Volume 59, No. 3/2003(March)
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 Clinical Nephrology
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Originals
Twenty-year follow-up of acquired renal cystic disease
Abstract
I. Ishikawa, Y. Saito, M. Asaka, N. Tomosugi, T. Yuri, M. Watanabe and R. Honda
1Division of Nephrology, Department of Internal Medicine, Kanazawa Medical University, Uchinada, 2Keijyu General Hospital, 3Asanogawa General Hospital, and 4Department of Hygiene, Kanazawa Medical University, Uchinada, Japan
Aims: Since 1979 the diseased kidneys of 96 patients on replacement therapy with chronic renal failure due to chronic glomerulonephritis have been followed to investigate the development of acquired cysts and tumors. This is a report of the 20-year follow-up. Materials and methods: Ninety-six patients were followed using periodic CT scan and were divided into hemodialysis, renal transplantation, bilateral nephrectomy and deceased groups during the follow-up. In the hemodialysis group, 36 patients (19 males, 17 females) were followed for 20 years. Results: Kidney volumes which were 57.8 (1.51) (geometric mean (geometric SD)) ml at start of the follow-up had become 185.3 (2.03) ml 20 years later in males, and in females, 57.3 (1.64) ml had become 99.7 (2.36) ml. The increased rate was 3.2 (2.06) fold in males and 1.7 (2.57) fold in females. This enlargement of the kidneys was due to acquired cysts. Kidney volumes at the 20-year follow-up had increased more significantly than those at the 15-year follow-up in males; however, kidney volumes at the 20-year follow-up had not changed in females, if compared with data at the 15-year follow-up. Kidney volumes in males at 20-year follow-up were significantly larger than those in females (p = 0.0232). Males with more than 3.2-fold in kidney volume increase at the 20-year follow-up were under the age of 40 at entry into this study (p = 0.0055), although the correlation between the degree of kidney volume increase and age was not significant (p = 0.0910). Kidney volumes in the transplantation group remained small. There was no new renal cell carcinoma development after 15-year follow-up except for the local recurrence of a previous operated case. Although 7 of 44 patients died during the past 20 years due to malignancy, no patient died of renal cell carcinoma because of early detection and treatment. One patient died of retroperitoneal bleeding, which is a complication of acquired renal cystic disease. Conclusion: Male preponderance of acquired cysts was maintained at the 20-year follow-up. There was a tendency for the rate of increase in acquired renal cystic disease to be larger in young males. No one died of renal cell carcinoma, although the incidence of renal cell carcinoma was high.
Originals
Which factors account for renal stone formation in cystic fibrosis?
Abstract
R. von der Heiden, A.P.G. Balestra, M.G. Bianchetti, C. Casaulta Aebischer, P.E. Mullis, K. Lippuner and P. Jaeger
1Department of Pediatrics, 2Osteoporosis Unit, and 3Policlinic of Medicine, University Hospital, Berne, Switzerland
Aims: Studies dealing with the increased tendency to stone formation noted in cystic fibrosis, focus on enteric hyperoxaluria. It is well recognized, however, that low urine volume, hypocitraturia and perhaps even hypercalciuria are further risk factors for stone formation. Methods: Nineteen patients with cystic fibrosis (14 boys and 5 girls, aged 10 – 23, median 15 years) underwent a standard protocol for metabolic evaluation of the lithogenic tendency. In 10 patients, the study was repeated after treatment with recombinant human growth hormone 43 mg/kg body weight daily for 12 months. Results: The metabolic evaluation disclosed low urine output in 12, hyperoxaluria in 8 and hypocitraturia in 9 of the 19 cystic fibrosis patients. The mentioned parameters were not influenced by treatment with recombinant human growth hormone. Conclusion: The report indicates that in cystic fibrosis low urine volume, hypocitraturia and hyperoxaluria act in concert and contribute to the likelihood of stone formation. This tendency is not modified by treatment with recombinant human growth hormone.
Originals
Combined effects of vasopressin V2 receptor antagonist and loop diuretic in humans
Abstract
K. Shimizu
Sumiyoshi Clinic Hospital, Mito, Ibaraki, Japan
Aims: Patients with edematous diseases are generally treated with diuretics, but frequently present with hyponatremia associated with impaired water excretion. This study investigated the combined effects of vasopressin V2 receptor antagonist OPC-31260, an aquaretic, and furosemide, a saluretic, on free water excretion and serum sodium concentration (PNa). Material and methods: The study was planned as an open-label, 4-period, 4-treatment, crossover study in 12 healthy subjects using single doses of placebo, furosemide 20 mg (F), OPC-31260 30 mg (O), and furosemide 20 mg plus OPC-31260 30 mg (O+F). Results: OPC-31260 co-administered with furosemide induced an increase in PNa and serum osmolality (F: 281.6 ± 0.7, O+F: 284.9 ± 0.7 mOsm/kgH2O) as a result of an additive increase in maximal urine volume (F: 7.7 ± 1.9, O: 6.8 ± 0.5, O+F: 13.2 ± 1.4 ml/min) with increased electrolyte-free water excretion (F: 0.35 ± 0.15, O: 5.3 ± 0.5, O+F: 4.8 ± 0.5 ml/min) while maintaining sodium excretion (F: 731 ± 110, O+F: 1,064 ± 149 mEq/min). It was suggested that by the co-administration, the resulting decreased generation of free water in Henle’s loop was canceled out by a decrease in back-diffusion of free water across the collecting ducts. Conclusions: The co-administration may be particularly effective in treating edema and hyponatremia in edematous diseases.
Originals
Renal ultrasonography is useful for evaluating diabetic renal failure
Abstract
M. Nishimura, H. Terawaki,Y. Hoshiyama, K. Joh, K. Hamaguchi and K. Yamada
1Department of Internal Medicine, Sakura National Hospital, Chiba,
2Department of Public Health, Showa University School of Medicine, Tokyo, 3Department of Pathology, and 4Department of Clinical Investigation, Sakura National Hospital, Chiba, Japan
Aim: It has been reported that the course of renal function is heterogeneous in patients with diabetic nephropathy. This study was undertaken to examine the clinical usefulness of renal ultrasonography in evaluating diabetic chronic renal failure (CRF) patients. Methods: The renal sizes of type 2 diabetic patients with various degrees of renal injury, non-diabetic subjects without renal diseases and patients with non-diabetic CRF were measured by ultrasonography. The renal area index (RAI) was calculated from renal measurements and body surface area. The rate of renal function decline (D 1/cre) was analyzed by calculating the slope of the regression line for the reciprocal of serum creatinine concentrations over time. The correlations between D 1/cre and various clinical and laboratory parameters, including RAI, were analyzed. Results: The RAI values of type 2 diabetic patients with nephropathy increased on the whole. It was also found that the RAI value of diabetic CRF patients was heterogeneous. There was a significant correlation between RAI and log D 1/cre (r = 0.492, p < 0.01). In addition to RAI, urinary protein excretion, serum albumin concentration and mean blood pressure significantly correlated with log D 1/cre. The correlation between RAI and log D 1/cre remained significant after adjustment for age, gender and serum albumin concentration. However, it was no longer significant after inclusion of mean blood pressure in the multivariate analysis. Conclusion: Although RAI is not a completely independent predictor of the risk of progression of diabetic renal failure, RAI could be a useful marker for the evaluation of diabetic renal failure. Renal involvement in diabetic patients is heterogeneous, and since renal ultrasonography is non-invasive and safe to perform, it is useful in evaluating diabetic CRF patients.
Originals
Influence of hemodialysis on echocardiographic Doppler indices of the left ventricle: changes in parameters of systolic and diastolic function and Tei index
Abstract
S. Koga, S. Ikeda, K. Matsunaga, T. Naito, Y. Miyahara, K. Taura and S. Kohno
1Department of Internal Medicine, Nagasaki Municipal Medical Center, and 2Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan
Aims: Numbers of previous studies have evaluated the influence of dialysis-induced altered loading condition on Doppler-echocardiographic indices of left ventricle in patients with chronic renal failure. It has been suggested that most of Doppler-derived indices are preload-dependent. On the other hand, there are no studies that have evaluated the influence of hemodialysis on Tei index; a new Doppler-derived index obtained by isovolumetric contraction time plus isovolumetric relaxation time divided by ejection time. The aim of this study is to evaluate whether Tei index is also influenced by dialysis-induced altered loading condition as well as other Doppler-derived indices, and to assess the possibility that Tei index is also preload-dependent. Patients and methods: Thirty-two patients with chronic renal failure (21 men and 11 women, aged 48 – 93 years) on maintenance hemodialysis were evaluated for Doppler-derived indices before and after hemodialysis. We studied parameters of diastolic function (peak velocities of mitral inflow in early diastole (E) and late diastole from atrial filling (A), ratio of A to E (A/E), deceleration time (DT), and isovolumetric relaxation time (IRT)), parameters of systolic function (ejection time (ET), pre-ejection period (PEP), ratio of PEP to ET (PEP/ET), and isovolumetric contraction time (ICT)) and Tei index. Results: Hemodialysis resulted in significant decreases in E, increase in A/E, prolongation of IRT, no change in A and DT; significant prolongation of ICT and PEP, shortening of ET, and increase in PEP/ET and a significant increase in Tei index (0.42 ± 0.16 vs 0.51 ± 0.16, p < 0.0001). When patients were subdivided into 2 groups based on weight loss after hemodialysis (³ 1.5 kg and < 1.5 kg), only the group that lost ³ 1.5 kg had significant change in Tei index before and after hemodialysis (0.40 ± 0.15 vs 0.52 ± 0.17, p = 0.0002). Conclusion: This study demonstrates that not only most of Doppler-derived indices but also Tei index is affected by dialysis-induced altered loading condition and suggests that Tei index is possibly preload-dependent.
Originals
The effect of vitamin B12 on total plasma homocysteine concentration in folate-replete hemodialysis patients
Abstract
M. Arnadottir and B. Hultberg
1The Department of Medicine, Landspitali University Hospital, Reykjavik, Iceland, and 2Department of Laboratory Medicine, Division of Clinical Chemistry, University of Lund, University Hospital, Lund, Sweden
Aim: Results from several studies indicate that the total homocysteine (tHcy) concentration in plasma is an independent risk factor for cardiovascular disease in hemodialysis patients. Folic acid is the established mainstay of homocysteine-lowering treatment, but since such treatment does not normalize plasma tHcy concentration in hemodialysis patients, it is of importance to search for additional therapy. Methods: Twenty-eight folate-replete hemodialysis patients were randomized to 2 equally sized groups, a treatment group and a control group. The treatment group received vitamin B12 tablets at a dose of 2 mg 3 times a week for 6 weeks (after each dialysis session) while the control group received no such treatment. Blood samples were collected before and at the end of the treatment period for analysis of tHcy in plasma and vitamin B12, methylmalonic acid as well as folate in serum. Results: At the end of the study period, serum vitamin B12 concentrations were significantly higher in the treatment group than in the control group. Plasma tHcy concentrations decreased significantly in both groups during the study period. However, there was no difference between the responses of the 2 groups. Conclusion: The results of this open, randomized controlled study did not support the hypothesis that treatment with oral vitamin B12 has considerable homocysteine-lowering effect in folate-replete hemodialysis patients.
Originals
Evaluation of bone mineral density after renal transplantation under a tacrolimus-based immunosuppression: a pilot study
Abstract
E. Goffin, J.-P. Devogelaer, G. Depresseux, J.-P. Squifflet, Y. Pirson and C. van Ypersele de Strihou
Departments of 1Nephrology, 2Rheumatology, and 3Renal Transplantation, Hôpital St. Luc, Université Catholique de Louvain, Brussels, Belgium
Background: Progressive bone loss consistently complicates renal transplantation (TP) in patients given an immunosuppression including prednisolone. The adjunction of cyclosporine in the immunosuppressive regimen does not reverse the negative impact of renal TP on the skeleton. The post-transplant effect of tacrolimus on bone mass is still unknown. Methods: We evaluated the evolution of bone mineral density (BMD) and various biochemical markers over the first 12 months following renal TP in 23 patients given an immunosuppression combining tacrolimus and low-dose prednisolone. BMD of lumbar spine, total hip and hip subregions was measured by dual-energy X-ray absorptiometry within the first 15 days and 1 year after TP. Results: At the time of TP, the average BMD was low in both the lumbar spine and the hip. After TP, a normalization of serum creatinine and a decrease in serum phosphate and iPTH levels occurs. Serum alkaline phosphatase level significantly rose transiently within the first 6 months and decreased thereafter. At 1 year post TP, BMD remained unchanged in the lumbar and in the trochanter subregions and rose in the other sites. BMD increased by at least 2% in 8, 13, 10 and 10 out of the 23 patients in the lumbar, neck, trochanter and total hip subregions, respectively. No correlation was found between evolution in BMD and age, sex, dialysis duration, level of hyperparathyroidism, prednisolone and tacrolimus cumulative intake and prescription of calcium, vitamin D or hormone replacement therapy. Conclusions: An immunosuppression combining tacrolimus and low-dose prednisolone might avoid the usual post-TP bone loss. Further randomized double-blind studies evaluating a larger cohort of patients should be undertaken to compare the effect of cyclosporine and tacrolimus on bone mass.
Case reports
Late onset seizures, hemiparesis and blindness in hemolytic uremic syndrome
Abstract
B. Bennett, T. Booth and A. Quan
1Children’s Medical Center of Dallas, USA, and
2University of Texas Southwestern Medical Center, Dallas, USA
Neurologic complications of hemolytic uremic syndrome, including seizures, usually occur early during the acute phase of the illness. We report a 3-year-old girl with classic diarrhea-associated hemolytic uremic syndrome who developed late onset seizures, hemiparesis and transient blindness on the 17th hospital day, at which time her recovery was characterized by improvement in her blood pressure, serum electrolytes, renal function, hematocrit and platelet count. A CT and MR revealed brainstem and posterior parietal and occipital infarct/edema. The association of these radiologic findings within the posterior distribution along with visual loss and seizures are unique to posterior reversible encephalopathy syndrome. Within 7 days, she regained motor function and vision and had no further seizure activity. At 6 months follow-up, physical examination revealed normal motor function and vision and a repeat MR showed near resolution of the previous findings with minimal occipital lobe gliosis. This case report describes the uncommon finding of late onset seizures occurring during the recovery phase of hemolytic uremic syndrome with MR findings consistent with posterior reversible encephalopathy syndrome.
Case reports
Steroid-induced tumor lysis syndrome in a patient with preleukemia
Abstract
S.-S. Yang, T. Chau, M.-S. Dai and S.-H. Lin
1Division of Nephrology, and 2Division of Hematology and Oncology,
Department of Medicine, Tri-Service General Hospital,
National Defense Medical Center, Taipei, Taiwan, R.O.C.
Tumor lysis syndrome (TLS) is a well recognized complication of chemotherapy and radiotherapy for leukemia, lymphoma as well as rapidly growing malignancies. Less described is the occurrence of TLS following steroid therapy alone. Herein, we report on a 32-year-old male with myelodysplastic syndrome, characterized by refractory anemia with excess blasts in transformation, who developed acute oliguric renal failure 12 hours after methylprednisolone 1.0 g for presumed autoimmune thrombocytopenia. Laboratory investigations revealed typical findings of TLS, including hyperkalemia, marked hyperuricemia, hyperphosphotemia, hypocalcemia and urine uric acid to creatinine ratio 1.8 (> 1.0). Long hemodialysis (8 hours) was initiated for 3 consecutive sessions. Renal function recovered 1 week later. This case high-lights that single-dose steroid administration in a patient with hematological malignancy may cause the potential life-threatening complications of TLS. Prophylactic management prior to the use of steroid therapy for a variety of purposes is absolutely required in high-risk patients.
Case reports
Recurrent angiolymphoid hyperplasia with eosinophilia mimicking temporal arteritis associated with nephrotic syndrome
Abstract
E. Sandstad, H. Aksnes, S. Sund and F.P. Reinholt
1Department of Pathology, 2Department of Internal Medicine, Oppland Central Hospital, Lillehammer, 3Department/Institute of Pathology, Rikshospitalet University Hospital, University of Oslo, and 4Department of Pathology, Förde Central Hospital, Förde, Norway
We report on a middle-aged Caucasian male who presented with nephrotic syndrome that on 2 consecutive recurrences was accompanied by a pulsating tumor suggesting temporal arteritis. Renal biopsies showed features of a low-grade mesangial-proliferative glomerulonephritis. The resected tumor in the temporal region revealed a lesion consistent with angiolymphoid hyperplasia with eosinophilia (ALHE), with moderate inflammatory involvement of the temporal artery. The patient was successfully treated with oral prednisolone in addition to removal of the tumor, but has remained steroid-dependent. To our knowledge, only 2 cases of ALHE and nephrotic syndrome have been reported so far in non-Japanese individuals [Altman et al. 1995, Sonkodi et al. 1987], and we are not aware of any previous case combining these features while simultaneuosly mimicking temporal arteritis.
Case reports
Efficacy of mycophenolate mofetil on recurrent glomerulonephritis after renal transplantation
Abstract
K. Harzallah, C. Badid, D. Fouque, N. Lefrancois, J.-L. Touraine and M. Laville
1Service de Néphrologie, and 2Service de Chirurgie et Médecine de la Transplantation, Hôpital Edouard Herriot, Lyon Cedex, France
Recurrent glomerulonephritis in transplanted kidneys is not rare despite classical immunosuppressive drugs and depends on the etiology of nephropathy. Treatment of recurrence of renal disease on graft remains controversial. We report 6 cases of patients with recurrent glomerulonephritis after renal transplantation treated with mycophenolate mofetil (MMF). The glomerular diseases were Wegener’s granulomatosis (n = 1), membranoproliferative glomerulonephritis type I (n = 1), focal and segmental glomerular sclerosis (n = 1), membranous glomerulonephritis (idiopathic membranous nephropathy (n = 1) and systemic lupus erythematous) (n = 1)) and immunoglobulin A nephropathy (n = 1). MMF was introduced because of intolerance of classical immunosuppressive treatment in 2 cases and because of its inefficiency in the other cases. MMF was introduced between 3 months and 36 months (13.5 ± 7 months) after recurrence of the primitive glomerulonephritis. During combined MMF/cyclosporine/prednisone therapy, only 3 patients responded to MMF. MMF was disrupted precociously in 1 out of 3 patients who stabilized renal function because of discovery of lung cancer and in 2 out of the 3 other patients because of gastrointestinal intolerance and severe anemia. We supposed that MMF could represent a new effective alternative therapy of recurrent glomerulonephritis on renal graft in some cases.
Case reports
Hemodynamically relevant hematuria several months after biopsy of a kidney graft: an unusual cause
Abstract
A. Voiculescu, M. Brause, V. Engelbrecht, W. Sandmann, T. Pfeiffer and B. Grabensee
1Department of Nephrology and Rheumatology, 2Department of Diagnostic Radiology, and 3Department of Vascular Surgery and Renal Transplantation, Heinrich Heine University, Düsseldorf, Germany
We report the case of a 52-year-old female patient, who after a complicated living donor kidney transplantation, underwent kidney biopsy for suspected rejection. Duplex scanning revealed a small, asymptomatic arteriovenous (AV) fistula which was assessed as being hemodynamically unimportant. During follow-up, several urinary tract infections occurred and recurrent short episodes of hematuria were attributed to cystitis, urethritis and urosepsis. Eight months later, the patient developed suddenly massive hematuria, tamponade of the urinary bladder and hemorrhagic shock as well as urosepsis. Duplex sonography showed a massive pseudoaneurysm in addition to the AV fistula. Arteriography confirmed the Duplex sonographic findings and embolization was performed after treatment of concomitant urosepsis. The fistula was closed completely and bleeding ceased. Although AV fistulas are rare complications of kidney biopsies and in most cases they remain asymptomatic, life-threatening hematuria can present several months after a biopsy due to the development of a pseudoaneurysm. Concomitant infectious complications of the urinary tract, bleeding disorders and other factors can be misleading during the assessment of the cause of gross hematuria. Regular Duplex sonographic follow-up examinations in patients with AV fistulas are advisable.
Case reports
Staghorn calculi complicating renal transplantation in patients with persistent post-transplantation hyperparathyroidism
Abstract
S.A. Jayawardene and D.J.A. Goldsmith
Departments of Nephrology and Transplantation, Guy’s and St. Thomas’ Hospitals, London, UK
Renal stones rarely complicate renal transplantats. Their causation is diverse. We describe 2 patients with significant staghorn calculi caused by metabolic factors.
Case reports
Successful retransplantation using rapamycin in a patient with previous calcineurin inhibitor-induced posterior leukoencephalopathy syndrome
Abstract
B. Afzali and D.J A. Goldsmith
Nephrology and Transplantation, Guy’s Hospital, London, UK
Posterior Leukoencephalopathy Syndrome (PLES) is a rare but serious neurological condition with many aetiologies. In the era of organ transplantation there have been sporadic reports of calcineurin-inhibitor associated PLES. We describe a case, with subsequent uneventful retransplantation using sirolimus.
Case reports
Successful perioperative blood purification therapy in patients with maintenance hemodialysis therapy who underwent living donor liver transplantation
Abstract
J.J. Kazama, N. Takahashi, Y. Ito, Y. Watanabe, N. Iino, S. Iguchi, A. Oyanagi, H. Obayashi, S. Ito, H. Maruyama, I. Narita, S. Yamamoto, Y. Sato, A.Tsuchiya, T. Ichida and F. Gejyo
1Division of Clinical Nephrology and Rheumatology, 2Division of General Surgery, and 3Division of Gastroenterology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
Living donor liver transplantation (LDLT) is a treatment for end-stage liver failure, and was developed to overcome the distinct insufficiency of cadaveric donors. Case 1 is a 56-year-old man who had undergone maintenance hemodialysis therapy for 4 years. An LDLT was performed for the treatment of advanced liver cirrhosis and hepatocellular carcinoma. Continuous hemodiafiltration (CHDF) was performed from the 2nd to 5th days after the operation. Case 2 is a 55-year-old man with primary amyloidosis and chronic renal failure. An LDLT was performed for the treatment of severe abdominal distention caused by a large liver volume. Although CHDF was started at the 3rd day after the operation, it was discontinued within 24 hours because of an increased urinary volume. CHDF was required again from the 6th ? 8th days, after which the blood purification mode was switched to regular intermittent hemodialysis. Meanwhile, no major problems occurred in either case. In conclusion, CHDF was required for about 5 days from the 2nd day after the operation. The application of careful and aggressive blood purification therapy during the perioperative period is a key to successful LDLT in dialysis patients.
Letters to the Editor
Behçet’s disease and focal segmental glomerulosclerosis
Abstract
N. Cengiz, M. Karaoglanoglu, K. Cengiz and T. Akpolat
Letters to the Editor
A case of giant condylomata acuminata involving anus after renal transplantation
Abstract
H.C. Yu, B.H. Cho, M.J. Chung, M.J. Kang, B.J. La, W. Kim, S.K. Kang and S.K. Park
Letters to the Editor
Acute hyponatremia and renal failure following percutaneous nephrolithotomy
Abstract
C.-H. Chou, T. Chau, S.-S. Yang and S.-H. Lin
Obituary
Prof. Dr. Erwin Hecking?
