Volume 67, No. 4/2007(April)
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 Clinical Nephrology
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Review
Clinical and economic burden of fractures in patients with renal osteodystrophy
Abstract
G.T. Schumock and S.M. Sprague
G.T. Schumock and S.M. Sprague
Renal osteodystrophy is a key cause of fractures in patients with chronic kidney disease (CKD). Aims: This article reviews the clinical and economic burden of fractures and explores the types of studies that need to be conducted in order to fully understand the impact of fractures in renal osteodystrophy. We also discuss the role that active vitamin D compounds and calcimimetics play in treating secondary hyperparathyroidism. Materials and methods: Medline was searched for relevant articles on renal osteodystrophy and fractures. Results: CKD-related fractures are the source of significant morbidity and costs. Extensive osteoporosis research has been utilized to guide fracture prevention and improve disease management, but further costs and outcomes analyses are needed for renal osteodystrophy. Recent research regarding newer, present-day treatment paradigms has suggested that distinct cost savings and improved patient outcomes are possible. Conclusions: In order to realize such economic and human benefits, the medical community must first have sufficient pathologic, pharmacoeconomic and epidemiologic data to properly understand, manage and prevent renal osteodystrophy and fractures.Correspondence to:
G.T. Schumock
Director and Associate Professor
Center for Pharmacoeconomic Research
University of Illinois at Chicago
833 S. Wood St. MC 886
Chicago, IL 60612, USA
Email: schumock@uic.edu
Originals
Association between biomarkers of inflammation and left ventricular hypertrophy in moderate chronic kidney disease
Abstract
S. Cottone, E. Nardi, G. Mulè, A. Vadalà, M.C. Lorito, R. Riccobene, A. Palermo, R. Arsena, M. Guarneri and G. Cerasola
S. Cottone, E. Nardi, G. Mulè, A. Vadalà, M.C. Lorito, R. Riccobene, A. Palermo, R. Arsena, M. Guarneri and G. Cerasola
Aims: Left ventricular hypertrophy (LVH) is a predictor for cardiovascular mortality, and it is considered to be a surrogate marker of preclinical cardiovascular disease. This study aimed at evaluating whether fetuin-A plasma levels are decreased in patients with moderate chronic kidney disease (CKD) and their linkage to plasma concentrations of hs-C-reactive protein (CRP), cardiotrophyn-1 (CT-1), tumor necrosis factor-α (TNF-α), propeptide of collagen Type I (PIP) and to LVH. Material and methods: We enrolled 64 moderate CKD and 55 essential hypertensives (EH) with normal renal function as controls. All the patients underwent an echocardiographic examination; plasma samples were obtained to measure routine clinical parameters and the molecules listed above (measured by ELISA). Results: Among CKD there were 30/64 patients with LVH, and in EH group 14/55 subjects had LVH. Fetuin A was reduced in CKD when compared with EH (p < 0.0001). The comparison between CKD having LVH with those without LVH showed significant differences in plasma levels of fetuin-A (p < 0.002), TNF-α (p < 0.01) and hs-CRP (p < 0.001), CT-1 and PIP (p < 0.002). CKD with LVH had lower values of fetuin-A (p < 0.001), and higher values of hs-CRP (p < 0.001) TNF-α(p < 0.001), CT-1 (p < 0.001) and PIP (p < 0.001) than EH with LVH. The multivariate analysis of correlation demonstrated that in CKD patients hs-CRP (β 0.42, p < 0.00006), and systolic blood pressure (β 0.29, p < 0.02) were independent predictors of LV mass index. The relationship between LV mass index and fetuin-A did not reach statistical significance. Conclusions: For the first time in moderate CKD patients, we demonstrate that fetuin-A is decreased and relates to LVH depending on C-reactive protein.Correspondence to:
S. Cottone, MD
Via del Vespro 129
90127 Palermo, Italy
Email: sancott@tin.it
Originals
Tuberculosis in chronic kidney disease
Abstract
R.K.C. Venkata, S. Kumar, R.P. Krishna, S.B. Kumar, S. Padmanabhan and S. Kumar
R.K.C. Venkata, S. Kumar, R.P. Krishna, S.B. Kumar, S. Padmanabhan and S. Kumar
Background: The incidence of tuberculosis is high in chronic kidney disease (CKD) which needs a high index of suspicion, early diagnosis and management for gratifying outcome. Materials: The clinical, laboratory profile, management and outcome of tuberculosis in 36 patients with chronic kidney disease between 2000 and 2005 constitute the material of this study. Results: During this study period, over 900 chronic renal failure patients were evaluated in our unit and 36 of them were found to have tuberculosis, the incidence being 4%. In majority (69.4%), tuberculosis was observed in association with CKD Stage V. Age range was 25 – 77 years, male : female ratio was 33 : 3. Fever, malaise and weight loss were the commonest symptoms observed at presentation. Extrapulmonary tuberculosis (23 patients, 63.8%) predominated over pulmonary tuberculosis (10 patients, 36.1%). Tuberculin skin test was negative in 23 patients (63.8%). The diagnosis of tuberculosis was confirmed by tissue or specimen examination in 17 patients (47.2%) and in the rest it was empirical basing on clinical picture, pleural fluid analysis and radiological tests. All the patients were planned for a minimum period of 9-month antituberculous therapy (ATT). Of them, 17 patients (47.2%) were cured from tuberculosis and did not relapse, 9 patients (25%) died during treatment and 10 patients were lost for follow-up. Two patients were managed for anti-tuberculous therapy-related side effects: hepatotoxicity and psychosis. Conclusions: We observed a 4% incidence of tuberculosis in CKD. Extrapulmonary form of tuberculosis predominated over pulmonary form. Fever and malaise were important clues for suspicion of tuberculosis. Tuberculin skin test was negative in the majority. Diagnostic confirmation was possible in 47.2% of patients and in the rest it was based on clinical suspicion, pleural fluid analysis and radiological findings. Cure from tuberculosis was observed in 47.2% of patients with antituberculous therapy.
Correspondence to:
S.K. Vishnubhotla
Professor and Head
Department of Nephrology
Sri Venkateswara Institute of Medical Sciences
Tirupati 517507, Andhra Pradesh, South India
Email: sa_vskumar@yahoo.com
Originals
Vitamins are associated with survival in patients with end-stage renal disease: a 4-year prospective study
Abstract
U. Domröse, J. Heinz, S. Westphal, C. Luley, K.H. Neumann and J. Dierkes
U. Domröse, J. Heinz, S. Westphal, C. Luley, K.H. Neumann and J. Dierkes
Background: Patients with end-stage renal disease are at high risk from premature death due mainly to cardiovascular disease and infections. Established risk factors do not sufficiently explain this increased mortality. We, therefore, investigated total mortality prospectively in a single-centre study in patients on hemodialysis and assessed the prognostic value of baseline disease status, laboratory variables including emerging risk factors, and the influence of vitamin treatment. Methods: Patients (n = 102) were followed-up for 4 years or until death (n = 49). Survival was calculated by the Kaplan-Meier method. Cox-proportional hazards model was used to determine independent predictors of total mortality. Results: The known risk factors age, baseline clinical atherosclerotic disease, low albumin and increased cardiac troponin T were significantly associated with mortality. Patients who received multivitamins during follow-up had a significantly lower mortality risk than those not receiving this treatment (hazard ratio 0.29, 95% confidence interval 0.15 – 0.56). These associations remained significant after adjustment for age, cardiovascular disease, albumin and cardiac troponin T at baseline. Conclusions: The present study suggests that multivitamin supplementation in patients with end-stage renal disease is closely associated with reduced mortality due to all causes. These observations have to be validated in randomized clinical intervention trials.Correspondence to:
Dr. J. Dierkes Institute of Clinical Chemistry Leipziger Straße 44 39120 Magdeburg, Germany
Email: judith.heinz@medizin.uni-magdeburg.de
Originals
Comparison of predilution hemodiafiltration and low-flux hemodialysis at temperature-controlled conditions using high calcium-ion concentration in the replacement and dialysis fluid
Abstract
N. Karamperis, D. Jensen, E. Sloth and J.D. Jensen
N. Karamperis, D. Jensen, E. Sloth and J.D. Jensen
Background: It is the prevailing view that convective dialysis techniques stabilize blood pressure. The aim of this study was to compare the hemodynamics of high-dose predilution hemodiafiltration (HDF) and low-flux hemodialysis (HD), under matched conditions and using high calcium-ion concentration in the replacement/dialysis fluid. Methods: 13 stable hemodialysis patients were investigated in a randomized crossover, blinded controlled trial. The patients were allocated to one session of predilution HDF (substitution fluid 1.20 l/kg BW) and one session of HD at 4.5 hours. At the start of the dialysis the patient’s core temperature was “locked” by an automatic feedback system regulating the dialysate temperature, thereby patient’s temperature was kept stable throughout the whole treatment. The Ca ion concentration in the substitution/dialysis fluid was 1.75 mM. Cardiac output was measured hourly by the ultrasound velocity dilution method. Results: Within treatments comparisons revealed that both treatments displayed stable mean blood pressure and equally reduced cardiac output. HDF showed decreased stroke volume and increased total peripheral resistance. The pulse rate decreased significantly only during HD. Arterial temperature was kept constant during both treatments. Ultrafiltration volume, cardiopulmonary recirculation, relative blood volume, Kt/V and total energy transfer were matched for HD and HDF. The overall between treatments comparisons revealed no significant differences. Conclusions: We have shown that during matched conditions and high calcium concentrations, the hemodynamic profiles of high dose predilution HDF and lowflux HD were similar. Both modalities showed stable mean blood pressure profiles. An acute circulatory benefit of convective solute removal over diffusive, could not be demonstrated.
Correspondence to:
N. Karamperis, MD
Research Laboratory C
Department of Renal Medicine C
Skejby, Aarhus University Hospital
Aarhus, Denmark
Email: karamperis@stofanet.dk
Case Reports
Patient with antibody-negative relapse of Goodpasture syndrome
Abstract
K. Benz, K. Amann, K. Dittrich, C. Hugo, K. Schnur and J. Dötsch
K. Benz, K. Amann, K. Dittrich, C. Hugo, K. Schnur and J. Dötsch
Smoking in young men may trigger anti-GBM disease manifesting with hemoptysis. We present a male adolescent in whom hemoptysis was mistaken to be a sign of airway infection for several months and who later on underwent an unusual antibody-negative relapse. The 16-year-old patient had a history of smoking and therapy-refractant hemoptysis and, later, acute macrohematuria with renal insufficiency necessitating hemodialysis (initial creatinine 4.2 mg/ dl). Chest X-ray showed diffuse lung infiltration. Renal biopsy revealed linear IgG deposits along the glomerular basement membrane (GBM) and cellular crescents in 13/16 glomeruli, simultaneously increased anti-GBM antibodies were detected. Thus, anti-GBM glomerulonephritis was diagnosed. After treatment with prednisone, oral cyclophosphamide and plasmapheresis, chest X-ray and hemoptysis improved, but renal failure persisted. Anti-GBM antibodies were negative. 4 weeks later, the patient presented again with a clinical relapse of severe hemoptysis and respiratory insufficiency after smoke exposition. Despite negative anti-GBM antibodies, he was treated similarly to a relapse and after the second course of plasmapheresis the patients’ general condition improved and hemoptysis subsided. During the next 10 months the patient was stable with negative antibodies. He was under intermittent hemodialysis until laboratory measurements showed improved renal function. Now, 30 months after the acute episode, the patient is off dialysis for 17 months with stable creatinine values of 1.9 – 2.4 mg/dl, and is currently being treated with antihypertensive medicaments, calcitriol, calciumacetate, natriumhydrogencarbonate and allopurinol. The prognosis of anti-GBM glomerulonephritis depends on serum creatinine and the need of dialysis at initial presentation. In these patients, one-year survival rate is 67% and 5% for kidney function. Of note, despite the unfavorable prognosis in our patient, renal function recovered after 1 year of hemodialysis treatment. It is important to consider that in patients with anti-GBM disease antibody-negative relapses are possible.Correspondence to:
Dr. K. Benz Kinder und Jugendklinik Universität Erlangen-Nürnberg Loschgestraße 15 91054 Erlangen, Germany
Email: kerstin.benz@kinder.imed.uni-erlangen.de
Case Reports
Effective treatment of hepatitis C-associated immune-complex nephritis with cryoprecipitate apheresis and antiviral therapy
Abstract
M.J. Koziolek, A. Scheel, C. Bramlage, H.-J. Groene, G.A. Mueller and F. Strutz
M.J. Koziolek, A. Scheel, C. Bramlage, H.-J. Groene, G.A. Mueller and F. Strutz
A 38-year-old pregnant woman (19th week of pregnancy) complained of fatigue, cold inducible paresthesias, generalized edema and mild arterial hypertension. Her past medical history was notable for frequent episodes of polyarthralgia and positivity for rheumatoid factor. On admission, acanthocyturia and unselective glomerular-tubular proteinuria with 19 g/d were detected with a slight decrease in creatinine clearance. Rheumatoid factor was robustly elevated and a cryocrit of 1.5 vol%, caused by a so far unknown replicative hepatitis C, was detected. Renal biopsy yielded membranoproliferative glomerulonephritis. During pregnancy, high-dose corticosteroid therapy was administered. Edema disappeared and blood pressure normalized under albumin substitution and low-dose furosemide application. However, Cesarian section became necessary due to placental insufficiency at 27 weeks of gestation. Thereafter, neither virus load, cryocrit nor proteinuria decreased significantly under a combined therapy with pegylated interferon-a and ribavirin. Thus, cryoprecipitate apheresis was initiated resulting in robust decreases of clinical complaints, viral load, cryocrit and proteinuria. Cryoglobulinemia with renal involvement caused by hepatitis C is difficult to treat due to limitations of immunosuppressive and anti-viral therapy. In our patient, cryoprecipitate apheresis was a safe and effective therapeutic addition to standard therapy.Correspondence to:
M. Koziolek, MD Department of Nephrology and Rheumatology University of Göttingen Robert-Koch-Straße 40 37075 Göttingen, Germany
Email: mkoziolek@med.uni-goettingen.de
Case Reports
Treatment of focal segmental glomerular sclerosis with rituximab: 2 case reports
Abstract
N. Kamar, S. Faguer, L. Esposito, J. Guitard, M.B. Nogier, D. Durand and L. Rostaing
N. Kamar, S. Faguer, L. Esposito, J. Guitard, M.B. Nogier, D. Durand and L. Rostaing
Background: Primary focal segmental glomerular sclerosis (FSGS) recurs in 20 – 40% of patients after kidney transplantation. Rituximab has been used to treat several glomerular diseases. Patients and results: We treated two renal-transplant patients with recurrence of FSGS with rituximab. Despite a prophylactic perioperative therapy of plasmapheresis (PE) and i.v. cyclosporine A, Patient 1 developed significant proteinuria, at 1 day after his first kidney transplantation. After two infusions of rituximab (375 mg/m2) he had complete remission. A second relapse, which occurred on Day 40, was also successfully treated by PE and one additional infusion of rituximab. 10 months after transplantation, he still has complete remission from recurrent nephrotic syndrome. Patient 2 also developed significant proteinuria, but 1 day after a second kidney transplantation. Nephrotic syndrome persisted despite 27 sessions of PE and cyclophosphamide therapy. At 13 months after transplantation, he received four infusions of rituximab (375 mg/m2), but this was ineffective. Conclusion: There is a need to demonstrate whether or not rituximab therapy is of interest to prevent and to treat nephritic syndrome in renal-transplant patients who suffer from FSGS.Correspondence to:
Dr. N. Kamar MD, PhD
Department of Nephrology, Dialysis, and Multi-Organ Transplantation Toulouse University Hospital
1 avenue J. Poulhes, TSA 50032
31059 Toulouse Cedex 9, France
Email: kamar.n@chu-toulouse.fr
Case Reports
Adult-onset acute tubulointerstitial nephritis and uveitis with Fanconi syndrome
Case report and review of the literature
Abstract
K. Koike, S. Iida, M. Usui, Y. Matsumoto, K. Fukami, S. Ueda, K. Tamaki, S. Kato and S. Okuda
K. Koike, S. Iida, M. Usui, Y. Matsumoto, K. Fukami, S. Ueda, K. Tamaki, S. Kato and S. Okuda
We report a case of tubulointerstitial nephritis and uveitis (TINU syndrome) with full type Fanconi syndrome. A 32-year-old woman presented with fatigue, anorexia and weight loss. Laboratory findings showed anemia, polyclonal hypergammaglobulinemia and moderate renal dysfunction. Tubular function abnormalities were normoglycemic glucosuria, panaminoaciduria, phosphaturia and kaliuresis leading to hypokalemia. Renal tubular acidosis and hypouricemia were also evident. Serum antistreptolysin O titer was high. Ocular symptoms (bilateral anterior uveitis) emerged soon after admission. Renal biopsy showed diffuse tubulointerstitial infiltration by lymphocytes and plasma cells without granuloma. Treatment with systemic steroids was given and renal function, and ocular symptom returned to normal with 3 months. Although tubular abnormalities involving TINU syndrome has already been reported, the disease associated with full type Fanconi syndrome has rarely been seen, and systemic steroid may be beneficial in reducing the development of tubulointerstitial injury.Correspondence to:
K. Koike, MD
Division of Nephrology
Department of Medicine
Kurume University School of Medicine
67 Asahi-machi,
Kurume city, Fukuoka, 830-0011, Japan
Email: koike_kiyomi@kurume-u.ac.jp
Letters to the Editor
Coxsackie virus B1 infection in a child, complicated by severe oliguric renal
failure
Abstract
K.D. Kollios, E. Skiadopoulou, I. Siondi and Z.L. Papadopoulou
K.D. Kollios, E. Skiadopoulou, I. Siondi and Z.L. Papadopoulou
Correspondence to:
K.D. Kollios
Aristotle University of Thessaloniki
Medical School
3rd Department of Pediatrics
GR-546 42, Thessaloniki, Greece
Email: kkollios@auth.gr
Letters to the Editor
Potential effect of zoledronate therapy in heavy proteinuria
Abstract
N. Gokden, M. Zangari, F. Elici, B. Barlogie and J. Kumar
Correspondence to:
N. Gokden, MD
Department of Pathology
University of Arkansas for Medical Sciences
4301 West Markham slot #517,
Little Rock AR 71205, USA
Email: gokdenneriman@uams.edu
