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Dustri-Verlag
Volume 62, No. 5/2004(November)
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Review
Chronic renal failure: oxidative stress, endothelial dysfunction and wine
331
24$
Abstract
Atherosclerosis development is accelerated in chronic renal failure (CRF) and is the major cause of death in this clinical condition. An increased oxidative stress and an endothelial dysfunction, with their complex interrelationships, are relevant aspects of atherogenesis in CRF patients and might be targets for treatment. Many studies have underlined the cardiovascular protection provided by a moderate wine consumption. This beneficial effect is due to both alcohol and nonalcoholic components of wine including several phenolic molecules such as quercetin and resveratrol. Wine polyphenols have antioxidant properties and favorably influence endothelial function, in particular by stimulating nitric oxide-mediated vasodilation and inhibiting the endothelin-1 pathway. The possible advantage of a moderate wine consumption in CRF patients can be hypothesized and deserves clinical investigation.Correspondence to:
Prof. G. Caimi Via Leonardo da Vinci, 52 I-90145 Palermo, Italy
Email: caimigre@unipa.it
G. Caimi, C. Carollo and R. Lo Presti
Department of Internal Medicine, Cardiovascular and Nephrourologie Diseases, University of Palermo, Palermo, Italy Atherosclerosis development is accelerated in chronic renal failure (CRF) and is the major cause of death in this clinical condition. An increased oxidative stress and an endothelial dysfunction, with their complex interrelationships, are relevant aspects of atherogenesis in CRF patients and might be targets for treatment. Many studies have underlined the cardiovascular protection provided by a moderate wine consumption. This beneficial effect is due to both alcohol and nonalcoholic components of wine including several phenolic molecules such as quercetin and resveratrol. Wine polyphenols have antioxidant properties and favorably influence endothelial function, in particular by stimulating nitric oxide-mediated vasodilation and inhibiting the endothelin-1 pathway. The possible advantage of a moderate wine consumption in CRF patients can be hypothesized and deserves clinical investigation.Correspondence to:
Prof. G. Caimi Via Leonardo da Vinci, 52 I-90145 Palermo, Italy
Email: caimigre@unipa.it
Originals
Analysis of macrophages in urine sediments in children with IgA nephropathy
336
36$
Abstract
Aim: Although infiltrating macrophages found in renal biopsy specimens have been accepted as a useful marker for evaluating the activity of IgA nephropathy (IgAN), it is difficult to perform renal biopsies repeatedly, especially in children. To establish a more convenient and noninvasive method for estimating the degree of macrophage infiltration we examined the number of macrophages in urinary sediments. Patients and methods: Ten ml of morning urine were collected from 30 children with IgAN, 10 with thin basement membrane disease (TBMD), 8 with idiopathic renal hemorrhage (IRH) which was defined as nonglomerular hematuria due to nutcracker phenomenon revealed on ultrasonography, and 10 healthy children as controls. Ten of the 30 children with IgAN were treated with combination therapy comprising prednisolone, warfarin and dipyridamole and urine samples were collected weekly during the period of treatment. Two ml of the urine sediment were smeared on glass slides, dried and stained with a monoclonal antibody to human macrophages (anti-CD68, PG-M1) followed by a FITC-conjugated secondary antibody. After staining with propidium iodide (PI), the cells were examined by fluorescence microscopy with cells stained with both FITC and PI being counted as macrophages. In addition, anti-CD68 staining was used to quantify macrophage infiltration in renal biopsies from the same group of IgAN patients. Results: The number of urine macrophages in children with IgAN was significantly higher than in children with TBMD and IRH as well as the control group (p < 0.01), whereas that was similar among TBMD, IRH and healthy children. In IgAN, there was a significant correlation between urine macrophage number and the activity index (p < 0.01), proteinuria (p < 0.01) and urine WBC count (p < 0.01). In addition, there was also a significant correlation between urine macrophage number and glomerular (p < 0.05) as well as interstitial macrophage infiltration (p < 0.01). In children with IgAN who received combination therapy, urine macrophage number decreased significantly (p < 0.01) in the 1st week of treatment whilst the degree of proteinuria decreased significantly (p < 0.01) in the 4th week. Conclusion: Urinary macrophage number may represent a noninvasive and straightforward estimate of the pathological activity evident in renal biopsy specimens, and may also be a more sensitive indicator than proteinuria of the therapeutic effect of interventional treatments in childhood IgAN.
Correspondence to:
Dr. M. Nakajima
Department of Pediatrics
Nara Medical University
840, Shijo-cho
Kashihara City, Nara 634-8522, Japan
Email: jintarow@naramed-u.ac.jp
Y. Maruhashi, M. Nakajima, H. Akazawa,H. Shimoyama, M. Nishiguchi, Y. Yamoto,H. Kamitsuji and A. Yoshioka
1Department of Pediatrics, Nara Medical University, Kashihara City, and 2Pediatric Clinic, Nara Prefectural Nara Hospital, Nara City, Nara, Japan Aim: Although infiltrating macrophages found in renal biopsy specimens have been accepted as a useful marker for evaluating the activity of IgA nephropathy (IgAN), it is difficult to perform renal biopsies repeatedly, especially in children. To establish a more convenient and noninvasive method for estimating the degree of macrophage infiltration we examined the number of macrophages in urinary sediments. Patients and methods: Ten ml of morning urine were collected from 30 children with IgAN, 10 with thin basement membrane disease (TBMD), 8 with idiopathic renal hemorrhage (IRH) which was defined as nonglomerular hematuria due to nutcracker phenomenon revealed on ultrasonography, and 10 healthy children as controls. Ten of the 30 children with IgAN were treated with combination therapy comprising prednisolone, warfarin and dipyridamole and urine samples were collected weekly during the period of treatment. Two ml of the urine sediment were smeared on glass slides, dried and stained with a monoclonal antibody to human macrophages (anti-CD68, PG-M1) followed by a FITC-conjugated secondary antibody. After staining with propidium iodide (PI), the cells were examined by fluorescence microscopy with cells stained with both FITC and PI being counted as macrophages. In addition, anti-CD68 staining was used to quantify macrophage infiltration in renal biopsies from the same group of IgAN patients. Results: The number of urine macrophages in children with IgAN was significantly higher than in children with TBMD and IRH as well as the control group (p < 0.01), whereas that was similar among TBMD, IRH and healthy children. In IgAN, there was a significant correlation between urine macrophage number and the activity index (p < 0.01), proteinuria (p < 0.01) and urine WBC count (p < 0.01). In addition, there was also a significant correlation between urine macrophage number and glomerular (p < 0.05) as well as interstitial macrophage infiltration (p < 0.01). In children with IgAN who received combination therapy, urine macrophage number decreased significantly (p < 0.01) in the 1st week of treatment whilst the degree of proteinuria decreased significantly (p < 0.01) in the 4th week. Conclusion: Urinary macrophage number may represent a noninvasive and straightforward estimate of the pathological activity evident in renal biopsy specimens, and may also be a more sensitive indicator than proteinuria of the therapeutic effect of interventional treatments in childhood IgAN.
Correspondence to:
Dr. M. Nakajima
Department of Pediatrics
Nara Medical University
840, Shijo-cho
Kashihara City, Nara 634-8522, Japan
Email: jintarow@naramed-u.ac.jp
Originals
Evolution and predictive power of serum cystatin C in acute renal failure
344
32$
Abstract
Aims: The serum concentration of cystatin C has recently been proposed as a better indicator of glomerular filtration rate (GFR) than plasma creatinine. Little is known about cystatin C in critical illness. We assessed serum cystatin C as a marker of renal function in acute renal failure (ARF) and its power in predicting survival of ARF patients. Material: 202 consecutive adult patients admitted into the intensive care unit (ICU) during a period of 9 months. Method: Serum cystatin C, plasma creatinine and plasma urea were measured on admission, daily during the first 3 days, and 5 – 7 times a week during the rest of the ICU stay. The patients with and without ARF were compared by the Mann-Whitney U-test. The correlation between different variables was calculated by Spearman’s correlation. Forward stepwise multiple regression analysis was performed to test independent predictors of mortality. The positive predictive value of serum cystatin C and plasma creatinine for ARF and mortality was calculated by ROC analysis. Results: ARF occurred in 54 patients (27%). Serum cystatin C showed excellent positive predictive value for ARF in critical illness by ROC analysis. In acute renal dysfunction, abnormal values of serum cystatin C and plasma creatinine appeared equally quickly (median 3 days). The diagnosis of ARF, the day 1 Apache II score and admission plasma creatinine appeared as independent predictors of hospital mortality. ROC analysis showed only weak predictive power for serum cystatin C and plasma creatinine regarding hospital mortality. Conclusions: Serum cystatin C was as good as plasma creatinine in detecting ARF in intensive care patients. Neither marker was clinically useful in predicting mortality.Correspondence to:
Dr. A. Åhlström
Sepeteuksentie 2 B
FIN-00760 Helsinki, Finland
Email: annika.ahlstrom@hus.fi
A. Åhlström1, M. Tallgren1, S. Peltonen2 and V. Pettilä1
1Department of Surgery, Division of Anesthesiology and Intensive Care Medicine, Intensive Care Unit, Helsinki University Hospital, and 2Department of Internal Medicine, Division of Nephrology, Helsinki University Hospital, Helsinki, Finland Aims: The serum concentration of cystatin C has recently been proposed as a better indicator of glomerular filtration rate (GFR) than plasma creatinine. Little is known about cystatin C in critical illness. We assessed serum cystatin C as a marker of renal function in acute renal failure (ARF) and its power in predicting survival of ARF patients. Material: 202 consecutive adult patients admitted into the intensive care unit (ICU) during a period of 9 months. Method: Serum cystatin C, plasma creatinine and plasma urea were measured on admission, daily during the first 3 days, and 5 – 7 times a week during the rest of the ICU stay. The patients with and without ARF were compared by the Mann-Whitney U-test. The correlation between different variables was calculated by Spearman’s correlation. Forward stepwise multiple regression analysis was performed to test independent predictors of mortality. The positive predictive value of serum cystatin C and plasma creatinine for ARF and mortality was calculated by ROC analysis. Results: ARF occurred in 54 patients (27%). Serum cystatin C showed excellent positive predictive value for ARF in critical illness by ROC analysis. In acute renal dysfunction, abnormal values of serum cystatin C and plasma creatinine appeared equally quickly (median 3 days). The diagnosis of ARF, the day 1 Apache II score and admission plasma creatinine appeared as independent predictors of hospital mortality. ROC analysis showed only weak predictive power for serum cystatin C and plasma creatinine regarding hospital mortality. Conclusions: Serum cystatin C was as good as plasma creatinine in detecting ARF in intensive care patients. Neither marker was clinically useful in predicting mortality.Correspondence to:
Dr. A. Åhlström
Sepeteuksentie 2 B
FIN-00760 Helsinki, Finland
Email: annika.ahlstrom@hus.fi
Originals
Kidney biopsy and power Doppler imaging
351
20$
Abstract
Teaching Hospital Maribor, Maribor, Slovenia
Background: Practically, all complications of kidney biopsy are connected with hemorrhage. In the last years, the use of color Doppler sonography in monitoring kidney biopsies was being described, later the possibility of using power Doppler (PD) in performing kidney biopsies was presented. PD depicts the amplitude, or power, of Doppler signals rather than the frequency shift. This allows detection of a larger range of Doppler shifts and thus better visualization of small vessels, but at the expense of directional and velocity information. Patients and methods: Biopsy of native kidneys was performed in 144 patients. We performed real-time ultrasound-guided biopsy with an automatic biopsy device, 2 – 4 MHz convex probe and modified 18 G tru-cut needles were used. The vessels in the region of the biopsy were imaged with color Doppler sonography and with PD immediately before, after and the day following biopsy. Results: Adequate tissue for histologic diagnosis was obtained in all patients with average 3.28 attempts at biopsy (range from 2 – 5). Average 24.15 (range from 7 – 58) glomeruli were obtained during each session. We observed complications in 6 (4.2%) patients, macrohematuria was presented in 4, and small hematoma with no need for intervention in 2 patients. In 138 (95.8%) patients, no complications were observed, microhematuria was present in 116 (80.6%) patients. Conclusions: In our study, complication rate of kidney biopsy was low and no complication requiring intervention was observed. Number of glomeruli obtained during each session was high. For better visualization of kidney vessels in biopsy path, PD was used. This additional kidney investigation itself does not essentially prolong the duration of the biopsy.Correspondence to:
Prof. Dr. R. Hojs
Ucna bolnisnica Maribor
Klinicni oddelek za interno medicino
Oddelek za nefrologijo
Ljubljanska 5
SLO-2000 Maribor, Slovenia
Email: Radovan.Hojs@sb-mb.si
R. Hojs
Clinical Department of Internal Medicine, Department of Nephrology,Teaching Hospital Maribor, Maribor, Slovenia
Background: Practically, all complications of kidney biopsy are connected with hemorrhage. In the last years, the use of color Doppler sonography in monitoring kidney biopsies was being described, later the possibility of using power Doppler (PD) in performing kidney biopsies was presented. PD depicts the amplitude, or power, of Doppler signals rather than the frequency shift. This allows detection of a larger range of Doppler shifts and thus better visualization of small vessels, but at the expense of directional and velocity information. Patients and methods: Biopsy of native kidneys was performed in 144 patients. We performed real-time ultrasound-guided biopsy with an automatic biopsy device, 2 – 4 MHz convex probe and modified 18 G tru-cut needles were used. The vessels in the region of the biopsy were imaged with color Doppler sonography and with PD immediately before, after and the day following biopsy. Results: Adequate tissue for histologic diagnosis was obtained in all patients with average 3.28 attempts at biopsy (range from 2 – 5). Average 24.15 (range from 7 – 58) glomeruli were obtained during each session. We observed complications in 6 (4.2%) patients, macrohematuria was presented in 4, and small hematoma with no need for intervention in 2 patients. In 138 (95.8%) patients, no complications were observed, microhematuria was present in 116 (80.6%) patients. Conclusions: In our study, complication rate of kidney biopsy was low and no complication requiring intervention was observed. Number of glomeruli obtained during each session was high. For better visualization of kidney vessels in biopsy path, PD was used. This additional kidney investigation itself does not essentially prolong the duration of the biopsy.Correspondence to:
Prof. Dr. R. Hojs
Ucna bolnisnica Maribor
Klinicni oddelek za interno medicino
Oddelek za nefrologijo
Ljubljanska 5
SLO-2000 Maribor, Slovenia
Email: Radovan.Hojs@sb-mb.si
Originals
Vitamin E-coated dialyzers reduce oxidative stress related proteins and markers in hemodialysis - a molecular biological approach
355
32$
Abstract
2Division of Nephrology 2, 6Nephrology Clinic, 4Technology Assessment, University of Padova-Azienda Ospedaliera di Padova and 5Division of Nephrology, Azienda Ospedaliera Bolzano, Italy, and 3Department of Internal Medicine, University of California, Davis, CA, USA
Background: Hemodialysis patients (HD) are exposed to oxidative stress which contributes to cardiovascular disease and accelerated atherosclerosis, major causes of mortality in these patients. A new dialysis membrane coated with vitamin E has been proposed against oxidative stress and atherosclerosis due to their ability to inhibit lipid peroxidation by interacting with scavengers. The mechanisms however are not completely clarified. This study evaluated, using a molecular biology approach, the effect of 6 months treatment with vitamin E-modified dialyzers, CL-E, on the gene expression of oxidative stress related proteins and markers. Patients and methods: To this end, the gene expression of p22phox, a NAD(P)H oxidase subunit closely linked with the generation of superoxide anions and of Heme oxygenase-1 (HO-1), induced by and protective from oxidative stress, were evaluated by RT-PCR in mononuclear cells from 5 patients under 3 times a week chronic bicarbonate dialysis. Hydroperoxide (HPO) and total antioxidant power (AOP) plasma levels were evaluated at 3 and 6 months of treatment. HPO was also evaluated in 8 patients under CL-E treatment for 1 year and compared with 8 patients treated with cuprammonium-ryon filter (TAF). Results: p22phox mRNA decreased from 0.61 ± 0.05 d.u. to 0.48 ± 0.03, p < 0.01 while HO-1 increased from 0.55 ± 0.04 d.u. to 0.62 ± 0.03, p < 0.01. HPO decreased in CL-E treated patients: from 2.72 ± 0.26 mM to 1.45 ± 0.27 at 3 months (p < 0.001) to 0.87 ± 0.11, p < 0.001 at 6 months, while AOP increased: from 752 ± 90 mmol/L to 1057 ± 105, p < 0.001 at 6 months. HPO was also reduced in 1 year Excebrane CL-E treated patients compared with cuprammonium treated patients: 2.25 ± 0.3 vs. 1.42 ± 0.11 mM, p < 0.001. Conclusion: The reduced expression of oxidative stress related proteins and markers gives further support to the efficacy of the use of Vitamin E coated dialysers for the prevention or slowing progression of cardiovascular disease and atherosclerosis, major complications and causes of mortality in these patients in which oxidative stress plays a pivotal role.Correspondence to:
L.A. Calò, MD
Department of Clinical and Experimental Medicine
Clinica Medica 4
University of Padova
Via Giustiniani 2
I-35128 Padova, Italy
Email: renzcalo@unipd.it
L.A. Calò1, A. Naso2, E. Pagnin1, P.A. Davis3, M. Castoro4, R. Corradin5, P. Riegler5, C. Cascone2, W. Huber5 and A. Piccoli6
1Department of Clinical and Experimental Medicine, Clinica Medica 4,2Division of Nephrology 2, 6Nephrology Clinic, 4Technology Assessment, University of Padova-Azienda Ospedaliera di Padova and 5Division of Nephrology, Azienda Ospedaliera Bolzano, Italy, and 3Department of Internal Medicine, University of California, Davis, CA, USA
Background: Hemodialysis patients (HD) are exposed to oxidative stress which contributes to cardiovascular disease and accelerated atherosclerosis, major causes of mortality in these patients. A new dialysis membrane coated with vitamin E has been proposed against oxidative stress and atherosclerosis due to their ability to inhibit lipid peroxidation by interacting with scavengers. The mechanisms however are not completely clarified. This study evaluated, using a molecular biology approach, the effect of 6 months treatment with vitamin E-modified dialyzers, CL-E, on the gene expression of oxidative stress related proteins and markers. Patients and methods: To this end, the gene expression of p22phox, a NAD(P)H oxidase subunit closely linked with the generation of superoxide anions and of Heme oxygenase-1 (HO-1), induced by and protective from oxidative stress, were evaluated by RT-PCR in mononuclear cells from 5 patients under 3 times a week chronic bicarbonate dialysis. Hydroperoxide (HPO) and total antioxidant power (AOP) plasma levels were evaluated at 3 and 6 months of treatment. HPO was also evaluated in 8 patients under CL-E treatment for 1 year and compared with 8 patients treated with cuprammonium-ryon filter (TAF). Results: p22phox mRNA decreased from 0.61 ± 0.05 d.u. to 0.48 ± 0.03, p < 0.01 while HO-1 increased from 0.55 ± 0.04 d.u. to 0.62 ± 0.03, p < 0.01. HPO decreased in CL-E treated patients: from 2.72 ± 0.26 mM to 1.45 ± 0.27 at 3 months (p < 0.001) to 0.87 ± 0.11, p < 0.001 at 6 months, while AOP increased: from 752 ± 90 mmol/L to 1057 ± 105, p < 0.001 at 6 months. HPO was also reduced in 1 year Excebrane CL-E treated patients compared with cuprammonium treated patients: 2.25 ± 0.3 vs. 1.42 ± 0.11 mM, p < 0.001. Conclusion: The reduced expression of oxidative stress related proteins and markers gives further support to the efficacy of the use of Vitamin E coated dialysers for the prevention or slowing progression of cardiovascular disease and atherosclerosis, major complications and causes of mortality in these patients in which oxidative stress plays a pivotal role.Correspondence to:
L.A. Calò, MD
Department of Clinical and Experimental Medicine
Clinica Medica 4
University of Padova
Via Giustiniani 2
I-35128 Padova, Italy
Email: renzcalo@unipd.it
Originals
The mechanism of hypoglycemia caused by hemodialysis
362
32$
Abstract
Background: Although it is well-known that plasma glucose concentration ((G)p) decreases during hemodialysis, the precise mechanism underlying this decrease has not yet been fully elucidated. The aim of the present study was to investigate the mechanism underlying hemodialysis-induced decrease (HID) in (G)p during the dialysis in vivo or in vitro. Methods: Using high CO2/ HCO3– dialysate, we measured (G)p by a hexose kinase method ((G)pHK) and concentrations of electrolytes, as well as pH, PCO2 and PO2 for both plasma and dialysate samples at pre- and postdialyzer sites obtained from hemodialysis patients with nondiabetic chronic renal failure (CRF). Furthermore, we studied the effect of PCO2 and acetazolamide (ACZ) on the changes in (G)pHK during the dialysis in vitro. Results: After the first dialysis of CRF patients, the (G)pHK decreased from 118.3 ± 18.0 to 98.6 ± 5.7 mg/dl (p < 0.05), the latter value being significantly lower than glucose concentration in dialysate samples (approximately 105 mg/dl) at predialyzer sites. In the experiments of blood samples from healthy volunteers, (G)pHK decreased significantly after elevating or lowering CO2 level in the dialysates. In contrast, when the difference in PCO2 between the blood and dialysate was reduced, the HID in (G)pHK was abolished during hemodialysis. The addition of 10–4 M ACZ to the blood samples completely prevented the development of HID in (G)pHK caused by the perfusion of high or low CO2/HCO3– dialysates. Conclusions: During hemodialysis using high CO2/HCO3– dialysate, the HID in (G)p results from the diffusion of glucose from plasma into erythrocytes, probably due to the consumption of glucose resulting from the accelerated anaerobic metabolism induced by the changes in the cytoplasmic pH of erythrocytes.Correspondence to:
Dr. T. Kubota
Department of Physiology
Osaka Medical College
2-7 Daigakumachi
Takatsuki, Osaka 569-8686, Japan
Email: ph2008@art.osaka-med.ac.jp
A. Takahashi, T. Kubota, N. Shibahara, J. Terasaki,M. Kagitani, H. Ueda, T. Inoue and Y. Katsuoka
1Department of Urology, 2Department of Physiology, 3Blood Purification Center, and 4First Department of Internal Medicine, Osaka Medical College, Osaka, Japan Background: Although it is well-known that plasma glucose concentration ((G)p) decreases during hemodialysis, the precise mechanism underlying this decrease has not yet been fully elucidated. The aim of the present study was to investigate the mechanism underlying hemodialysis-induced decrease (HID) in (G)p during the dialysis in vivo or in vitro. Methods: Using high CO2/ HCO3– dialysate, we measured (G)p by a hexose kinase method ((G)pHK) and concentrations of electrolytes, as well as pH, PCO2 and PO2 for both plasma and dialysate samples at pre- and postdialyzer sites obtained from hemodialysis patients with nondiabetic chronic renal failure (CRF). Furthermore, we studied the effect of PCO2 and acetazolamide (ACZ) on the changes in (G)pHK during the dialysis in vitro. Results: After the first dialysis of CRF patients, the (G)pHK decreased from 118.3 ± 18.0 to 98.6 ± 5.7 mg/dl (p < 0.05), the latter value being significantly lower than glucose concentration in dialysate samples (approximately 105 mg/dl) at predialyzer sites. In the experiments of blood samples from healthy volunteers, (G)pHK decreased significantly after elevating or lowering CO2 level in the dialysates. In contrast, when the difference in PCO2 between the blood and dialysate was reduced, the HID in (G)pHK was abolished during hemodialysis. The addition of 10–4 M ACZ to the blood samples completely prevented the development of HID in (G)pHK caused by the perfusion of high or low CO2/HCO3– dialysates. Conclusions: During hemodialysis using high CO2/HCO3– dialysate, the HID in (G)p results from the diffusion of glucose from plasma into erythrocytes, probably due to the consumption of glucose resulting from the accelerated anaerobic metabolism induced by the changes in the cytoplasmic pH of erythrocytes.Correspondence to:
Dr. T. Kubota
Department of Physiology
Osaka Medical College
2-7 Daigakumachi
Takatsuki, Osaka 569-8686, Japan
Email: ph2008@art.osaka-med.ac.jp
Originals
Ethanol/Trisodium citrate for hemodialysis catheter lock
369
24$
Abstract
Aims: The objective of this study was to confirm the compatibility of ethanol and 4% trisodium citrate (TSC) for potential use as a catheter locking solution. Methods: Increasing concentrations of ethanol were combined with 4% TSC in glass test tubes and stored at 37ºC over 72 hours. Each tube was visually inspected to determine the highest compatible concentration. To confirm visual compatibility, HPLC analysis was used to compare the concentration of TSC in control solutions (n = 6) to solutions containing both TSC and the highest concentration of ethanol that was visually compatible (n = 6). Compatibility in carbothane hemodialysis catheters was then confirmed in vitro. Results: Results of the compatibility tests indicated that 30% ethanol was the maximum concentration visually compatible with 4% TSC. Ethanol concentrations of 35% or above form a crystalline precipitate in the glass test tubes within 72 hours. HPLC analysis showed no difference in the concentration of TSC in the control solutions compared to the TSC/ethanol solutions when incubated in glass test tubes. A slight, but statistically significant increase in the TSC concentration (1.27%; p < 0.0001) was observed when the ethanol/TSC solution was incubated in carbothane hemodialysis catheters. This slight increase may be due to ethanol absorption into the catheter polymer. Further studies are underway to determine if an ethanol/TSC lock affects the mechanical properties of these carbothane hemodialysis catheters. Conclusions: We conclude that 30% ethanol is compatible with 4% trisodium citrate in carbothane hemodialysis catheters in vitro. Until the lock’s affect on carbothane hemodialysis catheters is known, it cannot yet be recommended for clinical use.Correspondence to:
L.M. Vercaigne, PharmD
Office 407B
Faculty of Pharmacy
University of Manitoba
50 Sifton Road
Winnipeg, Manitoba, R3T 2N2, Canada
Email: lavern_vercaigne@umanitoba.ca
A.L. Bell, X. Gu, F.J. Burczynski and L.M. Vercaigne
1Faculty of Pharmacy, University of Manitoba, and 2Manitoba Renal Program, Health Sciences Center, Winnipeg, Manitoba, Canada Aims: The objective of this study was to confirm the compatibility of ethanol and 4% trisodium citrate (TSC) for potential use as a catheter locking solution. Methods: Increasing concentrations of ethanol were combined with 4% TSC in glass test tubes and stored at 37ºC over 72 hours. Each tube was visually inspected to determine the highest compatible concentration. To confirm visual compatibility, HPLC analysis was used to compare the concentration of TSC in control solutions (n = 6) to solutions containing both TSC and the highest concentration of ethanol that was visually compatible (n = 6). Compatibility in carbothane hemodialysis catheters was then confirmed in vitro. Results: Results of the compatibility tests indicated that 30% ethanol was the maximum concentration visually compatible with 4% TSC. Ethanol concentrations of 35% or above form a crystalline precipitate in the glass test tubes within 72 hours. HPLC analysis showed no difference in the concentration of TSC in the control solutions compared to the TSC/ethanol solutions when incubated in glass test tubes. A slight, but statistically significant increase in the TSC concentration (1.27%; p < 0.0001) was observed when the ethanol/TSC solution was incubated in carbothane hemodialysis catheters. This slight increase may be due to ethanol absorption into the catheter polymer. Further studies are underway to determine if an ethanol/TSC lock affects the mechanical properties of these carbothane hemodialysis catheters. Conclusions: We conclude that 30% ethanol is compatible with 4% trisodium citrate in carbothane hemodialysis catheters in vitro. Until the lock’s affect on carbothane hemodialysis catheters is known, it cannot yet be recommended for clinical use.Correspondence to:
L.M. Vercaigne, PharmD
Office 407B
Faculty of Pharmacy
University of Manitoba
50 Sifton Road
Winnipeg, Manitoba, R3T 2N2, Canada
Email: lavern_vercaigne@umanitoba.ca
Originals
Ascites reinfusion dialysis (ARD) for renal failure with refractory ascites
374
28$
Abstract
Background: Dialysis is difficult for patients who have simultaneous liver and kidney failure. Effective mobilization of ascites is rare, and hypotension is common. Combining repeated paracentesis with continuous renal replacement therapy can achieve effective volume removal with hemodynamic stability, but requires intensive care unit resources. Large amounts of albumin are lost from the body in the drained ascites. Combining ascites reinfusion with hemodialysis is a potential alternative therapy. Methods: Eight treatments were undertaken in 3 patients with refractory ascites in the setting of acute onset renal failure. Hemodialysis was unsuccessful due to hypotension in each case. Two patients were treated twice, and 1 patient was treated 4 times. Each patient underwent hemodialysis with reinfusion of ascites directly into the blood inlet of the dialysis machine. Weight, blood urea nitrogen, albumin and platelet counts were measured before and after treatment. Hemodynamic tolerance was assessed, and patients were observed for the development of encephalopathy, disseminated intravascular coagulation, infection and hemodynamic decompensation. Results: All patients survived. There was 1 episode of transient hemoperitoneum, but no encephalopathy, GI bleeding or infection. One patient recovered renal function, and the other 2 were discharged ambulatory to chronic hemodialysis programs. Blood pressure was supported easily during therapy, despite removal of 3 – 8 kg of fluid. Platelet counts decreased by 27,000 ± 13,000, and albumin increased by 0.5 ± 0.2 g/dl. All values returned to baseline over the next 1 – 4 days. Conclusions: Ascites recirculation with dialysis is a safe and effective therapy for patients with refractory ascites and severe renal failure, which can be carried out in routine inpatient and outpatient settings. Hemodynamic tolerance was good and thrombocytopenia was modest.Correspondence to:
Dr. R.L. McGill
Allegheny General Hospital
320 East North Avenue
Pittsburgh, PA 15212, USA
Email: rmcgill@wpahs.org
R.L. McGill, J.R. Bakos and R.J. Marcus
Division of Nephrology and Hypertension, West Penn Allegheny Health System, Allegheny General Hospital, Pittsburgh, PA, USA Background: Dialysis is difficult for patients who have simultaneous liver and kidney failure. Effective mobilization of ascites is rare, and hypotension is common. Combining repeated paracentesis with continuous renal replacement therapy can achieve effective volume removal with hemodynamic stability, but requires intensive care unit resources. Large amounts of albumin are lost from the body in the drained ascites. Combining ascites reinfusion with hemodialysis is a potential alternative therapy. Methods: Eight treatments were undertaken in 3 patients with refractory ascites in the setting of acute onset renal failure. Hemodialysis was unsuccessful due to hypotension in each case. Two patients were treated twice, and 1 patient was treated 4 times. Each patient underwent hemodialysis with reinfusion of ascites directly into the blood inlet of the dialysis machine. Weight, blood urea nitrogen, albumin and platelet counts were measured before and after treatment. Hemodynamic tolerance was assessed, and patients were observed for the development of encephalopathy, disseminated intravascular coagulation, infection and hemodynamic decompensation. Results: All patients survived. There was 1 episode of transient hemoperitoneum, but no encephalopathy, GI bleeding or infection. One patient recovered renal function, and the other 2 were discharged ambulatory to chronic hemodialysis programs. Blood pressure was supported easily during therapy, despite removal of 3 – 8 kg of fluid. Platelet counts decreased by 27,000 ± 13,000, and albumin increased by 0.5 ± 0.2 g/dl. All values returned to baseline over the next 1 – 4 days. Conclusions: Ascites recirculation with dialysis is a safe and effective therapy for patients with refractory ascites and severe renal failure, which can be carried out in routine inpatient and outpatient settings. Hemodynamic tolerance was good and thrombocytopenia was modest.Correspondence to:
Dr. R.L. McGill
Allegheny General Hospital
320 East North Avenue
Pittsburgh, PA 15212, USA
Email: rmcgill@wpahs.org
Originals
Evaluation of salivary parameters and dental status in adult hemodialysis patients
380
20$
Abstract
2Department of Internal Medicine, Division of Nephrology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
Aims: Caries is a multifactor disease, and impaired stimulated salivary flow rate and buffering capacity are the best-known risk factors. The salivary flow rate, pH, buffering capacity and DMFT (decayed, missing and filled teeth) index of adult hemodialysis patients were compared with those of healthy controls. Material and methods: Seventy-two (34 F, 38 M, mean age: 45.05 ± 14.15 years) hemodialysis patients and 50 (26 F, 24 M, mean age: 43.92 ± 18.80 years) control saliva were collected after prestimulation and expressed as ml/min. Salivary pH and buffering capacity were measured (Ericsson method). The dental examinations were performed according to WHO criteria and DMFT index was calculated. Statistical analysis was performed with Student t-test and Pearson correlation test. Results: The patients’ mean salivary flow rate was 0.69 ± 0.31 ml/min, pH, 8.15 ± 0.72, buffering capacity, 6.83 ± 0.71 and DMFT index was 11.91 ± 8.73. The salivary flow rate was less than the controls (p <0.001), but salivary pH and buffering capacity were higher (both p < 0.001). There was no difference in DMFT index between groups (p > 0.05). There was no significantly negative correlation between DMFT index and stimulated salivary flow rate, pH but there was a positive correlation with buffering capacity (r = 0.286, p < 0.05) in the patients. Moreover, there was no significantly positive correlation between stimulated salivary flow rate and pH buffering capacity in these patients. Conclusions: Salivary flow rate of hemodialysis patients was less than the hyposalivary limit. Salivary pH and buffering capacity were both above the reference values, but DMFT index of hemodialysis patients did not differ from that of controls. However, caries and related dental infections may lead to serious problems in infection-prone hemodialysis patients, so these patients should have regular dental examinations and careful treatments.Correspondence to:
Dr. G. Bayraktar
Istanbul University
Faculty of Dentistry
Department of Removable Prosthodontics
34390 Capa-Istanbul, Turkey
Email: gulsenbayraktar@hotmail.com
G. Bayraktar, R. Kazancioglu, S. Bozfakioglu, A. Yildiz and E. Ark
1Department of Removable Prosthodontics, Faculty of Dentistry, and2Department of Internal Medicine, Division of Nephrology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
Aims: Caries is a multifactor disease, and impaired stimulated salivary flow rate and buffering capacity are the best-known risk factors. The salivary flow rate, pH, buffering capacity and DMFT (decayed, missing and filled teeth) index of adult hemodialysis patients were compared with those of healthy controls. Material and methods: Seventy-two (34 F, 38 M, mean age: 45.05 ± 14.15 years) hemodialysis patients and 50 (26 F, 24 M, mean age: 43.92 ± 18.80 years) control saliva were collected after prestimulation and expressed as ml/min. Salivary pH and buffering capacity were measured (Ericsson method). The dental examinations were performed according to WHO criteria and DMFT index was calculated. Statistical analysis was performed with Student t-test and Pearson correlation test. Results: The patients’ mean salivary flow rate was 0.69 ± 0.31 ml/min, pH, 8.15 ± 0.72, buffering capacity, 6.83 ± 0.71 and DMFT index was 11.91 ± 8.73. The salivary flow rate was less than the controls (p <0.001), but salivary pH and buffering capacity were higher (both p < 0.001). There was no difference in DMFT index between groups (p > 0.05). There was no significantly negative correlation between DMFT index and stimulated salivary flow rate, pH but there was a positive correlation with buffering capacity (r = 0.286, p < 0.05) in the patients. Moreover, there was no significantly positive correlation between stimulated salivary flow rate and pH buffering capacity in these patients. Conclusions: Salivary flow rate of hemodialysis patients was less than the hyposalivary limit. Salivary pH and buffering capacity were both above the reference values, but DMFT index of hemodialysis patients did not differ from that of controls. However, caries and related dental infections may lead to serious problems in infection-prone hemodialysis patients, so these patients should have regular dental examinations and careful treatments.Correspondence to:
Dr. G. Bayraktar
Istanbul University
Faculty of Dentistry
Department of Removable Prosthodontics
34390 Capa-Istanbul, Turkey
Email: gulsenbayraktar@hotmail.com
Case reports
Temporal arteritis with pauci-immune glomerulonephritis: a systemic disease
384
16$
Abstract
Temporal arteritis is easily diagnosed and responds gratifyingly to treatment. Renal complications are unusual, but nevertheless occur. Earlier, an association between pauci-immune glomerulonephritis and temporal arteritis was shown. We present a patient who clearly had temporal arteritis but also developed cerebral hemorrhage, pulmonary infiltrates related to granulomatous pulmonary vasculitis, and pauci-immune glomerulonephritis. We suggest that temporal arteritis is neither always localized nor temporal. Instead, the condition can be a lethal, systemic disease. Renal involvement in patients with temporal arteritis is not common and the presence of glomerulonephritis is rare [Jennette and Falk 1994]. Lenz et al. [1998] described a patient who developed vision loss, optic nerve atrophy, elevated erythrocyte sedimentation rate, a positive rheumatoid factor and terminal glomerulonephritis. The renal biopsy showed focal and segmental necrotizing glomerulonephritis, despite negative antineutrophil cytoplasmatic antibodies (ANCA), antinuclear antibodies and antiglomerular basement membrane antibodies. Giant cells were identified in the necrotic vessel walls within the kidney. Immunofluorescence was negative and a diagnosis of ANCA-negative pauci-immune glomerulonephritis was made. The patient did not respond to immunosuppression and developed end-stage renal disease. Although the clinical attributes were consistent with temporal arteritis, no temporal artery biopsy was done in that patient. We recently treated a patient with temporal arteritis and pauci-immune glomerulonephritis. Our patient’s course was somewhat different in comparison to the patient described by Lenz et al. [1998].Correspondence to:
Dr. F.C. Luft
Franz Volhard Clinic
Wiltbergstraße 50
13125 Berlin, Germany
Email: luft@fvk-berlin.de
E. Müller1, W. Schneider1, U. Kettritz1, W.A. Schmidt2, F.C. Luft1 and U. Göbel1
1Medical Faculty of the Charité, Franz Volhard Clinic, HELIOS Klinikum, Berlin, and 2Rheumatology Clinic of Berlin-Buch, Germany Temporal arteritis is easily diagnosed and responds gratifyingly to treatment. Renal complications are unusual, but nevertheless occur. Earlier, an association between pauci-immune glomerulonephritis and temporal arteritis was shown. We present a patient who clearly had temporal arteritis but also developed cerebral hemorrhage, pulmonary infiltrates related to granulomatous pulmonary vasculitis, and pauci-immune glomerulonephritis. We suggest that temporal arteritis is neither always localized nor temporal. Instead, the condition can be a lethal, systemic disease. Renal involvement in patients with temporal arteritis is not common and the presence of glomerulonephritis is rare [Jennette and Falk 1994]. Lenz et al. [1998] described a patient who developed vision loss, optic nerve atrophy, elevated erythrocyte sedimentation rate, a positive rheumatoid factor and terminal glomerulonephritis. The renal biopsy showed focal and segmental necrotizing glomerulonephritis, despite negative antineutrophil cytoplasmatic antibodies (ANCA), antinuclear antibodies and antiglomerular basement membrane antibodies. Giant cells were identified in the necrotic vessel walls within the kidney. Immunofluorescence was negative and a diagnosis of ANCA-negative pauci-immune glomerulonephritis was made. The patient did not respond to immunosuppression and developed end-stage renal disease. Although the clinical attributes were consistent with temporal arteritis, no temporal artery biopsy was done in that patient. We recently treated a patient with temporal arteritis and pauci-immune glomerulonephritis. Our patient’s course was somewhat different in comparison to the patient described by Lenz et al. [1998].Correspondence to:
Dr. F.C. Luft
Franz Volhard Clinic
Wiltbergstraße 50
13125 Berlin, Germany
Email: luft@fvk-berlin.de
Case reports
Dent’s disease: identification of a novel mutation in the renal chloride channel CLCN5
387
20$
Abstract
1Campus Benjamin Franklin, 2Campus Buch, 3Rappmühlstrasse and
4KfH Nierenzentrum, Berlin, Germany
Dent’s disease is an inherited tubulopathy caused by a mutation in the CLCN5 chloride channel gene. It is characterized by low-molecular weight proteinuria, hypercalciuria, nephrolithiasis or nephrocalcinosis, rickets and eventual-progressive renal failure. Onset of clinical symptoms show a great variability, making a diagnosis at an early stage of the disease often difficult. Given the variably clinical picture, genetic analysis can provide a reliable method to confirm the diagnosis. Here, we report on the case of a patient with progressive renal failure showing signs of a tubular lesion and symptoms of Dent’s disease. Although this rare disease was suspected by means of the clinical features, it was genetic analysis that confirmed the diagnosis and revealed a novel mutation in the CLCN5 gene.Correspondence to:
Dr. J. Hoyer
Department of Nephrology
Charité – Universitätsmedizin Berlin
Campus Benjamin Franklin
Hindenburgdamm 30
12200 Berlin, Germany
Email: hoy@zedat.fu-berlin.de
S. Brakemeier1, H. Si1, M. Gollasch2, D. Höffler3, M. Buhl4, R. Köhler1, J. Hoyer1 and I. Eichler1
Department of Nephrology – Charité, Universitätsmedizin Berlin,1Campus Benjamin Franklin, 2Campus Buch, 3Rappmühlstrasse and
4KfH Nierenzentrum, Berlin, Germany
Dent’s disease is an inherited tubulopathy caused by a mutation in the CLCN5 chloride channel gene. It is characterized by low-molecular weight proteinuria, hypercalciuria, nephrolithiasis or nephrocalcinosis, rickets and eventual-progressive renal failure. Onset of clinical symptoms show a great variability, making a diagnosis at an early stage of the disease often difficult. Given the variably clinical picture, genetic analysis can provide a reliable method to confirm the diagnosis. Here, we report on the case of a patient with progressive renal failure showing signs of a tubular lesion and symptoms of Dent’s disease. Although this rare disease was suspected by means of the clinical features, it was genetic analysis that confirmed the diagnosis and revealed a novel mutation in the CLCN5 gene.Correspondence to:
Dr. J. Hoyer
Department of Nephrology
Charité – Universitätsmedizin Berlin
Campus Benjamin Franklin
Hindenburgdamm 30
12200 Berlin, Germany
Email: hoy@zedat.fu-berlin.de
Case reports
Group B Streptococcus (Streptococcus agalactiae) peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD)
391
28$
Abstract
Streptococcus agalactiae typically induces serious infections in pregnant women and newborns. Nonpregnant adult patients can also be infected and mortality rate exceeds 40%. CAPD peritonitis is very rarely induced by S. agalactiae. Seven cases have been described previously and all had a very severe course, which included bacteremia, septic shock and death. A 27-year-old male with end-stage renal disease due to membranoprolipherative glomerulonephritis type I, who was on CAPD for 17 months, was admitted with the clinical and laboratory picture of CAPD peritonitis. Severe abdominal pain, shaking chills and fever 38.5 °C were also observed at presentation. Streptococcus agalactiae was isolated from the peritoneal fluid and blood culture was sterile. Under treatment with ceftazidime and tobramycin (i.p.) and vancomycin (i.v.) cultures became negative after 48 hours, abdominal symptoms resolved after 12 days and WBC count in the dialysate normalized after 14 days. As a possible source of infection the patient’s partner was shown to be a vaginal carrier of a clone of S. agalactiae identical to that isolated in the peritoneal fluid. S. agalactiae is a rare cause of CAPD peritonitis with potentially very serious consequences. Anal or genital tract colonization is, in general, the source of contamination with S. agalactiae. The microbiological findings in the case presented here suggest that colonization of the patient or of his close environment may be important in the pathogenesis of S. agalactiae-induced CAPD peritonitis.Correspondence to:
Dr. I. Stefanidis
University of Thessaly
Department of Medicine
22 Papakyriazi str
41222 Larissa, Greece
Email: stefanid@med.uth.gr
V. Liakopoulos, E. Petinaki, S. Bouchlariotou, P.R. Mertens, M. Trakala, P. Kourti, J. Riehl, V. Ikonomov, and I. Stefanidis
1Division of Nephrology and 2Department of Microbiology, Department of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece, and 3Medical Clinic II, RWTH, Aachen, Germany Streptococcus agalactiae typically induces serious infections in pregnant women and newborns. Nonpregnant adult patients can also be infected and mortality rate exceeds 40%. CAPD peritonitis is very rarely induced by S. agalactiae. Seven cases have been described previously and all had a very severe course, which included bacteremia, septic shock and death. A 27-year-old male with end-stage renal disease due to membranoprolipherative glomerulonephritis type I, who was on CAPD for 17 months, was admitted with the clinical and laboratory picture of CAPD peritonitis. Severe abdominal pain, shaking chills and fever 38.5 °C were also observed at presentation. Streptococcus agalactiae was isolated from the peritoneal fluid and blood culture was sterile. Under treatment with ceftazidime and tobramycin (i.p.) and vancomycin (i.v.) cultures became negative after 48 hours, abdominal symptoms resolved after 12 days and WBC count in the dialysate normalized after 14 days. As a possible source of infection the patient’s partner was shown to be a vaginal carrier of a clone of S. agalactiae identical to that isolated in the peritoneal fluid. S. agalactiae is a rare cause of CAPD peritonitis with potentially very serious consequences. Anal or genital tract colonization is, in general, the source of contamination with S. agalactiae. The microbiological findings in the case presented here suggest that colonization of the patient or of his close environment may be important in the pathogenesis of S. agalactiae-induced CAPD peritonitis.Correspondence to:
Dr. I. Stefanidis
University of Thessaly
Department of Medicine
22 Papakyriazi str
41222 Larissa, Greece
Email: stefanid@med.uth.gr
Case reports
Secondary erythrocytosis associated with distal renal tubular acidosis
397
16$
Abstract
Aims: Diagnosis and classification of renal tubular acidosis (RTA) have traditionally been made on the basis of functional studies. Despite recent expanding knowledge about the molecular abnormalities involved in renal bicarbonate (HCO3–) and H+ transport, the pathophysiology of secondary erythrocytosis in association with distal RTA remains obscure. Case history: A 2-month-old boy with severe hyperchloremic metabolic acidosis with positive urine anion gap was diagnosed with distal RTA. Replacement therapy with sodium bicarbonate and potassium citrate succeeded in improving his metabolic acidosis and growth. His renal function remained normal. He had persistent erythrocytosis. Conclusion: Secondary erythrocytosis is a rarely reported association of distal RTA. It may increase the risk of thromboembolism.Correspondence to:
Dr. H. Matsukura
Department of Pediatrics
Saiseikai Toyama Hospital
33-1 Kusunoki
Toyama, 931-8533, Japan
Email: stingray19659@hotmail.com
H. Matsukura, H. Satoh, M. Arai, A. Higuchi, T. Miyawaki and K. Izumino
1Department of Pediatrics, Saiseikai Toyama Hospital, Toyama, 2Satoh Pediatric Clinic, Yamagata, 3Department of Pediatrics, Faculty of Medicine, Toyama Medical and Pharmaceutical University, Toyama, 4Higuchi Pediatric Clinic, Toyama, and 5Department of Community and Geriatric Nursing, Toyama Medical and Pharmaceutical University, Toyama, Japan Aims: Diagnosis and classification of renal tubular acidosis (RTA) have traditionally been made on the basis of functional studies. Despite recent expanding knowledge about the molecular abnormalities involved in renal bicarbonate (HCO3–) and H+ transport, the pathophysiology of secondary erythrocytosis in association with distal RTA remains obscure. Case history: A 2-month-old boy with severe hyperchloremic metabolic acidosis with positive urine anion gap was diagnosed with distal RTA. Replacement therapy with sodium bicarbonate and potassium citrate succeeded in improving his metabolic acidosis and growth. His renal function remained normal. He had persistent erythrocytosis. Conclusion: Secondary erythrocytosis is a rarely reported association of distal RTA. It may increase the risk of thromboembolism.Correspondence to:
Dr. H. Matsukura
Department of Pediatrics
Saiseikai Toyama Hospital
33-1 Kusunoki
Toyama, 931-8533, Japan
Email: stingray19659@hotmail.com
Letters to the Editor
Different glomerular pathologies in sickle
cell anemia
cell anemia
400
8$
Abstract
M. Balal, S. Paydas, N. Seyrek and I. Karayaylali
Letters to the Editor
A case of acute renal failure, rhabdomyolysis and disseminated intravascular coagulation associated with severe exercise-induced hypernatremic dehydration
401
12$
Abstract
S. Lee, W. Kim, S.K. Park, E.S. Kang, K.P. Kang and S.K. Kang
Letters to the Editor
ACTH therapy in nephrotic syndrome induced by idiopathic membranous nephropathy
403
12$
Abstract
L. Picardi, G. Villa, F. Galli, V. Piazza, G. Bovio,L. Picardi, E. Efficace, G. Montagna, L. Semeraro, S. Segagni and A. Salvadeo
