Volume 60, No. 6/2003(December)
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 Clinical Nephrology
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Review
Homocysteine-lowering therapy in renal disease
Abstract
S.K. Austen, J.S. Coombes and R.G. Fassett
1School of Human Movement Studies, University of Queensland, St. Lucia, Queensland, and 2Renal Research Unit, Launceston General Hospital, Launceston, Tasmania, Australia
Hyperhomocysteinemia is a potential risk factor for vascular disease and is associated with endothelial dysfunction, a predictor of adverse cardiovascular events. Renal patients (end-stage renal failure (ESRF) and transplant recipients (RTR)) exhibit both hyperhomocysteinemia and endothelial dysfunction with increasing evidence of a causative link between the 2 conditions. The elevated homocysteine appears to be due to altered metabolism in the kidney (intra-renal) and in the uremic circulation (extra-renal). This review will discuss 18 supplementation studies conducted in ESRF and 6 in RTR investigating the effects of nutritional therapy to lower homocysteine. The clinical significance of lowering homocysteine in renal patients will be discussed with data on the effects of B vitamin supplementation on cardiovascular outcomes such as endothelial function presented. Folic acid is the most effective nutritional therapy to lower homocysteine. In ESRF patients, supplementation with folic acid over a wide dose range (2 – 20 mg/day) either individually or in combination with other B vitamins will decrease but not normalize homocysteine. In contrast, in RTR similar doses of folic acid normalizes homocysteine. Folic acid improves endothelial function in ESRF patients, however this has yet to be investigated in RTR. Homocysteine-lowering therapy is more effective in ESRF patients than RTR.
Originals
ACE inhibitor enalapril diminishes albuminuria in patients with cystinosis
Abstract
E. Levtchenko, H. Blom, M. Wilmer, L. van den Heuvel and L. Monnens
1Department of Paediatric Nephrology, and 2Laboratory of Paediatrics and Neurology, University Medical Centre, Nijmegen, The Netherlands
Background/aims: Cystinosis, a rare autosomal recessive disease, manifests with renal Fanconi syndrome during the first year of life. Interstitial damage is a major cause of renal failure in patients with cystinosis. We presume that albuminuria contributes to the development of renal failure in these patients. The aim of this study was to examine whether the administration of ACE inhibitor enalapril diminishes albuminuria in patients with cystinosis. Methods: Five patients with cystinosis aged 4 – 9 years were studied. All patients had Fanconi syndrome and were treated with cysteamine. Median creatinine clearance was 48 ml/min/1.73 m2 (range 21 – 61). The excretion of albumin and a1 microglobulin as well as arterial blood pressure and serum creatinine were evaluated before and at 3 months on oral administration of enalapril (0.15 mg/kg once daily). Results: At 3 months on enalapril, albuminuria decreased in all patients (1,042 vs 629 mg per 24 h, p < 0.05). The median reduction of albuminuria was 43% (range: 4 – 72%, p < 0.05). Urinary excretion of a1 microglobulin remained constant. Systolic blood pressure decreased from median 110 – 100 mmHg (p < 0.05), while diastolic blood pressure remained stable (median 60 mmHg). Creatinine clearance decreased from median 48 – 45 ml/min/1.73 m2 (p < 0.05) and returned to previous values after discontinuation of enalapril. Conclusion: ACE inhibitor enalapril diminishes albuminuria in patients with cystinosis and might be used in these patients in order to slow the progression of renal insufficiency attributed to proteinuria.
Originals
Mizoribine oral pulse therapy for patients with disease flare of lupus nephritis
Abstract
H. Tanaka, K. Suzuki, T. Nakahata, K. Tsugawa, E. Ito and S. Waga
1Department of Pediatrics, Hirosaki University School of Medicine, and 2National Aomori Hospital, Hirosaki, Japan
Aim: Mizoribine (MZR) is a newly developed immunosuppressive agent in Japan. To relieve disease flare of lupus nephritis, a prospective pilot study of oral MZR pulse therapy (a phase II trial) is conducted as an alternative therapy to dose up of corticosteroids. Methods: Six Japanese patients with biopsy-proven lupus nephritis who experienced disease flare were prospectively evaluated. MZR at a dose of 5 – 10 mg/kg per day (up to 500 mg) in 1 or 2 divided daily doses was orally administered twice a week for 3 months. At the time of disease flare, 4 patients had refused to take dose up of corticosteroids, and the other 2 had complained of opportunistic infection. Results: At presentation, urine protein excretion, serum hemolytic complement activity (CH50) and serum anti-dsDNA antibody were 1.9 ± 0.6 g/day, 15.7 ± 5.8 U/ml (normal 23 – 46 U/ml) and 164.8 ± 184.0 IU/ml (normal < 12.0 IU/ml), respectively. Urine protein excretion and serum anti-dsDNA antibody decreased significantly following MZR oral pulse therapy (0.2 ± 0.1 g/day and 29.7 ± 23.4 IU/ml (p < 0.05), respectively), and serum CH50 recovered to normal (35.1 ± 10.4 U/ml, p < 0.05). Moreover, a significant histologic improvement was observed in a patient who received repeat renal biopsies at pre- and post-treatment. Reported peak serum MZR levels enough to inhibit human mixed-lymphocyte reaction (3.0 – 6.0 mg/ml) were achieved in all patients. No serious adverse effects were observed. Conclusion: Although we had no control subjects in this series, MZR oral pulse therapy may be of benefit to a proportion of patients with disease flare of lupus nephritis as an alternative therapy to dose up of corticosteroids.
Originals
Diagnostic role of [F-18]-FDG positron emission tomography in restaging renal cell carcinoma
Abstract
H. Jadvar, H.M. Kherbache, J.K. Pinski and P.S. Conti
1Department of Radiology, PET Imaging Science Center, and 2Department of Medicine, Division of Medical Oncology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
Aims: To retrospectively assess the diagnostic utility of positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) in restaging renal cell carcinoma. Materials and methods: We performed whole-body PET scans (45 minutes after intravenous injection of 10 – 15 mCi FDG) for restaging 25 patients (18 male, 7 female, 42 – 81 years old) with known or suspected metastatic renal cell carcinoma. Prior treatments included immunotherapy (n = 1), nephrectomy (n = 16), nephrectomy followed by chemotherapy (n = 3), by radiation therapy (n = 1), and by combined chemoradiation therapy (n = 4). Contrast-enhanced chest, abdomen and pelvis CT studies were available for all patients. Diagnostic validation was by histological sampling (n = 2) and clinical and imaging follow-up for up to 1 year (n = 23). Results: PET was concordant with the findings of CT in 18 patients (3 TN, 15 TP). PET was discordant with CT in 7 patients (28% of total). PET was falsely negative in 6 of these patients and did not demonstrate hypermetabolism in pulmonary (n = 4), mediastinal (n = 2), adrenal (n = 1) and lytic osseous (n = 2) metastatic lesions. PET was falsely positive in the remaining 1 patient in the discordant group with lumbar facet arthropathy. The diagnostic performance of PET in detection of recurrent and metastatic renal cell carcinoma revealed a sensitivity of 71%, specificity of 75%, accuracy of 72%, negative predictive value of 33% and positive predictive value of 94%. Conclusions: FDG PET demonstrates modest accuracy in the diagnostic imaging evaluation of patients with suspected or known metastatic renal cell carcinoma. A negative study may not exclude disease while a positive study is suspicious for malignancy.
Originals
Does hepatitis C virus infection increase hematocrit and hemoglobin levels in hemodialyzed patients?
Abstract
I. Sahin, F. Arabaci, H.A. Sahin, M. Ilhan, Y. Ustun, R. Mercan and L. Eminov
1Department of Nephrology, 2Department of Infectious Disease,
3Department of Family Medicine, and 4Department of Internal Medicine, Yüzüncü Yil University Medical School, Training Hospital, Van, Turkey
Objective: Some case reports indicated that red cell status increased after hepatitis C viral infection. The aim of study was to define the influence of hepatitis C infection (HCV) on red cell status in hemodialyzed patients. Materials and methods: A total of 49 (21 anti-HCV-positive and 28 anti-HCV-negative) patients with ESRD were included in this study. Exclusion criteria were blood transfusion and massive blood loss in the last 6 months preceding the study. None of the patients used any drug containing aluminum. Results: The prevalence of anti-HCV antibody was 42.8%. Mean age was 51.6 ± 14.3 in anti-HCV (+) group and 50.4 ± 17.0 in anti-HCV (–) group. There was no statistically significant difference between the ages of the 2 groups. Mean duration time of hemodialysis was significantly longer in patients with anti-HCV antibody (+) group (54.9 ± 34.2 months) compared to anti-HCV-negative group (12.5 ± 9.0 months) (p < 0.001). Mean hemoglobin (Hb) and hematocrit (Htc) levels were significantly higher in anti-HCV-positive patients than in anti-HCV-negative patients (Hb: 10.4 ± 1.8 g/dl, Htc: 30.5 ± 5.5% vs Hb: 8.8 ± 1.7 g/dl, Htc: 26.1 ± 5.3%) (for Hb p < 0.005, for Htc p < 0.007). There was no significant difference regarding the usage of rHuEPO between the 2 study groups (57.1% in anti-HCV antibody (+)/59.3% in anti-HCV antibody (–)) (p > 0.05). All patients not receiving rHuEPO did so because of economical reasons. Serum AST and ALT levels were significantly higher in the anti-HCV antibody-positive group compared with the anti-HCV antibody-negative group. (AST p < 0.04, ALT p < 0.04). Conclusion: Anti-HCV antibody-positive ESRD patients have higher hemoglobin and hematocrit levels compared to HCV-negative patients.
Case reports
Delayed renal allograft dysfunction and cystitis associated with human polyomavirus (BK) infection in a renal transplant recipient: a case report and review of literature
Abstract
M. Gupta, F. Miller, E.P. Nord and N.K. Wadhwa
1Division of Nephrology, Department of Medicine and 2Department of Pathology, School of Medicine, State University of New York at Stony Brook, New York, USA
Human polyomavirus type BK (BKV) associated nephritis (BKVAN) has recently emerged as an important cause of renal allograft dysfunction and failure. Early recognition of this entity as a cause of allograft dysfunction is extremely important since misdiagnosis can accelerate graft loss. We report a case of BKVAN that presented with symptoms related to cystitis, and review the risk factors, the diagnostic tools and the approach to treatment of BK virus associated allograft nephropathy.
Case reports
Disseminated Ochroconis gallopavum infection in a renal transplant recipient: the first reported case and a review of the literature
Abstract
T.K.F. Wang, W. Chiu, S Chim, T.M. Chan, S.S.Y. Wong and P.L. Ho
Centre of Infection and Departments of 1Microbiology, 2Paediatrics, and 3Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
Ochroconis gallopavum is a potentially fatal dematiaceous fungus causing opportunistic infections in immunocompromised hosts. We report the first case of disseminated O. gallopavum infection in a 13-year-old renal transplant recipient, which involved the brain, lung and spleen. He was treated with amphotericin B, itraconazole and voriconazole, a new antifungal agent first used to treat such an infection. Besides antifungal treatment, all immunosuppressive agents were stopped and automated peritoneal dialysis was resumed. The initial infection was under control with both clinical and radiological improvements after treatment. However, the patient later acquired Acremonium spp. peritonitis; he failed to respond to high-dose amphotericin B, and finally succumbed. A total of 13 reported O. gallopavum human infections, including the one described here, are reviewed. The most common site of involvement is the brain and the crude mortality rate is up to 46%. As the disease is potentially lethal in immunocompromised hosts, empirical antifungal coverage should be considered in post-renal transplant recipients with suspected brain abscess. Early biopsy of lesion for histopathological and microbiological diagnosis would be essential in managing such cases.
Case reports
mproved pregnancy outcome in a patient with renal allograft nephropathy undergoing temporary hemodialysis
Abstract
R. Al-Jayyousi, S. Carr, S. Hodgett, I. Scudamore, E. Howarth, A. Singlehurst and N. Brunskill
1John Walls Renal Unit, and 2Department of Obstetrics and Gynaecology, Leicester General Hospital, Leicester, UK m
We report a case of a woman with a poorly functioning renal allograft and a positive anti-cardiolipin antibody who was dialysis-independent and conceived 18 months following her transplant. She was electively maintained on hemodialysis during the pregnancy and delivered a live infant at 31 weeks gestation. Her renal function returned to prepregnancy levels post partum and she remained dialysis-independent.
Case reports
Acute renal failure in a hypothyroid patient with rhabdomyolysis
Abstract
P.M. Kar, A. Hirani and M.J. Allen
Orlando Nephrology, Winter Garden, FL, USA
A 49-year-old hypothyroid man developed rhabdomyolysis and acute renal failure. He had been on thyroid replacement therapy for 17 years following removal of a benign pituitary tumor. Rhabdomyolysis was diagnosed by elevated liver enzymes, CPK, and creatinine. The case illustrates how hypothyroidism can cause rhabdomyolysis and subsequently, acute renal failure.
Case reports
Idiopathic spontaneous bladder rupture in an intoxicated patient
Abstract
S.J. Lynn, S.D. Mark and M. Searle
Departments of 1Nephrology and 2Urology, Christchurch Hospital, Christchurch, New Zealand
Spontaneous bladder rupture is a rare condition associated with significant morbidity and mortality. We describe a case that occured following a period of alcohol intoxication and presented as acute renal failure. The factors that contribute to this condition in an intoxicated person are outlined and useful clinical markers are suggested. This case demonstrates the difficulties with diagnosis and the need for a high index of suspicion.
Case reports
A rare case of central post-gravid diabetes insipidus
Abstract
L.F. Morrone, A. Saracino, A. Ramunni, E. Fasianos, P. Coratelli and G. Passavanti
Department of Internal and Public Medicine, Division of Nephrology, University of Bari, Italy
Central diabetes insipidus (CDI) arising in the puerperal period has been attributed mainly to Sheehan’s syndrome or to lymphocytic infundibulo-neurohypophysitis. We report the case of a 24-year-old woman who came to our observation for the appearance, 3 weeks after a normal delivery, of a polyuric-polydipsic syndrome. Measurements of urinary volumes, plasma osmolality and urinary osmolality, in conditions of free water intake, water deprivation and a water deprivation-vasopressin administration test, demonstrated CDI. Brain magnetic resonance imaging showed a normal morphology of the adenohypophysis and total absence of the neurohypophysis. Assays of the pituitary hormones were found to be within normal limits. These results, incompatible with a diagnosis of Sheehan’s syndrome and lymphocytic infundibulo-neurohypophysis, excluded all the other known causes of acquired CDI. Our diagnosis was therefore of post-gravid idiopathic CDI. Thus, it is possible that in the puerperal period other diseases of the posterior hypophysis may develop, of unknown etiopathogenesis but equally responsible for CDI.
Letters to the Editor
Nephrotic syndrome associated with carcinoma of the breast
Abstract
P.A. Hill, D.G. Goodman and R.D. Snyder
Letters to the Editor
Minimal change nephropathy and renal tuberculosis
Abstract
S.H. Lambie and M.J.D. Cassidy
Letters to the Editor
Acute IgA nephropathy following keloid scar formation due to burn injury
Abstract
H. Tanaka and S. Waga
Letters to the Editor
Left atrial myxoma associated with systemic AA amyloidosis
Abstract
A. Navas-Parejo, E. Moreno, M. Riera, R. García-Orta and C. Correa
Letters to the Editor
CRP and depression in patients on chronic dialysis
Abstract
H. Taskapan, F. Ates, B. Kaya, M. Kaya, M. Emul, Ç. Taskapan and I. Sahin
