T. Shibata and T. Sugisaki
Department of Nephrology, Showa University, Shinagawa-ku, Tokyo
A 47-year-old Japanese woman with both Takayasu’s arteritis (TA) and systemic lupus erythematosus (SLE) presented with unequal pulses in the upper extremities, diarrhea and proteinuria. In 1986, when she was 38 years old, angiography revealed stenosis of the left subclavian artery. In 1994, SLE was diagnosed on the basis of clinical and laboratory findings, including renal dysfunction, hematologic and immunologic abnormalities, a high titer of antinuclear antibody and a positive lupus band test on the skin. Renal biopsy showed lupus nephritis and glomerular lesions with a bubble-like appearance of the glomerular capillary wall with TA. Lupus nephritis coexisting with glomerulonephropathy associated with TA has rarely been reported.
Letters to the Editor
A benign outcome of nephritis despite C-ANCA/PR3 positivity
Abstract
G. Wong, S.A. Jayawardene and N. Velasco
Letters to the Editor
Valacyclovir neurotoxicity in a patient with end-stage renal disease treated with continuous ambulatory peritoneal dialysis
Abstract
T. Okada, T. Nakao, H. Matsumoto, Y. Nagaoka, H. Iwasawa, K. Nanri and T. Yamazaki
