Volume 59, No. 4/2003(April)
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 Clinical Nephrology
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Originals
Clinical relevance of microalbuminuria screening in self-reported non-diabetic/ non-hypertensive persons identified in a large health screening - The Nord-Trøndelag Health Study (HUNT), Norway
Abstract
S. Romundstad, J. Holmen, K. Kvenild, O. Aakervik and H. Hallan
1HUNT Research Centre, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Verdal,
2Department of Internal Medicine, Hospital Levanger, Levanger, and
3Nærøy Health Centre, Nærøy, Norway
Aim: The aim of this study was to investigate the clinical relevance and consequences of screening for microalbuminuria (MA) in a randomly selected, apparently healthy population sample. Material and methods: A total of 2,113 individuals (³ 20 years) without known diabetes and treated hypertension, all identified in the large population-based Nord-Trøndelag Health Study (HUNT) 1995 – 1997, (n = 65,258), delivered 3 morning urine samples for MA analysis. Those with MA, defined as at least 2 out of 3 urine samples with albumin-to-creatinine ratio (ACR) ³ 2.5 mg/mmol, were invited to a second clinical examination. Results: In total, 54 men and 54 women had MA, and 42 men (84%) and 42 women (78%) attended the second examination. All with MA had 1 or more cardiovascular risk factors, like elevated cholesterol, c-peptides and blood pressure, and they were older than those without MA. Ten men (25%) and 19 women (46%), who were defined as MA-positive at the screening, had normal albumin excretion in the overnight collected urine sample in the second clinical examination. Five men (12%) and 2 women (5%) were still followed-up at the hospital out-patient clinic 3 years later. Conclusions: Several individuals in the second examination had cardiovascular risk factors and other pathology, but the clinical benefit of discovering this was not obvious. Due to low positive predictive value and reduced reliability and validity, MA did not satisfy the criteria for a good screening test in this apparently healthy population.
Originals
Urinary transferrin, high molecular weight proteinuria and the progression of renal disease
Abstract
B. Mackinnon1, L. Shakerdi2, C.J. Deighan1, J.G. Fox1, D.St.J. O’Reilly2 and M. Boulton-Jones1
1Renal Unit, and 2Department of Pathological Biochemistry, Glasgow Royal Infirmary, Glasgow, Scotland
Aims: Proteinuria predicts rate of progression in a variety of nephropathies. There is considerable evidence that iron-transferrin is toxic to proximal tubular cells in vitro, and recent clinical work suggests that selectivity of proteinuria influences the outcome of renal disease. The aim of this study was to examine the relationship between the nature of proteinuria and progression of renal disease. Methods: This was a prospective, cross-sectional study in 66 patients with primary glomerulonephritis, diabetic nephropathy and a variety of other renal diseases. Urinary transferrin was measured by sandwich ELISA and correlated with rate of change in estimated creatinine clearance (ECC). Urinary SDS-PAGE was undertaken to divide proteinuria into tertiles according to molecular weight and to quantify the protein in each tertile. The magnitude of each tertile was then correlated with rate of change in ECC over a median period of 20 months. Results: Rate of change of renal function correlated with total proteinuria (r2 = 18%, p < 0.001) and albuminuria (r2 = 17%, p < 0.001), but not urinary transferrin (r2 = 0%, p = 0.235). On univariate analysis high molecular weight proteinuria (r2 = 21%, p < 0.001), intermediate molecular weight proteinuria (r2 = 15%, p = 0.001) and low molecular weight proteinuria (r2 = 10%, p = 0.005) correlated with rate of change in ECC as did total fasting cholesterol (r2 = 7%, p = 0.003). On multivariate analysis, however, the only independent predictors of rate of change in ECC were high molecular weight proteinuria (r2 = 19%, p < 0.001), and total fasting cholesterol (r2 = 5%, p = 0.035). Conclusions: We found no evidence to support the hypothesis that iron-transferrin is important in the development of human renal injury. High molecular weight proteinuria correlates more strongly with rate of progression of renal disease than intermediate molecular weight, low molecular weight or even total proteinuria. This suggests either, that one or more high molecular weight proteins are implicated in causing progressive renal impairment, or that loss of size selectivity at the glomerular basement membrane is associated with accelerated tubulointerstitial damage.
Originals
Distal nephron sodium-potassium exchange in children with nephrotic syndrome
Abstract
R.A.M.G. Donckerwolcke, A. France, A. Raes and J. Vande Walle
1Department of Pediatrics, University Hospital Maastricht, The Netherlands, and 2Division of Pediatric Nephrology, Department of Pediatrics, University Hospital Gent, Belgium
While recent literature data suggest that a primary impairment in sodium excretion is the basic abnormality in the pathogenesis of edema formation in the nephrotic syndrome, there is ample evidence that functional hypovolemia contributes to stimulation of renal sodium and fluid retention. Vasoactive hormones such as renin and aldosterone are involved in this process. Discrimination between both mechanisms would be possible by assessment of aldosterone bioactivity and will have therapeutical consequences by indicating the need for administration of i.v. albumin or diuretics. In this paper, several indices of aldosterone bioactivity were assessed in 85 patients with minimal lesion nephrotic syndrome (118 measurements were performed in patients while in remission and 210 following relapses), and in 41 nephrotic patients with different types of nephropathy and were related to plasma renin and aldosterone levels. A better correlation was found between log aldosterone and UK+/UNa+ + UK+ ratio than with other parameters measuring renal potassium handling such as transtubular potassium gradient, fractional excretion of potassium and urine K+/urine Na+ or urine K+ creatinine ratios. In patients with renal sodium retention (FENa% less than 0.5), an UK+/UNa+ + UK+ ratio higher than 0.60 identifies patients with increased aldosterone levels and indicates functional hypovolemia. This index may therefore be used to assess which patients will benefit from i.v. albumin administration.
Originals
Effects of hypokalemia and hypomagnesemia on zidovudine (AZT) and didanosine (ddI) nephrotoxicity in rats
Abstract
A.C. Seguro, M. de Araujo, F.S. Seguro, M. Rienzo, A.J. Magaldi and S.B. Campos
1Nephrology, Faculdade de Medicina da Universidade de São Paulo, LIM-12, São Paulo, and 2Instituto de Infectologia Emílio Ribas, São Paulo, Brazil
Background: Zidovudine (AZT) and didanosine (ddI) are antiretroviral drugs widely used in AIDS patients. Hypokalemia and hypomagnesemia are frequently encountered in AIDS patients using AZT and/or ddI. Objective: To verify the effects of AZT and ddI on rat renal function submitted to normal diet, low potassium diet and magnesium-free diet. Methods: Glomerular filtration rate and renal hemodynamic were measured in Wistar rats submitted to a normal or a potassium-depleted diet. The animals were given AZT, ddI for 15 days. Six groups of rats were studied: normal diet, normal diet + AZT, normal diet + ddI, low K diet, low K diet + AZT and low K diet + ddI. Three additional groups of rats submitted to magnesium depletion for 15 days were also studied: magnesium-free diet, magnesium-free diet + AZT and magnesium-free diet + ddI. Results: AZT and didanosine did not modify renal function of rats on a normal diet. However, in hypokalemic rats, both drugs produced a decrease in glomerular filtration rate and in renal blood flow consequent to renal vasoconstriction and associated with alterations in tubular function (characterized by an increased fractional excretion of sodium). Hypomagnesemia induced a decrease in glomerular filtration rate and in renal blood flow only in AZT-treated rats. Conclusion: Our data suggest that hypokalemia predisposes to AZT and ddI nephrotoxicity, while hypomagnesemia predisposes only to AZT nephrotoxicity. Thus, chronic AZT and ddI administration may produce acute renal failure in AIDS patients with hypokalemia and/or hypomagnesemia. Serum K and Mg levels should be carefully monitored in these patients.
Originals
Chlamydia pneumoniae IgA seropositivity is associated with increased risk for atherosclerotic vascular disease, myocardial infarction and stroke in dialysis patients
Abstract
S.C. Wolf1, O. Mayer1, S. Jürgens2, R. Vonthein3, G. Schultze4, T. Risler1 and B.R. Brehm1
1Medical Clinic III, 2Institute of Virology, 3Department of Medical Statistics, University of Tübingen, Tübingen, and 4Dialysis Institute of Villingen Schwenningen, Villingen-Schwenningen, Germany
Background: Atherosclerotic cardiovascular disease is the major cause of morbidity and mortality in patients with chronic renal failure undergoing dialysis therapy. Aim of the study was to evaluate whether there is a correlation between a past infection with Chlamydia pneumoniae inducing antibody production and the manifestation of symptomatic atherosclerotic disease in patients with chronic renal failure on hemodialysis. Methods: A retrospective study was designed including 151 dialysis patients with a clinical apparent atherosclerotic disease (case subjects) and 116 dialysis patients without any symptomatic atherosclerotic manifestation (control group). An ELISA was used to measure seropositivity for IgA and IgG titers. Results: Elevated IgA titers against Chlamydia pneumoniae were found in 67% of the case subjects, but only in 29% of the controls (OR 5.34, CI 2.98 – 9.56). Forty-five patients of the case subjects had a history of myocardial infarction (OR 5.14, CI 2.38 – 11.09). Prior stroke was found in 30 patients in case subjects (OR 4.37, CI 1.73 – 11.01). The follow-up after 3 years showed that only 20 patients died from cardiovascular disease in the control group in comparison to 57 patients in the case group (OR 2.51). IgG seropositivity revealed an OR of 1.02 (CI 1.0 – 2.1). Conclusion: These results indicate that IgA seropositivity is associated with an increased frequency of symptomatic atherosclerotic manifestations. Especially an increased number of patients was found with prior myocardial infarction or stroke when elevated IgA titers were detected. IgA positivity seems to be a separate prospective risk factor in patients with chronic renal failure and hemodialysis for premature cardiovascular death.
Originals
Sleep quality and clinical correlates in patients on maintenance dialysis
Abstract
M.L. Unruh, M.G. Hartunian, M.M. Chapman and B.L. Jaber
1Division of Nephrology, University of Pittsburgh School of Medicine,
2Division of Nephrology, Department of Medicine, Tupper Research Institute, New England Medical Center, Tufts University School of Medicine, Boston, and 3Dialysis Clinic, Inc., Boston, MA, USA
Background: Sleep quality is a subject of increasing interest to clinicians caring for dialysis patients. Self-assessed sleep disturbances have been associated with quality of life outcomes. The goal of this study was to identify clinical and laboratory parameters that are independently associated with overall sleep quality among prevalent dialysis patients. Methods: The Epworth Sleepiness Scale (ESS) and the Sleep Problems Index (SPI), a questionnaire derived from the Medical Outcomes Study, were administered to 71 dialysis patients and 68 subjects without known kidney disease (control group). The ESS and the SPI sleep item responses between the 2 groups were compared. The sleep items from the SPI were also aggregated into a sleep quality score. Multivariate linear regression analyses of sleep quality scores were used to identify clinical factors that were independently associated with poor sleep. Results: The ESS score was not significantly different between the 2 groups. However, the responses to the SPI sleep items demonstrated significantly impaired subjective sleep quality in dialysis patients compared with control subjects. In addition, overall sleep quality, as measured by the aggregated sleep score, was lower in dialysis patients compared with the control group (41 vs. 47, p < 0.001). In multivariate analyses, factors that were independently associated with poor sleep quality in dialysis patients were male gender (p = 0.006), history of coronary artery disease (p = 0.003), and high phosphate level (p = 0.05). Conclusion: This study demonstrates that global sleep quality of dialysis patients is substantially impaired. Poor sleep quality was associated with male gender, coronary artery disease and high serum phosphate level, a modifiable factor. Future studies are needed to examine the relationship of serum phosphate level to sleep quality in dialysis patients.
Originals
Effect of ultrafiltration on blood pressure variability in hemodialysis patients
Abstract
S. Kürsat, B. Özgür and T. Alici
Department of Nephrology, Department of Internal Medicine, Medical School of Celal Bayar University, Manisa, Turkey
Aim: Increased blood pressure variability (BPV) in end-stage renal disease (ESRD) patients is proved to be a risk factor for cardiovascular disease [Tozawa et al. 1999]. The effect of ultrafiltration (UF) on BPV in hemodialysis (HD) patients has not been reported in the literature. This study was undertaken to define the effect of a single UF on BPV in HD patients. Methods: Prior and after HD with UF, 24-hour ambulatory BP monitoring (ABPM) was applied to each patient and then diurnal and nocturnal BP and BPV parameters (both before and after UF) were compared and correlated with UF values. Results: Increase in BPV after single UF in all groups was statistically significant (p < 0.05). Only the daytime systolic (DS) BPV increase (median 42.4%) was in positive correlation with D body weight (body wt) (median 3.07%) or UF amount (r = 0.649, p < 0.01). Conclusions: Large volume depletions and sympathetic hyperreactivity could explain the increase in BPV. Increased interdialytic weight gain requires more UF and subsequently BPV, morbidity and mortality also increase. Thus, considerable efforts must be made to prevent great interdialytic weight gain in HD patients.
Case reports
Tacrolimus in resistant primary membranous nephropathy - a report of 3 cases
Abstract
C.-C. Szeto, C.-B. Leung, F.M.-M. Lai and P.K.T. Li
1Department of Medicine and Therapeutics, and 2Department of Anatomical and Cellular Pathology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
Aim: To study the efficacy and safety of tacrolimus in primary membranous nephropathy. Method: We describe 3 patients with primary membranous nephropathy who were either resistant to or could not tolerate steroid with or without cytotoxic agents. They were treated with tacrolimus 0.2 mg/kg/day for 6 months. The dosage of tacrolimus was adjusted to keep a whole blood tacrolimus level of 5 – 10 ng/ml. Results: One patient had almost complete disappearance of proteinuria while the other 2 had at least 50% reduction in proteinuria. Proteinuria increased again in 2 of the patients after tacrolimus was stopped, but in neither of them proteinuria returned to the pretreatment level 6 months after tacrolimus was stopped. Conclusion: We conclude that tacrolimus may have a modest efficacy in the treatment of resistant membranous nephropathy.
Case reports
Pulmonary-renal syndrome due to hemorrhagic fever with renal syndrome: an unusual manifestation of Puumala virus infection in France
Abstract
D. Launay, Ch. Thomas, D. Fleury, S. Roueff, M.-L. Line, D. Droz and Ph. Vanhille
1Service de N
The authors report about a patient who presented with acute respiratory failure, bilateral alveolar infiltrates, without signs of fluid overload, and acute renal failure. Percutaneous renal biopsy revealed acute interstitial nephritis with medulla hemorrhages. Serologic tests for Puumala virus infection were positive. Hemorrhagic fever with renal syndrome should be considered when patients present with pulmonary-renal syndrome.
Case reports
A case of acute renal failure due to rhabdomyolysis, associated with non-autoimmune fulminant type 1B diabetes mellitus
Abstract
M. Iyoda, A. Kuroki, K. Kato, N. Kato, T. Hirano and T. Sugisaki
1Department of Nephrology, and 2Department of Endocrinology and Metabolism, Showa University School of Medicine, Tokyo, Japan
A 38-year-old man developed severe diabetic ketoacidosis complicated with rhabdomyolysis and acute renal failure after presenting hyperglycemic symptoms for 4 days. Initial investigation showed significant hyperglycemia (blood glucose level 1,593 mg/dl) with a relatively low level of HbA1c (7.0%) and a high pancreatic enzyme concentration without any signs of pancreatitis. Diabetes-related antibodies were absent except for the anti-glutamic acid decarboxylase antibody, which disappeared later on. Pancreatic biopsy examination showed the lack of insulin-secreting cells, without insulitis. These findings were almost consistent with non-autoimmune fulminant type 1B diabetes. The patient remained dependent on dialysis for 1 month, then his renal function recovered. In patients with this type of diabetes, the onset of overt diabetes, frequently accompanied with severe diabetic ketoacidosis, is rapid, hence, early detection, quick diagnosis and immediate treatment of this novel type of diabetes are important in the rescue of these patients.
Case reports
Paecilomyces peritonitis: case report and review of the literature
Abstract
K. Wright, S. Popli, V.C. Gandhi, J.R. Lentino, C.V. Reyes and D.J. Leehey
1Veterans Affairs Hospital, Hines, Illinois, and 2Loyola University Stritch School of Medicine, Maywood, Illinois, USA
While filamentous fungi are a rare cause of peritonitis in peritoneal dialysis patients, there is increasing recognition of Paecilomyces species as pathogens in such patients. We herein report a case of fungal peritonitis secondary to the filamentous Paecilomyces variotii species. The patient had a long and ultimately fatal course of illness despite catheter removal, discontinuation of peritoneal dialysis, recurrent intraabdominal abscess drainage, and prolonged courses of antifungal therapy. Our experience with this case and a review of the literature suggests that infection with this fungus can cause substantial morbidity and is probably best treated with prompt catheter removal, aggressive antifungal therapy and vigilant observation for complications.
Letter to the Editor
Successful treatment of chronic Parvovirus B19 infection by high-dose immunoglobulin
Abstract
R. Mareschal-Desandes, J.L. Andre, J.F. Lesesve, M.J. Krier, P. Bordigoni and J.C. Humbert
