Volume 59, No. 1/2003(January)
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 Clinical Nephrology
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Originals
Outcome of renal transplantation in patients with pauci-immune small
vessel vasculitis or anti-GBM disease
Abstract
J.K.J. Deegens, M.A. Artz, A.J. Hoitsma and J.F.M. Wetzels
Department of Medicine, Division of Nephrology, University Medical Center Nijmegen, Nijmegen, The Netherlands
Aim: Pauci-immune small vessel vasculitis (SVV) and anti-GBM disease are the most common causes of rapidly progressive glomerulonephritis (RPGN) and they frequently lead to end-stage renal disease. For renal replacement therapy, renal transplantation is the preferred treatment option. However, in patients with glomerular diseases, the outcome of renal transplantation can be adversely affected by recurrence of the original disease. The information in the medical literature on the outcome of renal transplantation in patients with RPGN is limited because most data are derived from case studies and from studies involving a small number of patients. Methods: We studied the outcome of renal transplantation in patients with pauci-immune SVV or anti-GBM disease, transplanted in our center between 1968 and 2000. Patient and graft survival were compared with a matched control group from our hospital. We specifically looked for any evidence of recurrent disease. Results: Included in the study were 43 patients (31 male, 12 female) with a mean age (± SD) of 48 ± 15 years at transplantation. Patients were diagnosed as Wegener’s granulomatosis (n = 8), microscopic polyangiitis (n = 7), renal limited vasculitis (n = 18) and anti-GBM disease (n = 10). The average follow-up was 62 ± 57 months. No graft was lost due to recurrence of the underlying disease. One patient with Wegener’s granulomatosis had a relapse with only extrarenal manifestations 5 months after transplantation. Patient and graft survival at 5 years after transplantation were 77% and 60%. Survival rates were not significantly different from a matched control group of renal transplant patients with other underlying diseases, 79% and 56%, respectively. Patients with pauci-immune SVV or anti-GBM disease developed significantly more malignancies than the control group (p = 0.02). Conclusions: Recurrence of pauci-immune SVV and anti-GBM disease after transplantation is rare. Renal transplantation can be successfully performed in patients with pauci-immune vasculitis or anti-GBM disease. Physicians should be aware of the greater risk of developing malignancies, especially skin cancer.
Originals
No association of the TGF-b1 gene polymorphisms with the renal progression in autosomal dominant polycystic kidney disease (ADPKD) patients
Abstract
J.G. Lee, C. Ahn, S.-C. Yoon, J.H. Park, H.-S. Eo, J.J. No, K.H. Kim, E.J. Lee, Y.H. Hwang, D.Y. Hwang, Y.S. Kim, J.S. Han, S. Kim, J.S. Lee and S.H. Kim
1Department of Internal Medicine, Eulji Medical College, 2Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, 3Department of Internal Medicine, College of Medicine, Dankook University, Chonan, 4Department of Biological Science, Sookmyung Women’s University, and 5Department of Radiology, College of Medicine, Seoul National University, Seoul, Korea
Background: Two genetic loci, PKD1 and PKD2, have been identified as being responsible for ADPKD, and PKD1 is known to be associated with a poor prognosis. However, the presence of an intrafamilial study clinical diversity suggests that there are disease-modifying loci. Because the mechanism of the renal failure in ADPKD includes a cystic growth and tubulointerstitial atrophy and fibrosis, we studied the associations between 2 polymorphisms in the TGF-b1 gene, which are known to be associated with chronic tubulointerstitial inflammation, and ADPKD progression in Korean patients. Patients and methods: One hundred and twenty-five individuals who had ADPKD and 47 normal control subjects were genotyped by PCR-RFLP, the T869C (Leu10Pro) variant of TGF-b1 gene leader sequence was discriminated with MspA1I and the G915C (Arg25Pro) variants with BglI. Statistical significances were determined using the Chi-square test. Results: The distribution of the alleles for the TGF b1 Leu10Pro polymorphism in ADPKD was: T 54%, C 46%, which was similar to the Korean (56 : 44, p = 0.887) and Western controls (65 : 35). In addition, no differences were found between the ESRD and the non-ESRD groups (p = 0.888) or the early hypertension and the normotension groups (p = 0.249). The distribution of alleles for the TGF b1 Arg25Pro polymorphism showed only the GG type which was different from the Western population controls (G : C = 90 : 10, p = 0.000). Conclusions: Our results suggest that the polymorphism at Arg25Pro of TGF-b1 in the Korean population has an allele distribution different from that of the Western population and that the polymorphism at Leu10Pro of TGF-b1 has no association with the renal progression in Korean ADPKD patients.
Originals
Comparison between serum creatinine and creatinine clearance for the prediction of postoperative mortality in patients undergoing major vascular surgery
Abstract
M.D. Kertai, E. Boersma, J.J. Bax, A.H. van denMeiracker, H. van Urk, J.R.T.C. Roelandt and D.Poldermans
1Departments of Cardiology, 2Internal Medicine and 3Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
Background: Poor renal function prior to surgery is associated with increased risk for mortality in patients undergoing major vascular surgery. Traditionally, this function is assessed by serum creatinine concentration (SeCreat). However, SeCreat is also influenced by age, gender and body weight. Hence, creatinine clearance (CCr) is considered to be a better reflection of renal function. This study was undertaken to explore the prognostic value of preoperative calculated CCr compared to SeCreat for the prediction of postoperative mortality. Patients and methods: The study group comprised 852 consecutive patients who underwent elective major vascular surgery at the Erasmus Medical Center, Rotterdam. Preoperative CCr was calculated based on the Cockroft-Gault equation using preoperative SeCreat, age, body weight and gender. Univariable logistic regression analyses were used to study the relation between preoperative SeCreat, CCr and postoperative mortality. Furthermore, multivariable logistic regression analysis was applied to evaluate the additional predictive value of age, body weight and gender additional to SeCreat. The receiver operating characteristic (ROC) curve was determined to evaluate the predictive power of several regression models for perioperative mortality. Results: Postoperative mortality was 5.9% (50/852) within 30 days of surgery. In a univariable analysis, 10 mmol/l increment of SeCreat were associated with a 20% increased risk of postoperative mortality (OR = 1.2, 95% CI, 1.1 – 1.3) with an area under the ROC curve of 0.64 (95% CI, 0.56 – 0.71). If age, gender and body weight were added, the area under the ROC curve increased to 0.70 (95% CI, 0.63 – 0.77; p < 0.001), indicating that these risk factors had additional prognostic value. Indeed, in a separate regression analysis 10 ml/min decrease in CCr was associated with a 40% increased risk of postoperative mortality (OR = 1.4, 95% CI, 1.2 – 1.5; ROC area: 0.70, 95% CI, 0.63 – 0.76). ROC curve analysis showed that the cut-off value of 64 ml/min for CCr yielded the highest sensitivity/specificity to predict postoperative mortality. Conclusion: Preoperative SeCreat was strongly associated with postoperative mortality, and adding age, gender, and body weight to the model showed improved predictive power indicating that preoperative CCr calculated with these data has additional prognostic value.
Originals
Nutritional effects of carnitine supplementation in hemodialysis patients
Abstract
C. Chazot, C. Blanc, J.M. Hurot, B. Charra, G. Jean and G. Laurent
Centre de Rein Artificiel, Tassin, France
Aims: Carnitine is involved in fatty acid metabolism and it is cleared by dialysis. As it plays a role in energy utilization and because malnutrition is a frequent complication of HD treatment, we studied the effects of carnitine supplementation on several nutritional parameters in HD patients. Material and methods: The main selection criterion was a body mass index (BMI; body weight/(height)2) < 22 kg/m2. Fifty-three patients were enrolled to participate in this open and randomized study. For 6 months, 28 patients received 15 mg/kg of intravenous L-carnitine at the end of each hemodialysis (HD) treatment (Group A), the remaining 25 patients were controls (Group B). The measured parameters were the post-dialysis body weight, serum albumin concentration (nephelemetry), food intake assessed by a 3-day food questionnaire, nPNA (normalized protein equivalent of nitrogen appearance), creatinine generation, and anthropometry. Results: Forty-five patients completed the study (Group A: 14 F/9 M, 66.7 years old; Group B: 11 F/11 M, 65.2 years old). At the beginning of the study, there were no differences between the groups for age, gender, HD duration, BMI, diabetes prevalence, plasma carnitine levels and measured nutritional parameters. 65.2% and 77.3% in each group were carnitine-deficient (plasma total carnitine level < 35 mmol/l). After 6 months of L-carnitine supplementation, none of the nutritional parameters had changed in either group, except that serum albumin concentration decreased in both groups. Dividing each group according to their respective median serum albumin concentrations, daily energy and protein intakes, creatinine generation or triceps skinfold thickness did not show any difference in the various nutritional parameters with or without carnitine supplementation. Conclusion: Carnitine supplementation, despite normalization of plasma carnitine levels, has no effect on the nutritional status of HD patients.
Originals
Relationship between plasma level of parathyroid hormone and carboxymethyllysine in hemodialyzed patients - does it exist?
Abstract
F. Kokot, R. Schinzel, J. Chudek, A. Heidland, M. Adamczak, R. Ficek and A. Wiecek
1Department of Nephrology, Endocrinology and Metabolic Diseases, Silesian University Medical School, Katowice, Poland, 2Physiologische Biochemie, and 3Innere Klinik der Universität Würzburg, Germany
Aims: Both parathyroid hormone and advanced glycated end products (AGEs) are uremic toxins. The present study aimed to examine the likely interrelationship between these compounds. Methods: Seventy-four hemodialyzed patients (41 female, 33 male; mean age 47 ± 2 years, mean duration on hemodialysis 36 ± 6 months) were enrolled in this study. In all subjects, the body mass index (BMI) was calculated and total lean mass (TLM) and total fat mass (TFM) were assessed by dual X-ray absorptiometry. Blood samples for estimation of plasma calcium, phosphorus, carboxymethyl lysine (as marker of AGEs) and PTH-1-84 were obtained after overnight fasting, before subsequent hemodialysis session. Results: BMI, TFM and TLM were 23.6 ± 0.5 kg/m2, 16.3 ± 1.0 kg and 46.3 ± 1.1 kg, respectively. PTH plasma level (223 ± 32 pg/ml) and plasma CML (1,837 ± 84 ng/ml) were markedly elevated as compared with reference values. A significant positive correlation was found between TLM and CML levels (t = 0.225; p = 0.04) and between plasma PTH and CML levels (t = 0.224; p = 0.04). Conclusion: It seems likely that PTH and AGEs are interrelated. The pathophysiological relevance of this finding in the pathogenesis of uremic toxicity remains to be elucidated.
Originals
Differential use of cardiac troponin T versus I in hemodialysis patients
Abstract
T. Fehr, A. Knoflach, P. Ammann, P. Pei and U. Binswanger
1Division of Nephrology and 2Institute of Clinical Chemistry, University Hospital, Zurich, and 3Division of Cardiology, Kantonsspital, St. Gallen, Switzerland
Background: Cardiac troponin T (cTnT) is frequently elevated in asymptomatic hemodialysis (HD) patients and predicts increased cardiovascular morbidity and mortality. Compared to cTnT, cardiac troponin I (cTnI) has a shorter half-life. How this influences its diagnostic reliability in chronic HD patients is only partially known. Patients and methods: First, in a cross-sectional study cardiac troponins were measured in 31 asymptomatic HD patients. A third-generation cTnT assay was used. The rate of false positive tests and the intraindividual variability were determined. Second, in a retrospective analysis over 12 months all acute events with clinical suspicion for acute coronary syndrome (ACS) were analysed in the same patients to determine the diagnostic power of cTnT by receiver-operating curve (ROC) plot. Results: Cross-sectional study: 9 of 52 (17%) cTnT and 0/52 cTnI (0%) tests were positive in asymptomatic HD patients with a low intraindividual variability. Retrospective analysis: 16 acute clinical events with determination of cTnT were recorded, and in 4/16 an ACS was diagnosed. Using a cut-off level of 0.1 mg/l, the cTnT test reached a sensitivity of 100%, a specificity of 42%, a positive predicitive value of 36% and a negative predictive value of 100%, using a cut-off level of 0.2 mg/l the corresponding values were 75%, 58%, 38% and 88%. Conclusions: Cardiac TnT, but only rarely cTnI, is elevated in a significant number of asymptomatic HD patients. For diagnosis of ACS in HD patients, a combination of cTnT and cTnI may be used, since the former has higher sensitivity and the latter higher specificity. A higher threshold value for cTnT in HD patients could further increase its diagnostic accuracy.
Originals
Large atrial thrombus formation associated with tunneled cuffed hemodialysis catheters
Abstract
O. Negulescu, M. Coco, J. Croll and M.H. Mokrzycki
1Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, and 2St. Barnabas Hospital, Bronx, New York, USA
Aims: In the existing literature, there is a paucity of data regarding large atrial thrombus (AT) formation occurring as a complication of tunneled cuffed hemodialysis catheter (TCC) use. This study was performed to determine the risk factors, mortality and the appropriate management of TCC-AT. Methods: We report 6 new cases of TCC-AT and have amalgamated these data with data from 16 previously published cases of TCC-AT found by performing a PubMed literature search (total of 22 cases). Demographic data were collected prospectively over 2 years in 85 consecutive patients initiating hemodialysis who were using a TCC as their primary vascular access, so that comparisons could be made between the 6 patients with TCC-AT versus all patients with a TCC at our center. Results: In patients with TCC-AT, the mean time from TCC insertion was 4.5 months, and infection was present at the time of diagnosis in 68% of cases. The mean thrombus size was 3.7 cm, range 1.5 ? 8 cm. All but 1 case were visualized by echocardiography; the remaining case required magnetic resonance imaging. Management included TCC removal and thrombectomy (n = 9), TCC removal and anticoagulation (AC) (n = 6), TCC removal alone (n = 5), and no intervention (n = 2). The overall mortality was 27%, and 5 of the 6 deaths (83%) occurred in patients with bacteremia. The mortality associated with each management strategy was as follows: TCC removal and thrombectomy (0%), TCC removal and AC (33%), TCC removal alone (40%), and no intervention (100%). Conclusions: AT is a serious complication of TCC use in hemodialysis patients and may be associated with a high mortality rate. TCC-AT may occur more commonly than previously reported and therefore warrants a high index of suspicion.
Originals
A preliminary survey of bacterial contamination of the dialysate circuit in continuous veno-venous hemodialysis
Abstract
N.S. Kanagasundaram, A.B. Larive and E.P. Paganini
1Department of Hypertension/Nephrology, Section of Dialysis and Extracorporeal Therapy, and 2Department of Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Aims: The problem of dialysate bacterial contamination has not been defined in continuous renal replacement therapy. We assessed the bacterial integrity of source bicarbonate dialysate (study 1) and the continuous veno-venous HD (CVVHD) bicarbonate dialysate circuit (study 2). Methods: Study 1: 50 ml dialysate were collected from 41 bags randomly selected from 150 consecutively made dialysate bags, immediately after manufacture or after 24, 48 or 72 h. Study 2: 10 ml dialysate were drawn from 4 sample points ranged along the dialysate circuit in 18 therapies (mean duration 119.5 ± 72.0 h). All points were sampled at therapy start then daily, bar the proximal point which was sampled after each dialysate bag change. All dialysate samples underwent Gram stain and aerobic/anaerobic culture. Samples over 10 ml were cultured after centrifugation (15 min, 4,000 rpm). A disseminated contamination (DC) involved ³ 1 sample point at a time and/or was sustained over time. Results: Study 1: One bag was culture-positive (staphylococcal/diphtheroid growths; 48-h sample). Study 2: Six DCs developed in 6 therapies (1 at therapy end, 5 sustained to therapy end (duration 57.25 ± 45.95 h), 5 with Gram-negative bacilli, all involving reported growths of ³ 1,000 cfu). Dialyzer-inclusive dialysate circuit changes were more frequent in non-DC therapies (change rate: DC, 0.08 ± 0.12/day, non-DC, 0.34 ± 0.23, p = 0.02, permutation tests with general scores) but did not entirely prevent DC or alter it once underway. Conclusions: Sustained bacterial contamination of bicarbonate-based CVVHD is common and could relate to the completeness of dialysate circuit change. The importance of technique and regular quality control is highlighted.
Case reports
Hemodialysis versus continuous veno-venous hemodiafiltration in the management of severe valproate overdose
Abstract
T.D. Kay, H.R. Playford and D.W. Johnson
Department of 1Renal Medicine and 2Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Australia
Valproate intoxication is a relatively common clinical problem that can result in coma, respiratory depression, pancytopenia, hemodynamic instability and death [Fernandez et al. 1996, Franssen et al. 1999]. The drug’s relatively low molecular weight, small volume of distribution and saturable protein-binding render it potentially amenable to extracorporeal removal (hemofiltration, hemodialysis or hemoperfusion), but published experience is scarce. This report describes a woman with a potentially fatal sodium valproate overdose, who did not respond to continuous veno-venous hemodiafiltration, but was successfully treated with low-flux hemodialysis. Based on our experience, we recommend hemodialysis for serious valproate intoxication.
Case reports
Cardiac and pulmonary calcification in a hemodialysis patient: partial regression 4 years after parathyroidectomy
Abstract
C. Di Leo, M. Gallieni, A. Bestetti, L. Tagliabue, M. Cozzolino, P. Carpani, C. Pozzato, G.L. Tarolo and D. Brancaccio
1Department of Nuclear Medicine, 2Division of Nephrology and Dialysis, and 3Department of Radiology, University of Milan, Ospedale San Paolo, Milan, Italy
Aims: The reversibility of extraskeletal calcifications in dialysis patients is an important and unresolved issue. Although periarticular calcifications have been shown to be reversible, little data are available on vascular or parenchymal calcifications. Case history: A patient on maintenance hemodialysis with severe hyperparathyroidism, hypercalcemia and hyperphosphatemia was admitted to undergo parathyroidectomy. A preoperative total body bone scintigraphy was performed to better evaluate a lytic lesion in the pelvis, the histology of which proved to be a “brown tumor”. The scan showed the typical findings of renal osteodystrophy, but also a diffuse extra-skeletal uptake of bone tracer in the lungs, kidneys, femoral arteries and myocardium. After surgery, good control of serum calcium, phosphate (Ca × P product < 50 mg2/dl2) and PTH levels was maintained during 4 years of follow-up. Bone scans were repeated after 2 and 4 years, showing marked improvement of periarticular uptake at the ends of long bones. Extraosseous calcium deposition was still markedly evident, but progressively decreased (at 4 years: heart –36%, lungs –18%). Conclusion: In this dialysis patient, extraskeletal calcification of visceral organs (particularly in the heart and the lungs) due to prolonged hypercalcemia and hyperphosphatemia was partially reversible by parathyroidectomy followed by good long-term control of serum phosphate and calcium.
Letters to the Editor
Acute poststreptococcal glomerulonephritis mimicking Henoch- Schönlein purpura
Abstract
H. Matsukura, A. Ohtsuki, T. Fuchizawa and T. Miyawaki
Letters to the Editor
Hemolytic uremic syndrome and cattle
Abstract
G. Ardissino, E. Taioli, V. Daccò and S. Testa
Letters to the Editor
Trichosporon inkin peritonitis in a patient on continuous ambulatory peritoneal dialysis returning from the Caribbean
Abstract
K.S. Crowther, A.T. Webb and P.H. McWhinney
Letters to the Editor
Erratum
Letters to the Editor
Long-term outcome of acute tubulointerstitial nephritis: report of a case
Abstract
H. Tanaka, K. Suzuki, T. Nakahata and S. Waga
