Volume 60, No. 3/2003(September)
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 Clinical Nephrology
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Laudatio
Reinhold Kluthe celebrates his 75th birthday
Abstract
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Reinhold Kluthe celebrated his 75th birthday on July 8th, 2003. Kluthe was born in Dillingen/Saar, Germany and studied medicine in Homburg/Saar and Freiburg. After receiving his doctor’s degree in 1956, he first worked as a research fellow at the Freiburg University Institute for Hygiene (Prof. Haas) and thereafter as a resident in Internal Medicine at the Medizinische Universitätspoliklinik (Prof. Sarre), also in Freiburg. This was followed by stays in Berlin/Switzerland at the Biochemical Institute under Professors Aebi and Isliker and at the Basel Canton Hospital. In 1964 he qualified as a University lecturer with a postdoctoral thesis on the pathogenesis and protein metabolism of nephrotic syndrome at Freiburg University, where he subsequently became senior physicion of the Medizinische Poliklinik in 1965 and Associate Professor in Internal Medicine in 1970. From 1975 to 1976 he served as a temporary director of the Medizinische Poliklinik and was appointed 1977 as a director of the newly established section of Nutritional Medicine and Dietetics.
Reinhold Kluthe’s scientific work found expression in more than 350 publications on renal, hypertensive, metabolic and nutritional diseases and their treatment. He played a major role in enabling dietetics to regain its former importance as an essential treatment of metabolic disease in this age of pharmacotherapy. One of his most outstanding achievements was the development of a low-protein potato-egg diet for patients with chronic and terminal renal failure. This strict dietary regimen enabled many patients in preterminal renal failure to stay alive until treatment with the artificial kidney became available for them. Its principles were described in a dietary handbook for patients with renal disease, which Reinhold Kluthe edited together with H. Quirin in 1968. Several later editions now exist.
Reinhold Kluthe can be considered as one of the pioneers in the development of our understanding of the relationship between metabolic disturbances (such as diabetes and obesity) and renal disease / and arteriosclerosis. He founded and edited several widely read and renowned journals such as Clinical Nephrology (1973), Nieren- und Hochdruckkrankheiten (1972) and Aktuelle Ernährungsmedizin (1975).
Reinhold Kluthe retired prematurely in 1991 to dedicate himself more intensively to his activities as the head of the German Academy for Nutritional Medicine (ANC), which he founded in 1983. There, his main field of responsibility is physician training in the area of nutritional medicine. He headed the committee in charge of developing a nutritional medicine curriculum for the German Bundesärztekammer (Federal Medical Chamber). Over 2000 physicians have since become ANC-certified as specialists for nutritional medicine. Kluthe is presently supervising the National Pilot Project on Clinical Nutritional Medicine, in which more than 30 hospitals are participating. Professor Kluthe was awarded the ISFE Medal for his achievements in the area of clinical nutrition and the development of nutritional education in 1997, and he received the first Konrad Lang Medal to be awarded by the German Society for Nutritional Medicine in 2003.
On behalf of Clinical Nephrology (CN) and most certainly many nephrologists all over the world we congratulate him with best wishes for many future years.
J. Feistle, Publisher
K.M. Koch and H.H. Malluche, Editors
Originals
Clinical and pathological features of children with Henoch-Schoenlein purpura nephritis: risk factors associated with poor prognosis
Abstract
Y. Kawasaki, J. Suzuki, N. Sakai, K. Nemoto, R. Nozawa, S. Suzuki and H. Suzuki
Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
Objective: To clarify the risk factors related to prognosis in patients with Henoch-Schoenlein purpura nephritis (HSPN), we investigated the cases with HSPN on long-term observation. Methods: We enrolled 114 patients who had been diagnosed with HSPN from 1974 ? 1997. These patients were divided into 2 groups based upon features at last follow-up. One group, designated ?favorable?, consisted of 69 patients with normal urine and 25 patients with minor urinary abnormalities, and the second group, designated ?unfavorable?, consisted of 15 patients with active renal disease and 5 patients with renal failure. The clinical features, laboratory data and pathological findings were investigated in 2 groups. Results: Nephrotic syndrome, decreased factor XIII activity, hypertension and renal failure at onset were more frequent in ?unfavorable? than in ?favorable?. The rate of glomeruli with crescents, macrophage infiltrations, tubulointerstitial changes and acute exacerbation in ?unfavorable? were higher than those in ?favorable?. There were 5 cases with renal insufficiency, and renal survival rate was 95.6% for over 15 years. Conclusions: These results suggest that the above mentioned risk factors play an important role in prognosis of the patients with active renal disease and renal failure.
Originals
Association between blood indoxyl sulfate and carbonyl stress marker in hemodialysis patients
Abstract
A. Kato, M. Odamaki and A. Hishida
1Shizuoka Cancer Center Hospital, 2First Department of Medicine, Hamamatsu University School of Medicine, Hamamatsu, and 3Department of Clinical Nutrition, School of Food and Nutritional Science, University of Shizuoka, Shizuoka, Japan
Background: Indoxyl sulfate (IS) is a protein-bound solute, which is progressively retained in blood according to the decline of renal function. However, clinical relevance of excess IS in hemodialysis (HD) patients remains unknown. Patients and methods: We measured serum IS and clinical parameters including pentosidine, carboxymethyllysine (CML) and homocysteine levels in 55 HD patients (age: 67 ± 2 years, time on HD: 67 ± 11 months, male/female = 30/25), and examined the relationship between IS and these data. Results: Serum IS was markedly increased in HD patients (80.49 ± 6.17 mg/ml) compared to normal range (< 1.9 mg/ml). IS was significantly and positively correlated with time on HD (p < 0.01), blood urea nitrogen (p < 0.01), b2-microglobulin (p < 0.03), and protein catabolic rate (PCR) (p < 0.01). The patients with increased IS needed a higher erythropoietin dosage. Blood IS was positively correlated with pentosidine (r = 0.505, p < 0.01) and CML (r = 0.275, p < 0.05). In contrast, blood IS was not associated with nutritional and inflammatory parameters. A stepwise multiple regression analysis revealed that time on HD, PCR and pentosidine were significant determinants of IS. Conclusions: Serum IS was related to time on HD and dietary protein intake. Accumulated IS may be associated with enhanced carbonyl stress in chronic HD patients.
Originals
Neither folic nor folinic acid normalize homocysteine levels in hemodialysis patients
Abstract
E. Armada1, C. Pérez1, A. Otero1, J. Esteban1, M. Camba1, P. Gayoso2 and D. Suárez3
1Section of Nephrology, 2Investigation Unit, and 3Laboratory C.,
Hospitalario de Ourense, Fundación Renal Iñigo Alvarez de Toledo, Spain
Aims: A greater decrease in total homocystein (tHcy) has been reported in patients on hemodialysis (HD) following the administration of reduced forms of folic acid (FA), however, the effect of the administration of moderated doses of oral levofolinic acid has not been compared with that of FA. We decided to perform a study to evaluate the therapeutic effectiveness of oral levofolinic acid, the pharmacologically active form of folinic acid in our population of HD patients already on treatment with oral FA and vitamin B6. Material and methods: We undertook a prospective study in HD patients who had been receiving oral supplements of both FA 5 mg every 48 hours and vitamin B6 40 mg every 7 days during at least 6 months, with a 17% initial decrease of tHcy levels. Patients matched for age, sex and time on HD were assigned to 1 of 2 groups: Those in group A continued to receive their previous supplements while in group B, FA was substituted by calcium levofolinate 5 mg given orally every 48 hours. The following parameters were measured at baseline and at month 6: urea kinetic model and concentrations of plasma albumin, C-reactive protein, folate, vitamin B12, pyridoxal phosphate and tHcy. Results: Group A: 30 patients aged 63.4 (57.9, 68.9) years, with a time on HD of 23.4 (15.8, 30.8) months, group B: 32 age-matched patients 66.2 (62.1, 70.3) years old, with a time on HD of 23.8 (16.7, 30.9) months. No differences were found either in folate levels (72.7 (47.9, 97.5) vs. 71.9 (44.0. 99.9) ng/ml), tHcy (23.5 (21.1, 25.9) vs. 23.3 (20.8, 25.8) mmol/l), or any other study variables. In the 2 groups a significant reduction in both residual renal function (RRF) and vitamin B12 levels was observed after supplementation, but no changes in tHcy values, folate levels or any of the other parameters were found. The prevalence of hyperhomocysteinemia in group A was 93.3% at study start and 100% at month 6, in group B the corresponding values were 93.8% and 96.9%. After 6 months, multiple regression analysis showed that tHcy levels were not influenced by the type of treatment (p = 0.543). Conclusions: After 6 months of calcium-levofolinate supplementation tHcy levels did not decrease and were similar to those in patients given the same dose of FA.
Originals
Simultaneous hemodialysis during coronary angiography fails to prevent radiocontrast- induced nephropathy in chronic renal failure
Abstract
H. Frank, D. Werner, V. Lorusso, L. Klinghammer, W.G. Daniel, U. Kunzendorf and J. Ludwig
1Department of Nephrology and 2Department of Cardiology, Friedrich Alexander University Erlangen-Nürnberg, Germany, and
3Research and Development Division, Bracco S.p.A., Milano, Italy
Background: Radiocontrast medium- (RM) associated nephrotoxicity continues to be a common cause of acute renal failure and may lead in patients with pre-existing chronic renal insufficiency even to end-stage renal failure requiring chronic dialysis. Since extracorporeal removal of RM after RM administration has been shown to be effective but does not prevent radiocontrast-induced nephropathy, the effect of a simultaneous dialysis during RM administration on renal function is not clear. Methods: In a prospective, randomized and controlled trial, we studied the effect of a 4-hour online dialysis during RM (iomeprol) application in patients with advanced chronic renal failure (serum creatinine ³ 3 mg/dl) undergoing coronary angiography. All patients received hydration with saline before and after standardized coronary angiography and were randomized to receive a simultaneous high-flux hemodialysis (7 patients, HD group) or to control group (10 patients). 24-hour creatinine clearance (CrCl) was measured in all patients before, 1 week and 8 weeks after coronary angiography. The clinical follow-up comprised 8 weeks after RM application. RM plasma levels were measured in both groups 15, 30, 60 minutes, 2, 4, 12, 24, 48 and 72 hours after application by high-pressure liquid chromatography. Results: At baseline, CrCl (19 ± 10 vs 17 ± 7 ml/min), percentage of diabetics (57 vs 70%) and dose of RM (77 ± 27 vs 86 ± 21 ml) were similar in both groups. Pharmacokinetics: Total clearance of iomeprol was significantly higher (54 ± 15 vs 20 ± 12 ml/min, p < 0.001) and the area under curve (AUC) was significantly lower (23 ± 10 g×h/l vs 94 ± 57 g×h/l, p < 0.001) in the HD group compared to control group. RM peak plasma levels 15 min after application were not different in both groups (3.0 ± 1.1 vs 4.2 ± 1.7 mmol/l, NS), however, significantly lower 60 min (1.6 ± 0.4 vs 3.7 ± 1.5 mmol/l, p < 0.01) and 240 min (0.7 ± 0.3 vs 2.3 ± 0.7 p < 0.001) after angiography. Clinical results: CrCl showed no difference 1 week (24 ± 11 vs 19 ± 9 ml/min, ns) and 8 weeks (24 ± 5 vs 20 ± 9 ml/min, NS) after angiography from baseline or between the groups. In each group, 2 patients developed end-stage renal disease and requested permanent dialysis during the 8-week follow-up. Conclusion: Simultaneous dialysis reduces AUC of iomeprol significantly, however, does not influence plasma peak concentration after angiography. Renal function and incidence of end-stage renal failure were not influenced by online-dialysis.
Originals
Relationship between different body size indicators and hernia development in CAPD patients
Abstract
B. Tokgöz1, A. Dogukan1, M. Güven2, K. Ünlühizarci2, O. Oymak1 and C. Utas1
Departments of 1Nephrology and 2Endocrinology, Erciyes University Medical School, Kayseri, Turkey
Aims: A small body size may increase the risk for hernia development in patients on continuous ambulatory peritoneal dialysis (CAPD). The present study investigates whether there is a relationship between body size and hernia development in CAPD patients. Material and methods: The records of 78 patients on CAPD were reviewed retrospectively. Body mass index (BMI), body surface area (BSA) and total body water (TBW) were calculated in all patients. Correlations between different body size indicators (BMI, BSA and TBW) and hernia development were assessed using analysis of covariance in which we adjusted for sex. Results: A total of 14 patients (17.9%) with no physical evidence of hernia before catheter insertion developed hernias. Body size was significantly lower in CAPD patients with hernias than those without hernias when adjusted for sex. Conclusions: We conclude that patients with small body size tend to have an increased risk for hernia development. A simple estimation of patients? height, weight, body surface area and total body water would be helpful to predict development of hernias or other complications related to increased intraperitoneal pressure in CAPD patients.
Case reports
Lupus-like nephritis in an HIV-positive patient: report of a case and review of the literature
Abstract
D. Tabechian, D. Pattanaik, U. Suresh, S.E. Cohn and T. Nadasdy
1Division of Allergy/Immunology and Rheumatology, 2Division of Nephrology, 3Division of Infectious Diseases, Department of Medicine, and 4Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
The most common manifestation of HIV/AIDS in the kidney is the collapsing variant of focal segmental glomerular sclerosis, HIV-associated nephropathy (HIVAN). Other forms of renal disease in HIV-infected patients include mesangial proliferative glomerulonephritis (GN), membranoproliferative GN, IgA nephropathy, minimal change disease and proliferative immune-complex GN. We present the case of a 42-year-old Caucasian male with HIV infection, treatment associated peripheral neuropathy, nephrotic syndrome and progressive renal failure. The initial and subsequent kidney biopsies showed diffuse proliferative glomerulonephritis resembling diffuse proliferative (WHO class IV) lupus nephritis. There was no clinical or serological evidence of systemic lupus erythematosus (SLE). Proteinuria improved with ACE-inhibitors, and renal function remained relatively stable while receiving highly active antiretroviral therapy (HAART). A precipitous decline in renal function to end-stage renal disease followed a brief period of withdrawal from potent antiretroviral therapy during which the viral load rebounded. Considering previously reported cases, it appears that lupus-like nephritis is a rare but well-defined pattern of immune-complex-induced renal injury seen in HIV-infected patients. It appears to be markedly responsive to HAART.
Case reports
Alport syndrome and benign familial hematuria (thin basement membrane disease) in two brothers of a family with hematuria
Abstract
T. Takemura, H. Yanagida, K. Yagi, K. Moriwaki and M. Okada
Department of Pediatrics, Kinki University School of Medicine, Osaka, Japan
Alport syndrome (AS) and benign familial hematuria (BFH) are inherited disorders of the glomerular basement membrane, which are sometimes difficult to differentiate at the early stage without type IV collagen staining of the renal basement membrane. Previous studies have indicated that mutation of type IV collagen a4 gene may be responsible for both BFH and AS. We report here a Japanese family with consanguinity, in which autosomal-recessive AS and BFH were separately identified in two brothers on the basis of findings of electron microscopy and type IV collagen chain staining of the renal biopsy specimens. Their parents, being first cousins, paternal uncle and grandmothers were found to have hematuria. Our observations suggest that BFH patients were heterozygous carriers of autosomal-recessive AS.
Case reports
Interstitial nephritis associated with perianeurysmal retroperitoneal fibrosis
Abstract
U.O. Igbokwe, S.M. Barnard, R.J. Marshall and R.G. Parry
Departments of 1Histopathology and 2Nephrology, Royal Cornwall Hospital, Truro, Cornwall, UK
Renal failure in retroperitoneal fibrosis is usually secondary to ureteric obstruction. We report a patient whose renal failure did not improve following relief of obstruction. Renal biopsy showed an interstitial nephritis, and function improved with steroid therapy. We suggest that renal biopsy should be considered in cases of renal failure associated with retroperitoneal fibrosis that do not respond to the relief of ureteric obstruction.
Case reports
Recurrent severe anion gap metabolic acidosis secondary to episodic ethylene glycol intoxication
Abstract
S. Moossavi, N.K. Wadhwa and E.P. Nord
Division of Nephrology, Department of Medicine, School of Medicine,
State University of New York at Stony Brook, Stony Brook, NY, USA
Acute ethylene glycol toxicity and its attendant metabolic derangement is a well described clinical entity. Recurrent severe anion gap metabolic acidosis consequent to episodic ingestion of ethylene glycol has not been previously reported. We present a patient who developed severe anion gap metabolic acidosis with no osmolar gap and hypokalemia, consequent to episodic ethylene glycol ingestion. Modest artifactual elevation of the serum lactic acid level and rapid response to intravenous bicarbonate infusion may serve as diagnostic clues. Consideration of these aberrant features should be included in the clinical assessment of severe anion gap metabolic acidosis.
Case reports
Worsening of hypertension in a pregnant woman with renal arteriovenous malformation: a successful superselective embolization after delivery
Abstract
A. Allione, F. Pomero, S. Valpreda, M. Porta, R. Mallone, C. Rabbia and P. Cavallo Perin
1Department of Internal Medicine, University of Torino, and
2Department of Vascular and Interventional Radiology, Hospital Molinette, Torino, Italy
A 30-year-old female presented with uncontrolled hypertension due to arteriovenous malformation in the upper third of the right kidney, which worsened during pregnancy. The arteriovenous malformation was detected by color-coded Doppler sonography, confirmed by angiography, and the fistula was sealed by superselective arterial embolization with metallic coils. Superselective embolization is the most effective and safe treatment for this rare and complex pathology.
Case reports
A case of anaphylactoid shock induced by the BS polysulfone hemodialyzer but not by the F8-HPS polysulfone hemodialyzer
Abstract
N. Ohashi, K. Yonemura, T. Goto, H. Suzuki, Y.Fujigaki, T. Yamamoto and A. Hishida
1First Department of Medicine, and 2Hemodialysis Unit, Hamamatsu University School of Medicine, Hamamatsu, Japan
A 57-year-old woman was admitted because of severe bradycardia and hypotension caused by an anti-arrhythmic agent and b-blocker. For 19 months before admission, she had been undergoing hemodialysis with an F8-HPS polysulfone membrane hemodialyzer without any complications. In 2 dialysis sessions after admission, when a BS polysulfone membrane was used, she experienced anaphylactoid shock with severe hypotension leading to syncope, dyspnea and vomiting, just after the start of hemodialysis. After the anaphylactoid shock, her dialyzer membrane was changed to a cellulose triacetate membrane and she did not suffer from such attacks. This case indicates that severe anaphylactoid shock may be caused by a biocompatible dialyzer membrane and that the reactions of patients to each polysulfone membrane may differ among polysulfone membranes made by different manufacturers.
Letters to the Editor
Clopidogrel-induced membranous nephropathy
Abstract
S.-H. Park, Y.-J. Cho, Y.-L. Kim, J.-S. Kwak, Y.-J. Kim and D.-K. Cho
Letters to the Editor
Gene polymorphism in the promoter region of lipopolysaccharide receptor CD14 and dyslipidemia in hemodialysis patients
Abstract
M. Fukui, I. Shou, T. Gohda, C. Hamada, K. Maeda, S. Horikoshi and Y. Tomino
Letters to the Editor
Partial exchange transfusion improved renal function and proteinuria in a patient with cyanotic heart disease nephropathy
Abstract
S. Takahashi, K. Ooya, N. Wada, T. Inagaki, Y. Takana, A. Saito, M. Nagata and K. Harada
Letters to the Editor
A case of encircling penile condylomata acuminata after renal transplantation
Abstract
S. Lee, W. Kim, J.K. Park and S.K. Park
