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Abstract

R.C. Özsoy¹, M.G. Koopman¹, J.J.P. Kastelein² and L. Arisz¹

Departments of ¹Nephrology and ²Vascular Medicine, The Academic Medical Center, University of Amsterdam, The Netherlands
Background: Hyperlipidemia may develop early in the course of renal disease, and statin treatment to lower lipid levels in these patients is effective. In addition, it has been suggested that proteinuria may decrease after prolonged periods of statin treatment. In the present study, we set out to evaluate the short-term effect of atorvastatin after only six weeks of therapy. Material and methods: Plasma albumin, creatinine, creatinine clearance, proteinuria and lipid profiles were assessed in 31 consecutive patients with glomerulonephritis and proteinuria > 0.3 g/24 h. All patients were treated with ACE inhibition for more than three months. Twenty patients consented to receive additional treatment with atorvastatin 10 mg daily in conjunction with a cholesterol-reducing diet, while 11 patients received standard care. Analyses were performed at baseline and after six weeks. Results: After six weeks of treatment with atorvastatin urinary protein excretion was reduced from 1.80 g/24 h to 1.42 g/24 h (22%, p = 0.005), while no change was observed in this parameter in the untreated patients over the same period. Plasma albumin did not change in treated or in untreated patients. Lipid and lipoprotein parameters improved in all treated patients (all p < 0.001). No correlation was observed between the percentual changes in lipids and proteinuria. Plasma creatinine and creatinine clearance did not change (p > 0.05). Conclusions: Six weeks of therapy with low-dose atorvastatin, added to ACE inhibition, resulted in a 22% decrease of proteinuria compared to untreated patients.
Correspondence to:
Dr. M.G. Koopman
Academic Medical Center
University of Amsterdam
Department of Nephrology/F4-215
Meibergdreef 9,
Postbus 22660
1100 DD Amsterdam, The Netherlands
Email: m.g.koopman@amc.uva.nl

Abstract

A.M. Sharma¹, A. Hollander² and J. Köster³

¹University Clinic Benjamin Franklin, Freie Universität, Berlin, ²Bosch Medicentrum, Den Bosch, The Netherlands, and ³Boehringer Ingelheim Pharma KG, Ingelheim, Germany, on behalf of the Efficacy and Safety in Patients with Renal Impairment treated with Telmisartan (ESPRIT) Study Group
Aims: This study assessed the clinical efficacy and safety of telmisartan, an angiotensin II receptor blocker with a long terminal elimination half-life and almost exclusively excreted in bile, in patients with varying severity of chronic kidney disease (CKD). Patients and methods: Adults with diastolic blood pressure (DBP) 90 – 109 mmHg and stable CKD were enrolled: mild/moderate (creatinine clearance (CrCl) 30 – 74 ml/ min/1.73 m2), severe (CrCl < 30 ml/min/1.73 m2) or requiring maintenance hemodialysis. A two- to four-week single-blind, placebo run-in period preceded once-daily telmisartan 40 mg administration for four weeks. Telmisartan 80 mg was given after four- or eight-week treatment if DBP ³ 85 mmHg. After 12-week treatment, trough DBP/systolic blood pressure (SBP), DBP and SBP control rates, renal function and tolerability were recorded. Results: Mean changes in DBP/SBP were –10.5/–10.7 mmHg for mild/moderate CKD (n = 27), –11.2/–14.9 mmHg for severe CKD (n = 27) and –15.0/–21.1 mmHg for hemodialysis patients (n = 28). DBP control rates (< 90 mmHg)/SBP responses (< 140 mmHg or ³ 10 mmHg reduction) occurred in 59.3%/66.7%, 63.0%/70.4% and 71.4%/92.9% of mild/moderate CKD, severe CKD and hemodialysis patients, respectively. Incidences of drug-related adverse events were low, and all were known adverse events of telmisartan and common to other angiotensin II receptor blockers. At the end of treatment, a decrease in 24-h urine creatinine occurred in 5/53 (9.4%) patients. Two patients discontinued treatment prematurely due to the worsening of CKD and one due to aggravated proteinuria. Conclusion: Once-daily telmisartan provided effective and well-tolerated treatment of mild/moderate hypertension in CKD patients, with no worsening of renal function.Correspondence to:
Dr. A.M. Sharma

Professor of Medicine Canada Research

Chair for Cardiovascular Obesity Research and Management

McMaster University

Hamilton General Hospital

237 Barton Street

East Hamilton, Ontario, Canada L8L 2X2
Email: sharma@ccc.mcmaster.ca

Abstract

Y.S. Kang, K.H. Han, S.Y. Han, H.K. Kim and D.R. Cha

¹Division of Nephrology, Department of Internal Medicine, College of Medicine, Korea University, Ansan, and ²Division of Nephrology, Department of Internal Medicine, College of Medicine, Inje University, Kyunggi-Do, Korea
Background and aims: Glomerular filtration rate (GFR) provides the most accurate estimation of renal function. This study investigated the clinical characteristics of patients with impaired renal function having a normal serum creatinine level. We also validated whether the new Modification of Diet in Renal Disease (MDRD) formula can be applied in a healthy general population. Material and methods: A total 393 participants who had serum creatinine concentration below 132.6 mmol/L without underlying diseases were randomly selected on an address basis in Ansan City. According to the level of GFR, they were divided into 3 groups and we analyzed their clinical characteristics. In 75 subjects, who were randomly selected 25 cases in each group based on GFR estimated by Cockcroft-Gault (C-G) formula, true GFR was measured using the 99mTc-DTPA renal clearance method. Results: A total 393 (male: 106, female: 287) participants were as follows: GFR < 60 ml/min/1.73 m2; 4% (n = 25); 60 £ GFR < 90 ml/min/1.73 m2; 26.2% (n = 103); GFR ³ 90 ml/min/1.73 m2; 67.4% (n = 265). In the group of decreased GFR, the mean age was older (67.4 ± 10.7 vs. 48.7 ± 12.8 vs. 39.4 ± 8.2 years, p < 0.001), the gender was male (90.33 ± 28.77 vs. 110.55 ± 31.64, p < 0.001), and amount of proteinuria more increased (0.61 (0.56) vs. 0.33 (0.34) vs. 0.38 (0.33) gm/day, p = 0.007). The accuracy and precision of each formula were assessed by the difference in GFR measured by the 99mTc-DTPA renal clearance method - estimated GFR by each formula (DGFR), and the coefficient of determination (r2) of different predictive equations. The results were as follows: DGFR = –14.78 ± 46.03, r2 = 0.79 (24-hour urinary creatinine clearance), DGFR = –16.79 ± 57.32, r2 = 0.66 (100/serum creatinine), DGFR = 9.54 ± 39.18, r2 = 0.87 (C-G formula), DGFR = –12.30 ± 54.31, r2 = 0.66 (AASK formula), DGFR = 8.70 ± 37.62, r2 = 0.79 (MDRD formula). Multiple linear regression analysis and logistic regression analysis showed that age, serum creatinine, total cholesterol and 24-hour urinary protein excretion were independently related to GFR and associated with a significant increase in the risk of decrement of GFR. Conclusions: From these results, a more accurate assessment of renal function should be required in a population characterized by older age, male gender and more proteinuria. The MDRD study formula and Cockcroft-Gault formula have greater accuracy and precision with true GFR, and this equation can be applied in subjects with healthy general population.Correspondence to:
Dr. D.R. Cha
Department of Internal Medicine
Korea University Hospital
516 Kojan-Dong
Ansan City, Kyunggi-Do, 425-020, Korea
Email: cdragn@unitel.co.kr

Abstract

A.S. Gangji, C.G. Rabbat and P.J. Margetts

Department of Medicine, Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
Aims: Acute renal failure in the intensive care setting is common and impacts on patient’s outcome. Continuous hemodialysis or hemofiltration offers theoretical benefit for patients with acute renal failure, but the clinical benefit has not been demonstrated in randomized trials. ICU patients with acute renal failure are a heterogeneous population and we hypothesize that patients with increased illness severity would benefit from continuous renal replacement therapy. Methods: From a comprehensive ICU database, we identified patients with acute renal failure exposed to continuous or intermittent renal replacement therapy. We a priori identified a subgroup of patients with multiple organ dysfunction syndrome, then used survival analysis to assess the effect of dialysis modality in the overall acute renal failure population and in the subgroup with increased illness severity. Results: We identified 66 patients treated with intermittent and 36 patients treated with continuous renal replacement therapy. Patients with severe illness were preferentially selected for treatment with continuous dialysis (p = 0.01). Overall, there was no significant difference in survival between patients treated with intermittent or continuous dialysis. The relative risk of in-hospital mortality was significantly decreased in patients with multiple organ dysfunction syndrome (relative risk = 0.42 ± 0.22, p = 0.027) treated with continuous therapy as compared with intermittent therapy. Among the survivors, continuous dialysis did not appear to hasten the return of renal function. Conclusions: This retrospective study suggests that continuous dialysis may be beneficial in a subgroup of ICU patients with multiple organ dysfunction syndrome or severe sepsis. Further randomized trials of dialysis modality should, if possible, concentrate on this population.Correspondence to:
Dr. P. Margetts
Assistant Professor
Division of Nephrology
McMaster University
St. Joseph’s Hospital
50 Charlton Ave E
Hamilton, Ontario, Canada
Email: margetts@mcmaster.ca

Abstract

R.W. Nette, M.A. van den Dorpel, H.P. Krepel, E.H.Y. Ie, A.H. van den Meiracker, D. Poldermans, W. Weimar and R. Zietse

Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
Aims: Hypotensive episodes are a major complication of hemodialysis. Hypotension during dialysis could be directly related to a reduction in blood volume or to a decrease in cardiovascular activation as a response to decreased cardiac filling. A decreased cardiovascular activation could be due to patient-related or to dialysis-related factors. In order to study the isolated effect of a reduction in filling pressure, lower body negative pressure (LBNP) causes activation of the cardiovascular reactivity with a decrease in cardiac filling, but without the influence of the dialysis procedure that could affect cardiovascular reactivity. Methods: We studied the relationship between relative blood volume (RBV), central venous pressure (CVP), systolic arterial pressure, heart rate, stroke volume index (SI), and total peripheral resistance index (TPRI) during a combined dialysis/ultrafiltration and during LBNP to –40 mmHg in 21 hemodialysis patients with a high incidence of hypotension. Systolic arterial pressure, heart rate, SI and TPRI were measured by Finapres. CVP was measured after cannulation of the jugular vein. During dialysis RBV was measured by a blood volume monitor (BVM). In order to study the conditions in which hypotension occurred after dialysis, we divided the patients into 2 groups: hypotensive (H) and non-hypotensive (NH) during dialysis. Results: Baseline levels did not show any significant differences. During dialysis systolic arterial pressure declined gradually in the H group from 30 minutes before the onset of hypotension. There was a similar decrease of RBV and increase of heart rate in both groups with a large interindividual variation. At hypotension, H patients showed a significantly smaller increase in TPRI as compared to NH patients. The reduction in SI tended to be greater at hypotension, while CVP decreased to a similar extent in both groups. Moreover, during LBNP, a similar reduction in CVP resulted in a much smaller decrease in SI. Systolic arterial pressure was only slightly lowered due to a much greater increase in TPRI. Conclusion: We conclude that dialysis-related hypotension in our patient group did not result from an inability to maintain blood volume or from decreased cardiac filling. Hypotension appeared to result from the inability to adequately increase arteriolar tone and a reduction in left ventricular function. Both vascular tone and left ventricular function appeared to be impaired by the dialysis procedure.Correspondence to:
Dr. R. Nette
Erasmus Medical Center Rotterdam
Department of Internal Medicine
Room Bd 391
Dr. Molewaterplein 40
3015 GD Rotterdam, The Netherlands
Email: rwnette@hotmail.com

Abstract

A. Gal-Moscovici and M.M. Popovtzer

Nephrology and Hypertension Services, Hadassah University Hospital, Jerusalem, Israel
Aims: Abnormal mineral metabolism in chronic renal disease is associated with bone disease and extraskeletal calcifications. High turnover, hyperparathyroid bone disease, the most common form of renal osteodystrophy, has been the target for aggressive therapy. More recently, an increasing occurrence of low turnover bone disease has been reported. The present study was undertaken to evaluate the current prevalence of different forms of bone disease in a large population on chronic hemodialysis and its relationship to parathyroid hormone (PTH) levels. Methods: Ninety-six chronic hemodialysis patients underwent double tetracycline-labeled bone biopsy. Serum PTH levels were obtained in 52 patients at the time of biopsy. Bone formation rate (BFR/BS) was plotted vs. PTH levels in all patients and in subgroups with PTH ranges between 0 – 150, 150 – 500 and 500 – 1,200 pg/ml. Results: The histomorphometric data showed that 40% of all patients were affected by osteitis fibrosa cystica (OFC). In the remaining 60%, various forms of lowturnover bone disease were observed. There was no correlation between PTH and BFR/BS in all patients (r = 0.28) and in subgroups whose PTH levels ranged between 150 – 500 and 500 – 1,200 pg/ml (r = 0.027, r = 0.21), respectively. A close correlation between PTH and BFR/BS (r = 0.84, p < 0.05) was found only in the subgroup with a PTH level ranging low-turnover bone disease. The predictive between 0 – 150 pg/ml. Conclusions: The histomorphometric findings present a wide spectrum of renal osteodystrophy with a shift towardsvalue of PTH is limited as high-turnover osteodystrophy may present with low PTH levels and that with low turnover may occur with high PTH levels. In the latter parathyroidectomy should be avoided. We share the view that bone biopsy remains the “gold standard” diagnostic tool for renal osteodystrophy.Correspondence to:
Dr. A. Gal-Moscovici
Nephrology and Hypertension Services
Hadassah University Hospital
PO Box 12000
Jerusalem 91120, Israel
Email: galanca@hadassah.org.il

Abstract

E. Kasimatis, D. Maksich, V. Jassal, J.M. Bargman and D.G. Oreopoulos

Division of Nephrology, University Health Network and University of Toronto, Toronto, ON, Canada
Background: Metabolic acidosis is a major metabolic abnormality in end-stage renal disease (ESRD) and alkali is provided with dialysis treatment to patients on chronic peritoneal dialysis (CPD) to keep their acid-base balance within normal serum HCO3– levels. Methods and results: We examined the levels of venous serum HCO3– in 163 patients on CPD and the predictive factors for HCO3– levels low enough to indicate metabolic acidosis. The mean value for HCO3– was 26 ± 2.4 mmol/l and for anion gap was 13.1 ± 3.1 mEq/l. A serum bicarbonate concentration of less than 24 mmol/l, compatible with metabolic acidosis, was observed in 13.5% of the patients. In a multivariate analysis HCO3– levels were directly correlated with older age and use of CaCO3– as phosphate binders, and inversely associated with serum potassium, the use of sevelamer and low lactate dialysis solutions. Higher serum urea levels, the use of low lactate solutions and sevelamer instead of CaCO3 were significantly predictive factors for HCO3– levels < 24 mmol/l. Conclusions: Venous HCO3– and anion gap values were within the normal ranges in stable CPD patients. In 13.5% of them, however, chronic metabolic acidosis was observed based on venous HCO3– levels < 24 mmol/l. Dietary protein intake, the use of sevelamer and low (35 mmol/l) concentration of lactate in dialysis solutions are important predictive factors for chronic metabolic acidosis in these patients.Correspondence to:
Dr. D.G. Oreopoulos

Division of Nephrology

University Health Network and University of Toronto

399 Bathurst St

Toronto, ON M5T 2S8, Canada
Email: dgo@teleglobal.ca

Abstract

S. Kapoulas, S. Liakos, G. Karkavelas, M. Ageloudi, D. Grekas and E. Giannoulis

¹First Medical Department, Renal Unit, University Hospital AHEPA, and ²Pathology Department, Aristotelian University of Thessaloniki, Greece
There are a few reported cases in the literature of thrombotic thrombocytopenic purpura (TTP), associated with systemic lupus erythematosus (SLE). We describe two cases of TTP which have been presented during rapidly progressive lupus nephritis, with grand-mal seizures, thrombocytopenia and microangiopathic hemolytic anemia. Both cases were treated with hemodialysis, plasma exchange, corticosteroids, cyclophosphamide and intravenous g-globulin. In both cases the TTP was improved but not the renal function. Further experience is needed to determine whether intensive and prompt treatment with plasma exchange, corticosteroids and chemotherapy leads to a favorable outcome, in cases of TTP associated with SLE.
Correspondence to:
Dr S. Kapoulas Associate Professor in Nephrology University Hospital AHEPA, Renal Unit First Medical Department 54006 Thessaloniki, Greece
Email: renunit@med.auth.gr

Abstract

D. Weiler-Bisig, G. Ettlin, T. Brink, W. Arnold, K. Glatz-Krieger and A. Fischer

¹Department of Internal Medicine, Division of Nephrology, Kantonsspital Luzern, ²Institute of Pathology, Kantonsspital Luzern, and ³Department of Pathology, University of Basel, Switzerland
Henoch-Schönlein purpura (HSP) is known to exist in association with a variety of malignant diseases including squamous and small cell lung cancer and hematological malignancies. We report the first cases of HSP associated with carcinoma of the esophagus and adenocarcinoma of the lung, respectively. We compare the main features of our patients with 23 previously published cases. We recommend that patients with HSP, especially men over 40 years of age, should undergo screening for occult neoplasia.Correspondence to:
Dr. A. Fischer
Division of Nephrology
Department of Internal Medicine
Kantonsspital Luzern
6000 Luzern 16, Switzerland
Email: andreas.fischer@ksl.ch

Abstract

M.Q. Tran, R.Y. Gohh, P.E. Morrissey, L.D. Dworkin, A. Gautam, A.P. Monaco and A.F. Yango Jr.

¹Division of Organ Transplantation and Nephrology, and ²Division of Hypertension and Renal Diseases, Rhode Island Hospital, Brown University School of Medicine, Rhode Island, Providence, RI, USA
Cryptosporidium parvum, an intracellular protozoan parasite, is a significant cause of gastrointestinal disease worldwide. Transmission can occur from an infected person, animal or fecally contaminated environment. The clinical manifestations of cryptosporidiosis are dependent on the immunologic state of the host. Infection among immunocompetent hosts results in diarrhea that is typically self-limited. In immunocompromised hosts, however, the infection may be protracted and life-threatening with no reliable antimicrobial therapy. In transplant patients, a course of antimicrobial therapy along with concurrent reduction in immunosuppression optimize immunologic status and may potentially lead to resolution of the infection.Correspondence to:
Dr. A.F. Yango Jr. Division of Hypertension and Renal Diseases Brown University School of Medicine, Rhode Island, and The Miriam Hospitals, APC Building, Suite 921 593 Eddy Street Providence, RI, 02903, USA
Email: ayango@lifespan.org

Abstract

S. Iguchi, B. Alchi, F. Safar, A. Kasai, K. Suzuki, H. Kihara, M. Hirota, S. Nishi, F. Gejyo and Y. Ohno

¹Department of Internal Medicine, Niigata Prefectural Muikamachi Hospital, Muikamachi, ²Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medicine and Dental Sciences, ³Department of Radiology, Niigata University Facu
Hepatic portal venous gas (HPVG) has been rarely described in chronic hemodialysis patients. We report a case of HPVG in a 59-year-old female patient with hemodialysis-dependent chronic renal failure due to diabetes who presented with acute onset of abdominal pain. Abdominal CT demonstrated the presence of gas in the portal veins. However, on laparotomy, no evidence of bowel necrosis or perforation could be found. HPVG seemed to be caused by nonocclusive mesenteric ischemia (NOMI), an increasingly recognized complication in hemodialysis patients. The patient responded favorably to intravenous hyperalimentation and antibiotics.
Correspondence to:
Dr. B. Alchi 1-757 Asahimachi-dori Niigata 951-8510, Japan
Email: bassamalchi@hotmail.com

Abstract

M. Nakagawa, K. Kise, N. Okamoto, H. Fujino, M. Iwai, Y. Nomura and H. Sawa

Department of Pediatrics, Shiga University of Medical Science, Seta, Otsu, Japan
We describe a 40-month-old male infant with renal failure, treated with peritoneal dialysis, who developed massive calcification of soft tissues including the heart and lungs with subsequent cardiopulmonary insufficiency. A diagnosis of Jeune syndrome was made. After starting peritoneal dialysis, the patient exhibited an intractable metabolic acidosis of unknown etiology necessitating treatment with intravenous or oral sodium bicarbonate. Myocardial calcification was first detected by 2-dimensional echocardiography performed 3 months after starting dialysis. The patient was not suitable for renal transplantation because of his cardiac dysfunction and died of cardiac and respiratory failure at the age of 6 years. Although the patient exhibited a variety of risk factors for ectopic calcification including hyperphosphatemia, hyperparathyroidism, high calcium-phosphate product and treatment with vitamin D, the early and massive soft tissue calcification may have been accelerated by correction of the metabolic acidosis. Therefore, the use of sodium bicarbonate may be involved in the etiology of the myocardial calcification.Correspondence to:
Dr. M. Nakagawa Department of Pediatrics Shiga University of Medical Science Seta, Otsu, Shiga, 520-2192, Japan
Email: masao@belle.shiga-med.ac.jp

Abstract

H. Nakamura, K. Katizawa, Y. Inada, N. Kato, M. Mukai, M. Akashi and T. Sugisaki

¹Department of Internal Medicine, Kanto Rosai Hospital, Kanagawa, and ²Department of Nephrology, Showa University School of Medicine, Tokyo, Japan
We present a rare case of perineal-onset Fournier’s gangrene in a patient undergoing hemodialysis. A 51-year-old Japanese man manifested an acute-onset perineal pain with perirectal abscess; subsequently, the pain extended to the abdomen, chest, and loin despite quick treatment. His consciousness deteriorated to delirium and he died of septic shock on the third day of admission. Computed tomography (CT) revealed soft-tissue air along the right rectal wall, moreover, the infection extended to the anterior wall of the bladder and the right peripsoas muscle. On the basis of the clinical course and CT findings, the patient was diagnosed as having the complications of Fournier’s gangrene, however, no scrotal lesions were detected. Fournier’s gangrene is considered to be easily diagnosed on the basis of skin lesions, such as scrotal erythema and swelling. However, in the early stage, the diagnosis of Fournier’s gangrene is difficult in a patient with perineal pain before the detection of skin lesions. In conclusion, definitely the key to improving the prognosis of this fulminant infection is the prompt recognition of the pathological process. Therefore, Fournier’s gangrene should always be considered when patients undergoing hemodialysis manifest perirectal disorders, even when no scrotal lesions are detected, because there is the possibility of intra-abdominal and intra-retroperitoneal infections resulting in septic shock.Correspondence to:
Dr. H. Nakamura
Department of Internal Medicine
Kanto Rosai Hospital
2035 Kituki-sumiyoshi cho, Nakahara-ku
Kawasaki, Kanagawa, Japan
Email: h-mon@east.dts.ne.jp

Abstract

Y.P. Siu, K.T. Leung, M.K.H. Tong and M.K.F. Lee

Division of Nephrology, Department of Medicine, Tuen Mun Hospital, Hong Kong, China
Atypical mycobacterial infection of the Tenckhoff catheter exit site is rare. Eradication of the infection is often difficult without the removal of the Tenckhoff catheter. We report here a case of Mycobacterium chelonae exit site infection in a peritoneal dialysis patient. He was treated with a combination regimen of prolonged antibiotics, local heat therapy, deroofing and shaving of the Tenckhoff catheter outer cuff. This resulted in the successful treatment of the infection without the need for removal of the Tenckhoff catheter. We recommend that this therapeutic approach could be considered in similar cases and that removal of Tenckhoff catheter is not mandatory.Correspondence to:
Dr. M. Tong Department of Medicine Tuen Mun Hospital Hong Kong, China
Email: khmtong@netvigator.com

Abstract

K. Kantartzi, A. Polychronidis, M. Theodoridis, S. Perente, V. Vargemezis and C. Simopoulos

Abstract

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Volume 63, No. 4/2005(April)