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Dustri-Verlag
Volume 64, No. 2/2005(August)
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Originals
Alport syndrome in southern Sweden
85
28$
Abstract
Aim: The aim of the present investigation is to study the epidemiology of Alport syndrome in southern Sweden, to search for mutations in the COL4A5 gene and to estimate the mutation frequency. Patients and methods: Patients with suspected Alport syndrome were identified in an area with a population of 1.45 million. Clinical criteria were used to establish the diagnosis and samples for mutation analysis were collected. Mutation analyses were performed with Single-Stranded Conformation Polymorphism analysis (SSCP) of PCR-amplified genomic DNA. Results: Altogether 25 families with hereditary nephritis were identified. Alport syndrome with X-linked transmission was evident in 14 families, with juvenile (< 31 years) progression to end-stage renal failure (ESRF) in ten, and adult (³ 31 years) in four families. Conclusion: The frequency of males with X-linked disease was calculated to one in 17,000 male births (95% confidence interval (CI) 1/10,500 – 1/28,600), and the prevalence to one in 40,000. A total of seven females with ESRF were identified, with a median age at ESRF of 45 years. The male to female ratio of cases with ESRF was 4.9 to 1. The risk of developing ESRF among females was from the expected incidence roughly estimated to 12%. Patients with X-linked disease constituted 1.8% of patients with ESRF in the examined area. A mutation was identified positive in 10 of 14 families with X-linked disease, but never in families not fulfilling the clinical criteria for Alport syndrome. In families with juvenile phenotype and positive mutation analysis, the mutation frequency was calculated to between 1/78,000 and 1/198,000 (95% CI 1/42,000 – 1/177,000) if the effective fertility was estimated to be between 0 and 0.2.
Correspondence to:
Ulf Persson, M.D.
Njurmedicinska kliniken
Njurmottagningen Blå stråket 5 1 tr
Sahlgrenska Universitetssjukhuset SU/S
413 45 Göteborg, Sweden
Email: ulf.m.persson@vgregion.se
U. Persson, J.M. Hertz, J. Wieslander and M. Segelmark
1Department of Nephrology, Lund University Hospital, Sweden, 2Department of Clinical Genetics, Aarhus University Hospital, Bartholin, Bygningen, Universtitetsparken, Århus C, Denmark, and 3Wieslab AB, IDEON, Lund, Sweden Aim: The aim of the present investigation is to study the epidemiology of Alport syndrome in southern Sweden, to search for mutations in the COL4A5 gene and to estimate the mutation frequency. Patients and methods: Patients with suspected Alport syndrome were identified in an area with a population of 1.45 million. Clinical criteria were used to establish the diagnosis and samples for mutation analysis were collected. Mutation analyses were performed with Single-Stranded Conformation Polymorphism analysis (SSCP) of PCR-amplified genomic DNA. Results: Altogether 25 families with hereditary nephritis were identified. Alport syndrome with X-linked transmission was evident in 14 families, with juvenile (< 31 years) progression to end-stage renal failure (ESRF) in ten, and adult (³ 31 years) in four families. Conclusion: The frequency of males with X-linked disease was calculated to one in 17,000 male births (95% confidence interval (CI) 1/10,500 – 1/28,600), and the prevalence to one in 40,000. A total of seven females with ESRF were identified, with a median age at ESRF of 45 years. The male to female ratio of cases with ESRF was 4.9 to 1. The risk of developing ESRF among females was from the expected incidence roughly estimated to 12%. Patients with X-linked disease constituted 1.8% of patients with ESRF in the examined area. A mutation was identified positive in 10 of 14 families with X-linked disease, but never in families not fulfilling the clinical criteria for Alport syndrome. In families with juvenile phenotype and positive mutation analysis, the mutation frequency was calculated to between 1/78,000 and 1/198,000 (95% CI 1/42,000 – 1/177,000) if the effective fertility was estimated to be between 0 and 0.2.
Correspondence to:
Ulf Persson, M.D.
Njurmedicinska kliniken
Njurmottagningen Blå stråket 5 1 tr
Sahlgrenska Universitetssjukhuset SU/S
413 45 Göteborg, Sweden
Email: ulf.m.persson@vgregion.se
Originals
Pentoxifylline is as effective as captopril in the reduction of microalbuminuria in non-hypertensive type 2 diabetic patients - a randomized, equivalent trial
91
32$
Abstract
Security Institute, and the Research Group on Diabetes and Chronic Illnesses, Durango, Mexico
Aims: To compare the efficacy of pentoxifylline and captopril on urinary albumin excretion (UAE) rate in non-hypertensive diabetic patients with microalbuminuria. Methods: 450 subjects were screened; of these 130 eligible, non-hypertensive, type 2 diabetic subjects were enrolled and randomly allocated to receive either pentoxifylline 400 mg t.i.d. (n = 65) or captopril 25 mg t.i.d. (n = 65) for six months in a randomized equivalent trial design study. Patients were eligible to participate if they had microalbuminuria, defined by UAE rate of 20 – 200 mg/min, and systolic/diastolic blood pressure lower than 140/85 mmHg. Diagnosis of high blood pressure and renal failure were exclusion criteria. In addition, subjects receiving ACE inhibitors or pentoxifylline were not included. Results: Both treatments were well tolerated, without serious adverse events; nonetheless, one subject (1.6%) in the group with pentoxifylline had severe headache, and three (4.7%) subjects in the group with captopril had intense dry cough and nasal congestion that required stopping pentoxifylline and captopril. In addition, slight headache and mild dry cough that did not require specific treatment or interruption of medication were present in two (3.2%) and five (7.8%) subjects treated with pentoxifylline and captopril. Four subjects dropped-out (one in the pentoxifylline group and three in the captopril group). Blood pressure and fasting glucose levels were similar between the two groups throughout the study. The UAE rate decreased from the first month of treatment in the subjects of both groups, a reduction that was sustained in the following months. At the end of the study, the average UAE rate in the subjects of both groups was lower than 25 mg/min. Conclusions: Pentoxifylline showed to be an effective alternative to ACE inhibitors in reducing UAE in non-hypertensive diabetic patients with microalbuminuria.
Correspondence to:
Martha Rodríguez-Morán, MD
MSc Siqueiros 225 esq./Castañeda
34000 Durango, Dgo., Mexico
Email: rodriquez_moran@hotmail.com
M. Rodríguez-Morán and F. Guerrero-Romero
Medical Research Unit in Clinical Epidemiology of the Mexican Social Security Institute, and the Research Group on Diabetes and Chronic Illnesses, Durango, Mexico
Aims: To compare the efficacy of pentoxifylline and captopril on urinary albumin excretion (UAE) rate in non-hypertensive diabetic patients with microalbuminuria. Methods: 450 subjects were screened; of these 130 eligible, non-hypertensive, type 2 diabetic subjects were enrolled and randomly allocated to receive either pentoxifylline 400 mg t.i.d. (n = 65) or captopril 25 mg t.i.d. (n = 65) for six months in a randomized equivalent trial design study. Patients were eligible to participate if they had microalbuminuria, defined by UAE rate of 20 – 200 mg/min, and systolic/diastolic blood pressure lower than 140/85 mmHg. Diagnosis of high blood pressure and renal failure were exclusion criteria. In addition, subjects receiving ACE inhibitors or pentoxifylline were not included. Results: Both treatments were well tolerated, without serious adverse events; nonetheless, one subject (1.6%) in the group with pentoxifylline had severe headache, and three (4.7%) subjects in the group with captopril had intense dry cough and nasal congestion that required stopping pentoxifylline and captopril. In addition, slight headache and mild dry cough that did not require specific treatment or interruption of medication were present in two (3.2%) and five (7.8%) subjects treated with pentoxifylline and captopril. Four subjects dropped-out (one in the pentoxifylline group and three in the captopril group). Blood pressure and fasting glucose levels were similar between the two groups throughout the study. The UAE rate decreased from the first month of treatment in the subjects of both groups, a reduction that was sustained in the following months. At the end of the study, the average UAE rate in the subjects of both groups was lower than 25 mg/min. Conclusions: Pentoxifylline showed to be an effective alternative to ACE inhibitors in reducing UAE in non-hypertensive diabetic patients with microalbuminuria.
Correspondence to:
Martha Rodríguez-Morán, MD
MSc Siqueiros 225 esq./Castañeda
34000 Durango, Dgo., Mexico
Email: rodriquez_moran@hotmail.com
Originals
The effect of calcitriol on fasting urine calcium loss and renal tubular reabsorption of calcium in patients with mild renal failure - actions of a permissive hormone
98
24$
Abstract
Aim: Renal production of 1,25-dihydroxycholecalciferol is attenuated in early renal failure. Renal tubular reabsorption of calcium is diminished in moderate renal failure and we wished to see if this were true in the early stages and whether supplementary calcitriol would bring about correction. We were interested in the idea of 1,25-dihydroxycholecalciferol being a permissive agent, operating indirectly. Methods: We measured calcium-related variables, including calculated ultrafiltrable serum calcium, before and after calcitriol 0.5 mg daily for six days in 34 subjects with stable mild renal failure. Results: The mean serum creatinine was 0.21 (± 0.08) mmol/l. The mean serum Ca++ was normal (1.18 mmol/l) but nine patients had values outside the normal range and in six cases, with low-normal serum Ca++ levels, there was a diminished tubular reabsorption. In five cases, basal serum Ca++ was mildly elevated. The coefficient of variation for serum Ca++ was 4.4%. PTH (1-84) levels were mildly elevated and 1,25-dihydroxycholecalciferol levels low-normal. The urine Ca/Cr, representing net bone resorption, was elevated in six cases. After calcitriol, the mean serum Ca++ level rose slightly and the coefficient of variation decreased to 3.6%. Changes in Ca++ whether upward or downward were accounted for by minor alterations in tubular reabsorption and a tendency to less net bone resorption. The initial Ca++ predicted (negatively) the magnitude of the correction. Neither the prevailing PTH nor the 1,25-dihydroxycholecalciferol levels explained any of the observed changes. Conclusion: In early renal failure, there may be impaired regulation of serum Ca++. Despite elevated PTH, mild hypocalcemia may exist in the presence of increased net bone resorption relative to GFR. Hypocalcemia was accounted for by reduced renal tubular reabsorption of calcium which corrected after calcitriol. Net bone resorption tended to fall after calcitriol. Mild hypercalcemia, when present, was corrected by a reduction in tubular reabsorption. Calcitriol did not have a simple unidirectional effect but instead contributed to efficiency of the homeostatic mechanisms controlling the serum Ca++ set-point.Correspondence to:
Dr. M. Cochran
Endocrine and Bone Center
130 Sydenham Road
Norwood, South Australia 5067, Australia
Email: mcochran@optusnet.com.au
M. Cochran, P.T.H. Coates and H.A. Morris
1Endocrine and Bone Center, Norwood, 2Renal Unit, Queen Elizabeth Hospital, Woodville, and 3Hanson Institute, Adelaide, South Australia Aim: Renal production of 1,25-dihydroxycholecalciferol is attenuated in early renal failure. Renal tubular reabsorption of calcium is diminished in moderate renal failure and we wished to see if this were true in the early stages and whether supplementary calcitriol would bring about correction. We were interested in the idea of 1,25-dihydroxycholecalciferol being a permissive agent, operating indirectly. Methods: We measured calcium-related variables, including calculated ultrafiltrable serum calcium, before and after calcitriol 0.5 mg daily for six days in 34 subjects with stable mild renal failure. Results: The mean serum creatinine was 0.21 (± 0.08) mmol/l. The mean serum Ca++ was normal (1.18 mmol/l) but nine patients had values outside the normal range and in six cases, with low-normal serum Ca++ levels, there was a diminished tubular reabsorption. In five cases, basal serum Ca++ was mildly elevated. The coefficient of variation for serum Ca++ was 4.4%. PTH (1-84) levels were mildly elevated and 1,25-dihydroxycholecalciferol levels low-normal. The urine Ca/Cr, representing net bone resorption, was elevated in six cases. After calcitriol, the mean serum Ca++ level rose slightly and the coefficient of variation decreased to 3.6%. Changes in Ca++ whether upward or downward were accounted for by minor alterations in tubular reabsorption and a tendency to less net bone resorption. The initial Ca++ predicted (negatively) the magnitude of the correction. Neither the prevailing PTH nor the 1,25-dihydroxycholecalciferol levels explained any of the observed changes. Conclusion: In early renal failure, there may be impaired regulation of serum Ca++. Despite elevated PTH, mild hypocalcemia may exist in the presence of increased net bone resorption relative to GFR. Hypocalcemia was accounted for by reduced renal tubular reabsorption of calcium which corrected after calcitriol. Net bone resorption tended to fall after calcitriol. Mild hypercalcemia, when present, was corrected by a reduction in tubular reabsorption. Calcitriol did not have a simple unidirectional effect but instead contributed to efficiency of the homeostatic mechanisms controlling the serum Ca++ set-point.Correspondence to:
Dr. M. Cochran
Endocrine and Bone Center
130 Sydenham Road
Norwood, South Australia 5067, Australia
Email: mcochran@optusnet.com.au
Originals
Cardiovascular risk factors in severe chronic renal failure: the role of dietary treatment
103
44$
Abstract
7Renal Unit Ospedale di Campi salentina, Azienda Ospedale di Campi Salentina, 8Nephrology Unit, Department of Internal Medicine, University of Pisa, 9Thrombosis Center, University of Florence, Florence, Italy
Background: Lipoprotein abnormalities and increased oxidized LDL (OxLDL) are often observed in uremia and are reported to play a central role in the development of cardiovascular disease (CVD). Vegan diet, known for its better lipoprotein profile and antioxidant vitamins content, could protect against CVD. Aim of this study was to investigate the influence of vegan diet supplemented with essential amino acids (EAA) and ketoanalogues (VSD) on both traditional and non-traditional cardiovascular risk factors (CVRF). Methods: Twenty-nine patients (18 M, 11 F) aged 55 years (range 29 – 79 years) with advanced chronic renal failure (median sCr: 5.6 mg/dl) on very low protein vegetarian diet (0.3 g/kg/day) supplemented with a mixture of EAA and ketoacids (VSD) and 31 patients (20 M, 11 F) aged 65 years (range 29 – 82 years) on conventional low-protein diet (CD: 0.6 g/kg/day) with a similar renal function (median sCr: 5.2 mg/dl), were investigated for lipids and apolipoprotein parameters (traditional CVRF) as well as for oxidative stress (oxidized LDL, antibodies against OxLDL and thiobarbituric acid-reactive substances (TBARS)), total homocysteine (tHcy), lipoprotein(a) (Lp(a)), albumin and c-reactive protein (CRP) (non-traditional CVRF) including vitamins A, E, B12 and folic acid. Results: Compared to patients on CD, those on VSD showed increased HDL cholesterol levels (p < 0.005) with a reduction of LDL cholesterol (p < 0.01) and an increase of apoA1/ apoB ratio (p < 0.02). Among non-traditional CVRF, a mild but significant reduction of OxLDL (p < 0.05) with lower TBARS concentrations (p < 0.01) and a significant reduction of total homocysteine (p < 0.002), Lp(a) (p < 0.002) and CRP levels (p < 0.05) were also observed in these patients. Concentrations of vitamin E and A were not different between the two groups while vitamin B12 and folic acid resulted markedly increased in patients on VSD. OxLDL significantly correlated with total and LDL cholesterol, triglycerides and Apo B in CD but not in VSD patients. Patients on CD also showed a significant correlation between urea and CRP. After a multivariate analysis, only urea (p < 0.001) and OxLDL (p < 0.006) were associated to a risk of CRP > 0.3 mg/dl. Conclusions: These results indicate a better lipoprotein profile in patients on vegan diet including non-traditional CVRF. In particular, these patients show a reduced oxidative stress with a reduced acute-phase response (CRP) as compared to patients on conventional diet. We hypothesize that urea, significantly lower in patients on VSD, may account, possibly together with the reduction of other protein breakdown products, for the decreased acute-phase response observed in these patients. Our findings suggest that low-protein diets, and vegan in particular, may exert a beneficial effect on the development of cardiovascular disease in patients with end-stage renal disease (ESRD).Correspondence to:
Dr. F. Bergesio
Via del Pino
50137 Firenze, Italy
Email: fraberge@tin.it
F. Bergesio, G. Monzani, A. Guasparini, R. Ciuti, M. Gallucci, C. Cristofano, E. Castrignano, A. Cupisti, G. Barsotti, R. Marcucci, R. Abbate, S. Bandini, M. Gallo, P.L. Tosi and M. Salvadori
1Department of Nephrology, Dialysis and Transplantation, Azienda Ospedale Careggi, Florence, 2Renal Unit Ospedale di Torregalli, Azienda Sanitaria Firenze, Florence, 3Dietary Service, 4Clinical Chemistry, Azienda Ospedale Careggi, Florence, 5Renal Unit Ospedale di Galatina, Azienda Ospedale Galatina, 6Renal Unit Ospedale di Manduria, Azienda Ospedale Manduria,7Renal Unit Ospedale di Campi salentina, Azienda Ospedale di Campi Salentina, 8Nephrology Unit, Department of Internal Medicine, University of Pisa, 9Thrombosis Center, University of Florence, Florence, Italy
Background: Lipoprotein abnormalities and increased oxidized LDL (OxLDL) are often observed in uremia and are reported to play a central role in the development of cardiovascular disease (CVD). Vegan diet, known for its better lipoprotein profile and antioxidant vitamins content, could protect against CVD. Aim of this study was to investigate the influence of vegan diet supplemented with essential amino acids (EAA) and ketoanalogues (VSD) on both traditional and non-traditional cardiovascular risk factors (CVRF). Methods: Twenty-nine patients (18 M, 11 F) aged 55 years (range 29 – 79 years) with advanced chronic renal failure (median sCr: 5.6 mg/dl) on very low protein vegetarian diet (0.3 g/kg/day) supplemented with a mixture of EAA and ketoacids (VSD) and 31 patients (20 M, 11 F) aged 65 years (range 29 – 82 years) on conventional low-protein diet (CD: 0.6 g/kg/day) with a similar renal function (median sCr: 5.2 mg/dl), were investigated for lipids and apolipoprotein parameters (traditional CVRF) as well as for oxidative stress (oxidized LDL, antibodies against OxLDL and thiobarbituric acid-reactive substances (TBARS)), total homocysteine (tHcy), lipoprotein(a) (Lp(a)), albumin and c-reactive protein (CRP) (non-traditional CVRF) including vitamins A, E, B12 and folic acid. Results: Compared to patients on CD, those on VSD showed increased HDL cholesterol levels (p < 0.005) with a reduction of LDL cholesterol (p < 0.01) and an increase of apoA1/ apoB ratio (p < 0.02). Among non-traditional CVRF, a mild but significant reduction of OxLDL (p < 0.05) with lower TBARS concentrations (p < 0.01) and a significant reduction of total homocysteine (p < 0.002), Lp(a) (p < 0.002) and CRP levels (p < 0.05) were also observed in these patients. Concentrations of vitamin E and A were not different between the two groups while vitamin B12 and folic acid resulted markedly increased in patients on VSD. OxLDL significantly correlated with total and LDL cholesterol, triglycerides and Apo B in CD but not in VSD patients. Patients on CD also showed a significant correlation between urea and CRP. After a multivariate analysis, only urea (p < 0.001) and OxLDL (p < 0.006) were associated to a risk of CRP > 0.3 mg/dl. Conclusions: These results indicate a better lipoprotein profile in patients on vegan diet including non-traditional CVRF. In particular, these patients show a reduced oxidative stress with a reduced acute-phase response (CRP) as compared to patients on conventional diet. We hypothesize that urea, significantly lower in patients on VSD, may account, possibly together with the reduction of other protein breakdown products, for the decreased acute-phase response observed in these patients. Our findings suggest that low-protein diets, and vegan in particular, may exert a beneficial effect on the development of cardiovascular disease in patients with end-stage renal disease (ESRD).Correspondence to:
Dr. F. Bergesio
Via del Pino
50137 Firenze, Italy
Email: fraberge@tin.it
Originals
Extended epoetin alfa dosing as maintenance treatment for the anemia of chronic kidney disease: the PROMPT study
113
48$
Abstract
Aim: To determine whether extended epoetin alfa dosing schedules of up to once every four weeks are as effective as weekly dosing in maintaining hemoglobin (Hb) levels in patients with anemia of chronic kidney disease (CKD). Methods: This randomized, open-label trial enrolled patients with anemia of CKD not on dialysis. Patients were required to have a stable Hb level (³ 11.0 g/dl) and to have been previously receiving epoetin alfa for two or more months. Patients were randomized to one of four subcutaneously administered epoetin alfa dosing regimens: 10,000 units (U) once weekly (QW), 20,000 U every two weeks (Q2W), 30,000 U every three weeks (Q3W) or 40,000 U every four weeks (Q4W). Dose reductions, but not escalations, were permitted. Patients received treatment for a total of 16 weeks. The primary endpoint for the trial was the mean final Hb measurements of the QW, Q2W, Q3W, and Q4W groups. The primary efficacy analyses were non-inferiority assessments of the mean final Hb measurements of the Q2W, Q3W, and Q4W groups, compared with the QW group. The primary efficacy analyses were performed using a modified intent-to-treat (MITT) population, defined as all patients meeting all inclusion/exclusion criteria (or, if not satisfying all criteria, were granted an exemption at study entry), and who were randomized and received at least one dose of study medication. A per-protocol population, based on all patients who met the MITT criteria and completed the entire study, was used to evaluate the robustness of the MITT results. Quality of life was assessed for all dosing groups throughout the study. Safety was based on all patients randomized who received at least one dose of study medication. Results: A total of 519 patients were enrolled; 445 were included in the MITT population. The four treatment groups were comparable with respect to baseline characteristics. The primary etiologies of CKD were diabetes (45.7%) and hypertension (29.9%). The mean baseline Hb, serum creatinine and glomerular filtration rate for all patients were 11.9 ± 0.8 g/dl, 3.1 mg/dl, and 21.1 ml/min/1.73 m2, respectively. The mean baseline transferrin saturation was 25.2% and the mean ferritin was 201.9 ng/ml for all patients. All groups had a mean final Hb of > 11.0 g/dl. The mean final Hb levels of the Q2W and Q4W groups were statistically non-inferior to the QW group. The results of the per-protocol analysis were consistent with the MITT results. In addition, 93.5%, 89.5%, 77.2%, and 76.0% of patients maintained a mean Hb ³ 11.0 g/dl throughout the course of the study in the QW, Q2W, Q3W, and Q4W groups, respectively. Quality of life was maintained or improved from baseline to final within each dosing group. There were no significant differences in the mean final quality of life scores between the QW group and the Q2W, Q3W, and Q4W groups. Among the 513 patients evaluated for safety, epoetin alfa was well tolerated with no differences in adverse events between groups. The incidence of thrombotic adverse events was low (2.5% of patients), as was mortality (1.4% of patients). Conclusions: Approximately 90% of patients dosed once every two weeks and over 75% of patients dosed once every three or four weeks maintained mean Hb levels ³ 11.0 g/dl, consistent with the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines. This study suggests that extended epoetin alfa dosing schedules are effective and safe for maintaining Hb, and may offer the possibility of increased flexibility and convenience for the majority of patients with the anemia of CKD.Correspondence to:
R. Provenzano, MD, FACP
Division of Nephrology
St. John Hospital and Medical Center
22201 Moross Road, Suite 250
Detroit, MI 48236, USA
Email: robert.provenzano@stjohn.org
R. Provenzano, S. Bhaduri and A.K. Singh for the PROMPT Study Group
1Division of Nephrology, St. John Hospital and Medical Center, Detroit, MI, 2Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ, and 3Renal Division, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA Aim: To determine whether extended epoetin alfa dosing schedules of up to once every four weeks are as effective as weekly dosing in maintaining hemoglobin (Hb) levels in patients with anemia of chronic kidney disease (CKD). Methods: This randomized, open-label trial enrolled patients with anemia of CKD not on dialysis. Patients were required to have a stable Hb level (³ 11.0 g/dl) and to have been previously receiving epoetin alfa for two or more months. Patients were randomized to one of four subcutaneously administered epoetin alfa dosing regimens: 10,000 units (U) once weekly (QW), 20,000 U every two weeks (Q2W), 30,000 U every three weeks (Q3W) or 40,000 U every four weeks (Q4W). Dose reductions, but not escalations, were permitted. Patients received treatment for a total of 16 weeks. The primary endpoint for the trial was the mean final Hb measurements of the QW, Q2W, Q3W, and Q4W groups. The primary efficacy analyses were non-inferiority assessments of the mean final Hb measurements of the Q2W, Q3W, and Q4W groups, compared with the QW group. The primary efficacy analyses were performed using a modified intent-to-treat (MITT) population, defined as all patients meeting all inclusion/exclusion criteria (or, if not satisfying all criteria, were granted an exemption at study entry), and who were randomized and received at least one dose of study medication. A per-protocol population, based on all patients who met the MITT criteria and completed the entire study, was used to evaluate the robustness of the MITT results. Quality of life was assessed for all dosing groups throughout the study. Safety was based on all patients randomized who received at least one dose of study medication. Results: A total of 519 patients were enrolled; 445 were included in the MITT population. The four treatment groups were comparable with respect to baseline characteristics. The primary etiologies of CKD were diabetes (45.7%) and hypertension (29.9%). The mean baseline Hb, serum creatinine and glomerular filtration rate for all patients were 11.9 ± 0.8 g/dl, 3.1 mg/dl, and 21.1 ml/min/1.73 m2, respectively. The mean baseline transferrin saturation was 25.2% and the mean ferritin was 201.9 ng/ml for all patients. All groups had a mean final Hb of > 11.0 g/dl. The mean final Hb levels of the Q2W and Q4W groups were statistically non-inferior to the QW group. The results of the per-protocol analysis were consistent with the MITT results. In addition, 93.5%, 89.5%, 77.2%, and 76.0% of patients maintained a mean Hb ³ 11.0 g/dl throughout the course of the study in the QW, Q2W, Q3W, and Q4W groups, respectively. Quality of life was maintained or improved from baseline to final within each dosing group. There were no significant differences in the mean final quality of life scores between the QW group and the Q2W, Q3W, and Q4W groups. Among the 513 patients evaluated for safety, epoetin alfa was well tolerated with no differences in adverse events between groups. The incidence of thrombotic adverse events was low (2.5% of patients), as was mortality (1.4% of patients). Conclusions: Approximately 90% of patients dosed once every two weeks and over 75% of patients dosed once every three or four weeks maintained mean Hb levels ³ 11.0 g/dl, consistent with the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines. This study suggests that extended epoetin alfa dosing schedules are effective and safe for maintaining Hb, and may offer the possibility of increased flexibility and convenience for the majority of patients with the anemia of CKD.Correspondence to:
R. Provenzano, MD, FACP
Division of Nephrology
St. John Hospital and Medical Center
22201 Moross Road, Suite 250
Detroit, MI 48236, USA
Email: robert.provenzano@stjohn.org
Originals
Improved survival in HIV-infected African-Americans with ESRD
124
24$
Abstract
Aims: To determine if there has been improvement in survival of HIV-infected patients with end-stage renal failure subsequent to widespread use of highly active antiretroviral therapy. Methods: The United States Renal Data System is a national data system funded by the National Institute of Diabetes and Digestive and Kidney Disease with the Centers for Medicare and Medicaid. Using the United States Renal Data System Standard Analysis Files, we analyzed all African-American end-stage renal failure patients in the United States from 1990 – 2001. We compared survival rates for patients with HIV disease, sickle cell anemia, diabetes, and all other diagnoses for the time periods 1990 – 1994 and 1995 – 2001. The main outcome measure was one- and five-year survival in each cohort. Results: One-year survival of African-American patients with end-stage renal disease and HIV increased from 46.6% during 1990 – 1994 to 65.1% during 1995 – 2001 (odds ratio 2.139). One-year survival decreased in the sickle cell group (odds ratio 0.595) and decreased slightly in the diabetic group (odds ratio 0.927) and all others (odds ratio 0.941). Five-year survival in the HIV group increased from 13.3% in 1990 – 1995 to 30.4% in 1995 – 2001 (odds ratio 2.847). There was no corresponding increase in survival for the sickle cell group (odds ratio 0.987), the diabetic group (odds ratio 1.06), or all others (odds ratio 1.137). Conclusions: We conclude that survival in African-American end-stage renal disease patients and HIV infection has substantially improved subsequent to introduction of highly active antiretroviral therapy. Our data support aggressive multi-drug treatment of end-stage renal failure patients with HIV infection.Correspondence to:
J. Macrae, MD
Department of Medicine, Box 50
SUNY Downstate Medical Center
450 Clarkson Avenue
Brooklyn, NY 11203, USA
Email: Jeanne.Macrae@Downstate.edu
J. Macrae, A.L. Friedman, P. Eggers and E.A. Friedman
1Department of Medicine, Downstate Medical Center, Brooklyn, NY, 2Department of Surgery, Yale University School of Medicine, New Haven, CT, and 3National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA Aims: To determine if there has been improvement in survival of HIV-infected patients with end-stage renal failure subsequent to widespread use of highly active antiretroviral therapy. Methods: The United States Renal Data System is a national data system funded by the National Institute of Diabetes and Digestive and Kidney Disease with the Centers for Medicare and Medicaid. Using the United States Renal Data System Standard Analysis Files, we analyzed all African-American end-stage renal failure patients in the United States from 1990 – 2001. We compared survival rates for patients with HIV disease, sickle cell anemia, diabetes, and all other diagnoses for the time periods 1990 – 1994 and 1995 – 2001. The main outcome measure was one- and five-year survival in each cohort. Results: One-year survival of African-American patients with end-stage renal disease and HIV increased from 46.6% during 1990 – 1994 to 65.1% during 1995 – 2001 (odds ratio 2.139). One-year survival decreased in the sickle cell group (odds ratio 0.595) and decreased slightly in the diabetic group (odds ratio 0.927) and all others (odds ratio 0.941). Five-year survival in the HIV group increased from 13.3% in 1990 – 1995 to 30.4% in 1995 – 2001 (odds ratio 2.847). There was no corresponding increase in survival for the sickle cell group (odds ratio 0.987), the diabetic group (odds ratio 1.06), or all others (odds ratio 1.137). Conclusions: We conclude that survival in African-American end-stage renal disease patients and HIV infection has substantially improved subsequent to introduction of highly active antiretroviral therapy. Our data support aggressive multi-drug treatment of end-stage renal failure patients with HIV infection.Correspondence to:
J. Macrae, MD
Department of Medicine, Box 50
SUNY Downstate Medical Center
450 Clarkson Avenue
Brooklyn, NY 11203, USA
Email: Jeanne.Macrae@Downstate.edu
Originals
Influence of hemodialysis on the mean blood flow velocity in the middle cerebral artery
129
40$
Abstract
Aims: To determine if there has been improvement in survival of HIV-infected patients with end-stage renal failure subsequent to widespread use of highly active antiretroviral therapy. Methods: The United States Renal Data System is a national data system funded by the National Institute of Diabetes and Digestive and Kidney Disease with the Centers for Medicare and Medicaid. Using the United States Renal Data System Standard Analysis Files, we analyzed all African-American end-stage renal failure patients in the United States from 1990 – 2001. We compared survival rates for patients with HIV disease, sickle cell anemia, diabetes, and all other diagnoses for the time periods 1990 – 1994 and 1995 – 2001. The main outcome measure was one- and five-year survival in each cohort. Results: One-year survival of African-American patients with end-stage renal disease and HIV increased from 46.6% during 1990 – 1994 to 65.1% during 1995 – 2001 (odds ratio 2.139). One-year survival decreased in the sickle cell group (odds ratio 0.595) and decreased slightly in the diabetic group (odds ratio 0.927) and all others (odds ratio 0.941). Five-year survival in the HIV group increased from 13.3% in 1990 – 1995 to 30.4% in 1995 – 2001 (odds ratio 2.847). There was no corresponding increase in survival for the sickle cell group (odds ratio 0.987), the diabetic group (odds ratio 1.06), or all others (odds ratio 1.137). Conclusions: We conclude that survival in African-American end-stage renal disease patients and HIV infection has substantially improved subsequent to introduction of highly active antiretroviral therapy. Our data support aggressive multi-drug treatment of end-stage renal failure patients with HIV infection.Correspondence to:
Dr. I. Stefanidis
Assistant Professor of Internal Medicine/Nephrology
University of Thessalia
School of Medicine
Papakyriazy 22
41222 Larissa, Greece
Email: stefanid@med.uth.gr
I. Stefanidis, R. Bach, P.R. Mertens, V. Liakopoulos, G. Liapi, H. Mann and B. Heintz
1Division of Nephrology, University of Thessalia, Greece, 2Clinic of Nephrology and Clinical Immunology, RWTH Aachen, and 3KfH Aachen, Germany Aims: To determine if there has been improvement in survival of HIV-infected patients with end-stage renal failure subsequent to widespread use of highly active antiretroviral therapy. Methods: The United States Renal Data System is a national data system funded by the National Institute of Diabetes and Digestive and Kidney Disease with the Centers for Medicare and Medicaid. Using the United States Renal Data System Standard Analysis Files, we analyzed all African-American end-stage renal failure patients in the United States from 1990 – 2001. We compared survival rates for patients with HIV disease, sickle cell anemia, diabetes, and all other diagnoses for the time periods 1990 – 1994 and 1995 – 2001. The main outcome measure was one- and five-year survival in each cohort. Results: One-year survival of African-American patients with end-stage renal disease and HIV increased from 46.6% during 1990 – 1994 to 65.1% during 1995 – 2001 (odds ratio 2.139). One-year survival decreased in the sickle cell group (odds ratio 0.595) and decreased slightly in the diabetic group (odds ratio 0.927) and all others (odds ratio 0.941). Five-year survival in the HIV group increased from 13.3% in 1990 – 1995 to 30.4% in 1995 – 2001 (odds ratio 2.847). There was no corresponding increase in survival for the sickle cell group (odds ratio 0.987), the diabetic group (odds ratio 1.06), or all others (odds ratio 1.137). Conclusions: We conclude that survival in African-American end-stage renal disease patients and HIV infection has substantially improved subsequent to introduction of highly active antiretroviral therapy. Our data support aggressive multi-drug treatment of end-stage renal failure patients with HIV infection.Correspondence to:
Dr. I. Stefanidis
Assistant Professor of Internal Medicine/Nephrology
University of Thessalia
School of Medicine
Papakyriazy 22
41222 Larissa, Greece
Email: stefanid@med.uth.gr
Originals
Use of LifeSite port systems for hemodialysis in German
138
28$
Abstract
Aim: Studies have shown lower infection rates of port systems compared to established, transcutaneous cuffed-tunneled dialysis catheters. This was shown in otherwise quite healthy patients starting hemodialysis treatment. It is unclear to what extent these results can be applied to countries such as Germany where, unlike the US, central venous access systems are used mainly for patients with a high comorbidity. We investigated complications in patients with exhausted access sites and a high comorbidity. Method: In a retrospective, representative multicenter study, 34 patients with a high rate of comorbidity were assessed. The age was 67.5 ± 12.5 years, the median number of failed AV fistulas or AV grafts was 4 (0 – 18). Results: The survival rate was 84.9%, 55.2% and 55.2% after 6, 12 and 24 months, respectively. The rate of local and systemic infections was 2.83 per 1,000 patient days. Thrombotic events occurred at a rate of 2.26 per 1,000 patient days. We did not see a statistically significant effect using 0.2% sodium oxychlorosene (n = 13) or 70% isopropyl alcohol solution (n = 21) as the antimicrobial solution used before opening the valve of the port with the dialysis needle. Conclusions: We showed that complications of hemodialysis treatment using LifeSite vascular access systems in patients with very high co-morbidity in Germany seem to occur less often than those reported for cuffed-tunneled catheters and were not more frequent than those reported for other patient groups using LifeSites in the US. Technical survival rates were encouraging for up to two years. LifeSite port systems might be a good or even better central venous access than cuffed-tunneled catheters for patients in which an AV fistula or -graft is not possible.Correspondence to:
PD Dr. M. Hollenbeck
Klinik für Nephrologie und Rheumatologie
Knappschaftskrankenhaus Bottrop
Osterfelderstraße 155a
46242 Bottrop, Germany
Email: hollenbeck@kk-bottrop.de
M. Hollenbeck, D. Zolotov, E.R. Debusmann, M. Koch and G. Wozniak
1Department of Nephrology and Rheumatology, Knappschaftskrankenhaus, Bottrop, 2Dialyisis Center, Mettmann, and 3Department of Vascular Surgery, Knappschaftskrankenhaus, Bottrop, Germany Aim: Studies have shown lower infection rates of port systems compared to established, transcutaneous cuffed-tunneled dialysis catheters. This was shown in otherwise quite healthy patients starting hemodialysis treatment. It is unclear to what extent these results can be applied to countries such as Germany where, unlike the US, central venous access systems are used mainly for patients with a high comorbidity. We investigated complications in patients with exhausted access sites and a high comorbidity. Method: In a retrospective, representative multicenter study, 34 patients with a high rate of comorbidity were assessed. The age was 67.5 ± 12.5 years, the median number of failed AV fistulas or AV grafts was 4 (0 – 18). Results: The survival rate was 84.9%, 55.2% and 55.2% after 6, 12 and 24 months, respectively. The rate of local and systemic infections was 2.83 per 1,000 patient days. Thrombotic events occurred at a rate of 2.26 per 1,000 patient days. We did not see a statistically significant effect using 0.2% sodium oxychlorosene (n = 13) or 70% isopropyl alcohol solution (n = 21) as the antimicrobial solution used before opening the valve of the port with the dialysis needle. Conclusions: We showed that complications of hemodialysis treatment using LifeSite vascular access systems in patients with very high co-morbidity in Germany seem to occur less often than those reported for cuffed-tunneled catheters and were not more frequent than those reported for other patient groups using LifeSites in the US. Technical survival rates were encouraging for up to two years. LifeSite port systems might be a good or even better central venous access than cuffed-tunneled catheters for patients in which an AV fistula or -graft is not possible.Correspondence to:
PD Dr. M. Hollenbeck
Klinik für Nephrologie und Rheumatologie
Knappschaftskrankenhaus Bottrop
Osterfelderstraße 155a
46242 Bottrop, Germany
Email: hollenbeck@kk-bottrop.de
Case reports
A Japanese family with Alport syndrome associated with esophageal leiomyomatosis: genetic analysis of COL4A5 to COL4A6 and immunostaining for type IV collagen subtypes
144
32$
Abstract
Background: In some families, X-linked Alport syndrome (AS) is associated with diffuse leiomyomatosis. We describe clinical, pathologic and molecular-genetic findings in a Japanese family with this inheritance mode of AS in association with leiomyomatosis. Patient: AS was diagnosed in a one-year-old boy with recurrent aspiration pneumonia caused by esophageal stenosis from leiomyomatosis. Diagnosis was confirmed by electron microscopy coupled with type IV collagen chain subtype staining in a renal biopsy specimen. His mother, who exhibited esophageal leiomyomatosis and is heterozygous for AS, showed a discontinuous staining pattern for collagen a5(IV) chain along the epidermal basement membrane in a skin biopsy specimen. Genetic analysis in the boy revealed the deletion of the first two exons of COL4A6 together with deletion of the 5? end of COL4A5. Despite administration of cyclosporin A, massive proteinuria has persisted in the boy, although renal function otherwise remains normal. Conclusion: Identification of an AS patient during infancy is extremely rare. Clinical manifestations, including macroscopic hematuria, cataracts and leiomyomatosis caused by the large deletion involving COL4A5 to COL4A6, led to early presentation with AS.Correspondence to:
T. Takemura, MD Department of Pediatrics Kinki University School of Medicine 377-2 Ohno-higashi Osaka-Sayama, 589-8511, Japan
Email: tsukasa@med.kindai.ac.jp
K. Sugimoto, H. Yanagida, K. Yagi, H. Kuwajima, M. Okada and T. Takemura
Department of Pediatrics, Kinki University School of Medicine, Osaka-Sayama, Japan Background: In some families, X-linked Alport syndrome (AS) is associated with diffuse leiomyomatosis. We describe clinical, pathologic and molecular-genetic findings in a Japanese family with this inheritance mode of AS in association with leiomyomatosis. Patient: AS was diagnosed in a one-year-old boy with recurrent aspiration pneumonia caused by esophageal stenosis from leiomyomatosis. Diagnosis was confirmed by electron microscopy coupled with type IV collagen chain subtype staining in a renal biopsy specimen. His mother, who exhibited esophageal leiomyomatosis and is heterozygous for AS, showed a discontinuous staining pattern for collagen a5(IV) chain along the epidermal basement membrane in a skin biopsy specimen. Genetic analysis in the boy revealed the deletion of the first two exons of COL4A6 together with deletion of the 5? end of COL4A5. Despite administration of cyclosporin A, massive proteinuria has persisted in the boy, although renal function otherwise remains normal. Conclusion: Identification of an AS patient during infancy is extremely rare. Clinical manifestations, including macroscopic hematuria, cataracts and leiomyomatosis caused by the large deletion involving COL4A5 to COL4A6, led to early presentation with AS.Correspondence to:
T. Takemura, MD Department of Pediatrics Kinki University School of Medicine 377-2 Ohno-higashi Osaka-Sayama, 589-8511, Japan
Email: tsukasa@med.kindai.ac.jp
Case reports
Nephrolithiasis and hematuria - sometimes a stony road to diagnosis
151
20$
Abstract
3Clinical Nephrology, Castrop-Rauxel, Germany
We report a case of a young man with a history of kidney stones. Occurrence of gross hematuria several months after the extracorporeal shock wave, lithotripsy (ESWL) treatment lead to hospitalization. By ultrasound and abdominal CT scan, the urologist could exclude post-renal causes of the gross hematuria and acute renal failure. After transfer to a department of nephrology hemodialysis was started, an immediate kidney biopsy was performed and prednisolone was administered on the same day. The kidney biopsy revealed an anti-glomerular basement membrane (GBM) disease. The renal function did not recover and the patient remained on hemodialysis. In the literature it has been hypothesized that ESWL-treated patients are prone to develop anti-GBM disease by liberation of glomerular basement antigen through the ESWL high energy shock waves. An additional hypothesis considering the higher susceptibility for anti-GBM disease among certain HLA-tissue types is discussed with regard to our case. Unfortunately, the prolonged track to diagnosis and delayed immunosuppressive treatment could not prevent poor clinical outcome. Although anti-GBM disease is a rather rare disease, it should be included as a differential diagnosis for hematuria – especially months after ESWL treatment. Otherwise early diagnosis may be missed and as in our patient immunosuppressive treatment will remain unsuccessful to recover renal function.Correspondence to:
Prof. Dr. L.C. Rump
Department of Nephrology, Medicine I
Marienhospital Herne
Hospital of the University of Bochum
Hölkeskampring 40
44625 Herne, Germany
Email: Christian.Rump@ruhr-uni-bochum.de
L. Sellin, I. Quack, S.M. Weiner, R. Waldherr, B. Henning, S. Hofebauer and L.C. Rump
1Department of Nephrology, Marienhospital Herne, Hospital of the University of Bochum, Herne, 2Clinical Pathology, Heidelberg, and 3Clinical Nephrology, Castrop-Rauxel, Germany
We report a case of a young man with a history of kidney stones. Occurrence of gross hematuria several months after the extracorporeal shock wave, lithotripsy (ESWL) treatment lead to hospitalization. By ultrasound and abdominal CT scan, the urologist could exclude post-renal causes of the gross hematuria and acute renal failure. After transfer to a department of nephrology hemodialysis was started, an immediate kidney biopsy was performed and prednisolone was administered on the same day. The kidney biopsy revealed an anti-glomerular basement membrane (GBM) disease. The renal function did not recover and the patient remained on hemodialysis. In the literature it has been hypothesized that ESWL-treated patients are prone to develop anti-GBM disease by liberation of glomerular basement antigen through the ESWL high energy shock waves. An additional hypothesis considering the higher susceptibility for anti-GBM disease among certain HLA-tissue types is discussed with regard to our case. Unfortunately, the prolonged track to diagnosis and delayed immunosuppressive treatment could not prevent poor clinical outcome. Although anti-GBM disease is a rather rare disease, it should be included as a differential diagnosis for hematuria – especially months after ESWL treatment. Otherwise early diagnosis may be missed and as in our patient immunosuppressive treatment will remain unsuccessful to recover renal function.Correspondence to:
Prof. Dr. L.C. Rump
Department of Nephrology, Medicine I
Marienhospital Herne
Hospital of the University of Bochum
Hölkeskampring 40
44625 Herne, Germany
Email: Christian.Rump@ruhr-uni-bochum.de
Case reports
Vancomycin-induced hypersensitivity reaction with acute renal failure: resolution following cyclosporine treatment
155
20$
Abstract
Drug rash with eosinophilia and systemic symptoms or DRESS syndrome is a distinct severe drug-induced hypersensitivity reaction characterized by skin rash, fever, eosinophilia and visceral involvement. The latter leads to a 10% mortality rate, with interstitial nephritis occurring in about 10% of the cases. The outcome is usually favorable after withdrawal of drug therapy; systemic corticosteroid therapy may hasten the recovery, although there are no data from prospective, randomized trials evaluating the efficacy of this approach. Administration of other immunosuppressive agents (cyclophosphamide, cyclosporine) has also been suggested. We report on a patient with vancomycin-induced DRESS syndrome with acute interstitial nephritis and hepatitis. There was no improvement after withdrawal of the offending agent and empiric corticosteroid use. After tapering the steroids, a five-day course of cyclosporine was followed by quick resolution of the skin rash and recovery of renal function. Cyclosporine could represent a treatment option in cases of severe visceral involvement such as persistent renal insufficiency that do not improve after discontinuation of the offending agent and administration of high doses of steroids.Correspondence to:
Dr. E. Zuliani Department of Internal Medicine Ospedale Civico via Tesserete 43 6900 Lugano, Switzerland
Email: eugenia_zuliani@hotmail.com
E. Zuliani, H. Zwahlen, F. Gilliet and C. Marone
1Department of Internal Medicine, Ospedale Regionale di Lugano,
2Department of Internal Medicine, Ospedale Regionale Bellinzona e Valli, and 3Department of Dermatology, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland Drug rash with eosinophilia and systemic symptoms or DRESS syndrome is a distinct severe drug-induced hypersensitivity reaction characterized by skin rash, fever, eosinophilia and visceral involvement. The latter leads to a 10% mortality rate, with interstitial nephritis occurring in about 10% of the cases. The outcome is usually favorable after withdrawal of drug therapy; systemic corticosteroid therapy may hasten the recovery, although there are no data from prospective, randomized trials evaluating the efficacy of this approach. Administration of other immunosuppressive agents (cyclophosphamide, cyclosporine) has also been suggested. We report on a patient with vancomycin-induced DRESS syndrome with acute interstitial nephritis and hepatitis. There was no improvement after withdrawal of the offending agent and empiric corticosteroid use. After tapering the steroids, a five-day course of cyclosporine was followed by quick resolution of the skin rash and recovery of renal function. Cyclosporine could represent a treatment option in cases of severe visceral involvement such as persistent renal insufficiency that do not improve after discontinuation of the offending agent and administration of high doses of steroids.Correspondence to:
Dr. E. Zuliani Department of Internal Medicine Ospedale Civico via Tesserete 43 6900 Lugano, Switzerland
Email: eugenia_zuliani@hotmail.com
Case reports
A transplanted kidney surviving total vessel occlusion and anuria
159
20$
Abstract
We report a case of a 46-year-old white male with renal graft artery stenosis who developed acute renal shutdown with total anuria while on the ACE inhibitor lisinopril, one week following the discontinuation of aspirin. The serum creatinine was 8.5 mg/dl. Doppler ultrasound and MAG3 scintigraphy of the grafted kidney were highly suggestive of a viable but nonfunctioning kidney. A femoro-femoral bypass for total thrombosis of the right common iliac artery was performed distal to the occlusion. Immediate diuresis was obtained after establishing the bypass. Serum creatinine dropped to 1.35 mg/dl three days later. In this case we believe that the collateral circulation played a significant role in immediate recovery of kidney function by maintaining renal perfusion pressure and preventing acute tubular necrosis (ATN). We also believe that the ACE inhibitor might have contributed to salvaging the kidney by improving medullary oxygen balance and maintaining adequate medullary blood flow.Correspondence to:
M.A. El-Harakeh, MD Department of Medicine Staten Island University Hospital 475 Seaview Ave Staten Island, NY 10305, USA
Email: mdharake@hotmail.com
M.A. El-Harakeh, A. Barbari, A. Stephan, S. Saggi, H. Kilany and A. Barakeh
1Department of Medicine, 2Division of Nephrology, Staten Island University Hospital, Staten Island, NY, USA, and 3Division of Nephrology, Lebanese University, Rizk Hospital, Ashrafieh, Lebanon We report a case of a 46-year-old white male with renal graft artery stenosis who developed acute renal shutdown with total anuria while on the ACE inhibitor lisinopril, one week following the discontinuation of aspirin. The serum creatinine was 8.5 mg/dl. Doppler ultrasound and MAG3 scintigraphy of the grafted kidney were highly suggestive of a viable but nonfunctioning kidney. A femoro-femoral bypass for total thrombosis of the right common iliac artery was performed distal to the occlusion. Immediate diuresis was obtained after establishing the bypass. Serum creatinine dropped to 1.35 mg/dl three days later. In this case we believe that the collateral circulation played a significant role in immediate recovery of kidney function by maintaining renal perfusion pressure and preventing acute tubular necrosis (ATN). We also believe that the ACE inhibitor might have contributed to salvaging the kidney by improving medullary oxygen balance and maintaining adequate medullary blood flow.Correspondence to:
M.A. El-Harakeh, MD Department of Medicine Staten Island University Hospital 475 Seaview Ave Staten Island, NY 10305, USA
Email: mdharake@hotmail.com
Case reports
Relative hypoparathyroidism induced by interferon treatment in a hemodialysis patient
163
20$
Abstract
Hospital Universitari Arnau de Vilanova, Lleida, Spain
Several authors have documented beneficial effects of interferon (IFN) in chronic hepatitis C virus (HCV) infection among the dialysis population. Reports about mineral metabolism disturbances during IFN treatment are scarce, especially in dialysis patients. We report the case of a 49-year-old woman on hemodialysis with chronic HCV infection who developed significant decrease in serum calcium (Ca) and phosphorus (P) levels accompanied by relative hypoparathyroidism while being under treatment with a-IFN. These changes were closely related to IFN treatment, because they disappeared after INF was discontinued, reaching Ca and P levels which were similar to those of the pre-IFN period. Because IFN may induce immune disorders, several autoimmune markers were analyzed. All of them were negative or within the normal range. To further explore these mineral metabolism disturbances, a number of parathyroid hormone (PTH) secretion-inhibiting factors, such as aluminum, magnesium, 25-hydroxyvitamin D, and calcitriol were excluded as a cause for these changes. We suggest that mineral metabolism should be carefully observed during interferon treatment in dialysis patients.Correspondence to:
Dra. E. Fernandez
Servicio de Nefrología
Hospital Universitari Arnau de Vilanova
Rovira Roure 80,
5198 Lleida, Spain
Email: efernandez@arnau.scs.es
S. Muray1, M.P. Marco1, I. Carrera2, G. Cao2, L. Craver1 and E. Fernández1
1Service of Nephrology and 2Service of Clinical Analysis, Hospital Universitari Arnau de Vilanova, Lleida, Spain
Several authors have documented beneficial effects of interferon (IFN) in chronic hepatitis C virus (HCV) infection among the dialysis population. Reports about mineral metabolism disturbances during IFN treatment are scarce, especially in dialysis patients. We report the case of a 49-year-old woman on hemodialysis with chronic HCV infection who developed significant decrease in serum calcium (Ca) and phosphorus (P) levels accompanied by relative hypoparathyroidism while being under treatment with a-IFN. These changes were closely related to IFN treatment, because they disappeared after INF was discontinued, reaching Ca and P levels which were similar to those of the pre-IFN period. Because IFN may induce immune disorders, several autoimmune markers were analyzed. All of them were negative or within the normal range. To further explore these mineral metabolism disturbances, a number of parathyroid hormone (PTH) secretion-inhibiting factors, such as aluminum, magnesium, 25-hydroxyvitamin D, and calcitriol were excluded as a cause for these changes. We suggest that mineral metabolism should be carefully observed during interferon treatment in dialysis patients.Correspondence to:
Dra. E. Fernandez
Servicio de Nefrología
Hospital Universitari Arnau de Vilanova
Rovira Roure 80,
5198 Lleida, Spain
Email: efernandez@arnau.scs.es
Letter to the Editor
Acute renal failure after right nephrectomy for spontaneous rupture and left renal vein ligature
167
20$
Abstract
B. Copercini, P. Ravani and F. Malberti
