Volume 68, No. 4/2007(October)
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 Clinical Nephrology
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Originals
Fractional excretion of high- and low-molecular weight proteins and outcome in primary focal segmental glomerulosclerosis
Abstract
J.K. Deegens and J.F. Wetzels
Department of Nephrology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
Aims: Predicting prognosis in patients with a nephrotic syndrome due to primary FSGS remains difficult. Recently, it was suggested that the fractional excretion (FE) of IgG (threshold 0.14%) predicts remission, progression to renal failure and response to therapy in FSGS. In the present study, we evaluated the usefulness of FE IgG to guide treatment of patients with primary FSGS in clinical practice. Methods: From 1995 onward, FE of IgG was measured in 32 adult patients with biopsy-proven primary FSGS. In addition, we quantified 24-hour proteinuria, selectivity index (SI) and FE of albumin, IgG, transferrin and β2-microglobulin (β2m). We evaluated outcome in patients with FE IgG above and below 0.14%. Receiver-operating curves were used to determine the best cut-off values for other urinary proteins in predicting remission, response to therapy and renal survival. Results: Mean age was 45 Correspondence to:
J.K.J. Deegens
Department of Nephrology 464
Radboud University Nijmegen Medical Center
PO Box 9101
6500 HB Nijmegen, The Netherlands
Email: j.deegens@nier.umcn.nl
Originals
Low-responders to angiotensin II receptor blockers and genetic polymorphism in angiotensin-converting enzyme
Abstract
H. Nonoguchi, Y. Nakayama, T. Shiigai, T. Inoue, H. Inoue, Y. Kohda, Y. Honda and K. Tomita
1Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, 2Department of Internal Medicine, Toride Kydo General Hospital, Hongo, Toride, Ibaraki, 3Kengun Clinic, Shinsei, Kumamoto, Japan
Aims: The existence of low-responders to angiotensin II receptor blockers (ARBs) in terms of the preservation of renal function is reported here. We investigated the relationship between the responsiveness to ARBs and insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene. Methods: The effects of ARBs on proteinuria and the progression of chronic renal failure were examined in 113 patients with chronic kidney disease for 34 months before and 27 months after the addition of ARBs. Results: Although a decrease in blood pressure was seen in the II, DI and DD patient subgroups of the ACE gene, the decrease in proteinuria and the amelioration of loss of renal function were observed in the II and DI but not in the DD patients. Kaplan-Meier analysis was employed with a decrease of the reciprocal of serum creatinine of more than 0.2, the induction of renal replacement therapy or death as endpoints. The analysis comparing the periods before and after the addition of ARBs revealed the extension of time to an end-point by the addition of ARBs in all groups together (II + DI + DD), in Group II, and Group DI but not in the DD patient Group. Conclusions: These data suggest that DD patients with ACE gene demonstrate diminished response to ARBs in terms of renoprotection and that ACE gene polymorphism needs to be taken into account when using ARBs as a means of renoprotective therapy.Correspondence to:
H. Nonoguchi, MD
Department of Nephrology
Kumamoto University Graduate School of Medical Sciences
1-1-1 Honjo, Kumamoto
Kumamoto 860-8556, Japan
Email: nono@kumamoto-u.ac.jp
Originals
A new approach to the evaluation of hyperphosphatemia in chronic kidney disease
Abstract
V. Savica, L.A. Cal�, A. Granata, R. Caldarera, A. Cavaleri, D. Santoro, P. Monardo, R. Savica, U. Muraca and G. Bellinghieri
1Chairs of Nephrology University of Messina, 2Nephrology and Dialysis Units, Papardo Hospital, Messina, 3Department of Clinical and Experimental Medicine, Clinica Medica 4, University of Padova, 4Department of Clinical-Experimental Medicine and Pharmacology, Clinica Medica, University of Messina and 5Department of Physiology, University of Messina, Italy
Aims: Hyperphosphoremia, main contributor to cardiovascular calcifications, has a major impact on the morbidity and mortality of chronic renal failure (CRF) patients. Phosphate binders and dietary phosphate limitation are not effective enough to abolish hyperphosphoremia-induced cardiovascular abnormalities, therefore, the identification of other and more timely approaches for serum phosphorous reduction is necessary. Salivary fluid contains phosphate which, if related to the daily salivary secretion (1,000 ? 1,800 ml), deserves attention as a marker for an earlier start of pharmacologic treatment for phosphorous removal. In ESRD patients under dialysis we have shown increased salivary phosphate closely to be related with serum phosphorous and interpreted as compensatory. This study evaluates salivary phosphate secretion in 77 nondialyzed CRF compared with healthy subjects and its relationship with renal function. Methods: Saxon?s test confirmed normal salivary function in patients and controls. Serum phosphorous, creatinine and GFR were also measured. Results: Salivary phosphorous was significantly higher in CRF patients compared with controls: 38.60 mg/dl (range 12.20 ? 95.60) vs 16.30 (10.30 ? 27.10), p < 0.0001; serum phosphate was also significantly higher: 3.70 (2.10 ? 6.80) vs 3.50 (2.3 ? 4.6), p = 0.013. In CRF patients, salivary phosphorous positively correlated with serum phosphorous (r = 0.45, p < 0.0001) and with serum creatinine (r = 0.72, p < 0.0001), while negatively correlated with GFR (r = ?0.72, p < 0.0001). Conclusions: The results of our study show also in CRF patients increased salivary phosphate secretion, which is related with renal function. On this basis the use of salivary phosphate secretion as a marker for an earlier start of the abnormal phosphate metabolism pharmacologic treatment could be proposed.Correspondence to:
L.A. Cal�, MD, PhD
Department of Clinical and Experimental Medicine
Clinica Medica 4
University of Padova
Via Giustiniani 2
35128 Padova, Italy
Email: renzcalo@unipd.it
Originals
Significant association between the presence of peripheral vascular calcification and lower serum magnesium in hemodialysis patients
Abstract
E. Ishimura, S. Okuno, K. Kitatani, T. Tsuchida, T. Yamakawa, A. Shioi, M. Inaba and Y. Nishizawa
Departments of 1Nephrology, 2Endocrinology, Metabolism and Molecular Medicine, 3Geriatrics and Vascular Medicine, Osaka City University Graduate School of Medicine, 4Shirasagi Hospital Kidney Center, Japan
Aim: Vascular calcification, which significantly increases cardiovascular and other causes of mortality, is highly prevalent in hemodialysis patients. The aim of the present study was to examine the association between serum magnesium levels and vascular calcification in hemodialysis patients. Methods: 390 nondiabetic patients on maintenance hemodialysis (226 males and 164 females, 59 Correspondence to:
E. Ishimura, MD, PhD
Department of Nephrology
Osaka City University Graduate School of Medicine
1-4-3, Asahi-machi, Abeno-ku,
Osaka 545-8585, Japan
Email: ish@med.osaka-cu.ac.jp
Originals
Loss of hepatitis B immunity in hemodialysis patients acquired either naturally or after vaccination
Abstract
I. Tsouchnikas, E. Dounousi, K. Xanthopoulou, S. Papakonstantinou, V. Thomoglou and D. Tsakiris
1Department of Nephrology and 2Department of Biopathology, General Hospital of Veria, Veria, Greece
Aim: The aim of our study was the long-term evolution of hepatitis B immunity and the titers of antibodies against the surface antigen (anti-HBs) acquired either naturally or after vaccination in hemodialysis (HD) patients with no history of hepatitis C virus (HCV) infection. Methods: 36 HD patients were vaccinated with 4 doses of 40 mg recombinant B vaccine (Engerix, Rixensart, Belgium), intramuscularly at 0, 1, 2 and 6 months. 21 patients (60%) seroconverted developing anti-HBs titers >= 10 IU/ml. Two patients were transferred to another unit before completion of 6 months after the last vaccine dose. We followed-up 19 HD patients who were immune against HBV after vaccination (Group A), and 30 immune patients (anti-HBs titers Correspondence to:
Dr. I. Tsouchnikas
General Hospital of Veria Asomaton
59100 Veria, Greece
Email: johntsou@otenet.gr
Case Reports
How we estimate GFR � a pitfall of using a serum creatinine-based formula
Abstract
R. Refaie, S.H. Moochhala and N.S. Kanagasundaram
1School of Clinical Medical Sciences, University of Newcastle-upon-Tyne and 2Department of Nephrology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
Chronic kidney disease (CKD) is defined using the estimated glomerular filtration rate (eGFR). This has led to a large increase in the diagnosis of CKD in the United Kingdom, the majority of which is in its earlier stages and is detected in non-hospital settings. It is important to be aware that eGFR calculations will reflect inaccuracies in the measured serum creatinine, as the latter is an important component of the calculation. We report a case in which a patient with high muscle-mass who had consumed large quantities of a creatine-containing nutritional supplement presented with apparently reduced renal function on the basis of the serum creatinine and therefore also the eGFR calculation (MDRD equation). Creatine is an amino acid which is a precursor of creatinine, and is known to transiently increase serum creatinine. 6 weeks after discontinuing creatine ingestion, serum creatinine had fallen but still gave rise to an apparently abnormal calculated eGFR. In fact, renal function was shown to be normal when estimated using 24-hour urinary creatinine clearance. This case demonstrates that the upper extreme of muscle mass and ingestion of creatine can affect not only serum creatinine but also the calculated eGFR. Knowledge of common confounding factors and their effects on serum creatinine and eGFR will allow appreciation of the limitations of these measures of renal function, and can prevent unnecessary over-investigation of such patients.Correspondence to:
Dr. S.H. Moochhala
Department of Nephrology, Freeman Hospital, High Heaton, Newcastle-upon-Tyne, NE7 7DN, United Kingdom
Email: s.h.moochhala@ncl.ac.uk
Case Reports
Sirolimus-associated diffuse alveolar hemorrhage in a renal transplant recipient on long-term anticoagulation
Abstract
N. Hashemi-Sadraei, S. Sadrpour, D. Baram, F. Miller and E.P. Nord
Divisions of 1Nephrology and 2Critical Care Medicine, 3Department of Medicine, 4Department of Pathology, School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
Sirolimus (rapamycin, rapamune) is an effective immunosuppressant that has been widely used in solid organ transplantation. Recently, two disconcerting side effects, namely pulmonary toxicity, usually in the form of interstitial pneumonitis, and the onset of nephrotic range proteinuria, have been recognized. We report the case of a renal transplant recipient who had been on chronic anticoagulation therapy for a mechanical aortic valve, and who developed pulmonary distress necessitating emergent intubation 18 days after starting sirolimus therapy. Open lung biopsy showed diffuse alveolar hemorrhage with fibrin deposits in the alveolar spaces and small bronchi. Urine protein/creatinine ratio at that time was 16.7. Upon discontinuation of sirolimus, alveolar hemorrhage and nephrotic range proteinuria resolved. We suggest that extra vigilance be paid in individuals who are on chronic anticoagulation and who are started on sirolimus.Correspondence to:
E.P. Nord, MD
Division of Nephrology, Department of Medicine, School of Medicine, HSC T-16 Rm-080, State University of NY at Stony Brook, Stony Brook, NY 11794, USA
Email: enord@notes.cc.sunysb.edu
Case Reports
Hypercalciuria induced by a high dose of cinacalcet in a renal-transplant recipient
Abstract
L. Esposito, L. Rostaing, I. Gennero, M. Mehrenberger, D. Durand and N. Kamar
1Department of Nephrology, Dialysis and Multi-Organ Transplantation, 2Department of Biochemistry, CHU Purpan, Toulouse University Hospital, Toulouse, France
The successful use of cinacalcet in dialysis patients and in patients with primary hyperparathyroidism has prompted transplant physicians to use it to treat renal-transplant patients with persisting hyperparathyroidism. However, in the setting of kidney transplantation, many questions remain unanswered, i.e. the time of initiation of cinacalcet after transplantation, its dosage and the side effects on kidney function all remain unknown. Herein, we report on a kidney-transplant recipient with persisting hyperparathyroidism who developed hypercalciuria after receiving high doses of cinacalcet. Cinacalcet was started 3 months after transplantation at a once-daily dose of 60 mg. Thereafter, the dosage was increased progressively because of persistant hyperparathyroidism and hypercalcemia. At a dose of 90 mg b.i.d, hypercalciuria occurred. The latter disappeared after reduction of cinacalcet dosage. Cinacalcet might be responsible for urinary calcium excretion, either by reduction of tubular calcium reabsorption via the reduction of PTH level, or by its direct effect on the calcium sensor receptor located in the upper thick ascending limb of the loop of Henle. We conclude that cinacalcet should be used with caution in renal-transplant patients. Further investigations are required to determine the best way to use this drug in this setting.Correspondence to:
N. Kamar, MD, PhD
Department of Nephrology, Dialysis and Multi-Organ Transplantation, Toulouse University Hospital, 1 avenue Jean Poulh
Email: kamar.n@chu-toulouse.fr
Case Reports
Nephrogenic systemic fibrosis following exposure to gadolinium-containing contrast agent
Abstract
S. Clorius, K. Technau, T. Watter, E. Schwertfeger, K.-G. Fischer, G. Walz and P. Gerke
1Department of Medicine, Renal Division, 2Department of Dermatology, University Hospital Freiburg, 3Center for Nephrology and Hypertension, Freiburg, Germany
Nephrogenic systemic fibrosis (NSF) is a disease recently described in patients with kidney failure. It is characterized by scleroderma-like thickening of the skin, subcutaneous edema and ensuing joint contractures leading to profound disability. Furthermore, involvement of internal organs has been described. Whereas the pathogenesis is not known to date, recent reports have linked NSF to high doses of gadolinium-containing contrast agents given at magnetic resonance angiography (MRA). We describe a patient with severe NSF. The patient had received erythropoietin and had undergone vascular interventions which are suspected risk factors for this disease. Notably, the disease developed shortly after the application of gadolinium at an MRA, giving support to the recently published hypothesis that gadolinium-containing contrast agents are among the causative factors. We provide a short overview and hope to raise overall awareness towards this entity and the use of MRA contrast agents in renal patients.Correspondence to:
PD Dr. P. Gerke
Renal Division, University Hospital Freiburg, Hugstetterstra
Email: gerke@med1.ukl.uni-freiburg.de
Case Reports
Celiac territory ischemic syndrome in a patient on chronic hemodialysis
Abstract
Y. Ori, A. Korzets, H. Neyman, M. Herman, S. Baytner, U. Gafter and E. Atar
1Institute of Nephrology and Hypertension, 2Unit of Vascular and Interventional Radiology, 3Unit of Vascular Surgery, Rabin Medical Center, Hasharon Campus, Petah-Tikva and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Mesenteric ischemia among chronic dialysis patients is usually of the nonocclusive type. Chronic occlusive mesenteric ischemia has been reported rarely in the dialysis population. The subset of ?celiac-territory ischemic syndrome? has not been described in dialysis. The current report involves a 66-year-old female on chronic dialysis for 11 years. She experienced abdominal pain following sessions of hemodialysis, that later became more pronounced after eating. Abdominal angiography showed heavily calcified aorta, celiac trunk and superior mesenteric artery (SMA), with a 50% narrowing of the celiac and superior mesenteric arteries. During the following 9 months the symptoms worsened and weight loss set in. She was admitted with an episode of upper abdominal pain. Acalculous cholecystitis was found, along with multiple gastric and duodenal erosions including the second part, with an antral ulcer and multiple duodenal bulb ulcers. Repeated abdominal angiography showed progression of the stenotic lesions with significant narrowing of both the celiac trunk and the SMA. A stent was placed in the SMA. Following the procedure, the patient noted marked symptomatic improvement. On follow-up gastroduodenoscopy, all ischemic ulcers had healed completely. Serum albumin rose from a nadir of 31 to 40 g/l, and an extremely elevated c-reactive protein of 205,000 Correspondence to:
U. Gafter, MD, PhD
Institute of Nephrology and Hypertension, Rabin Medical Center, Hasharon Campus, 7 Keren Kayemet St. Box 121, Petah Tikva, Israel 49372
Email: uzig@clalit.org.il
Case Reports
Spontaneous bacterial peritonitis in terminal renal failure
Abstract
K. Cengiz
Department of Nephrology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
We herein report a case of spontaneous bacterial peritonitis (SBP) caused by Staphylococcus epidermidis in an adult patient on regular hemodialysis (due to terminal renal failure caused by hypertension) and not on immunosuppressive therapy.Correspondence to:
K. Cengiz, MD
Ondokuz Mayis University School of Medicine, Department of Nephrology,
55139 Kurupelit, Samsun, Turkey
Email: kcengiz@omu.edu.tr
Case Reports
Splenic infarction: an unrecognized cause of culture-negative peritonitis in a continuous ambulatory peritoneal dialysis patient
Abstract
C.-C. Yang, S.-H. Lin, Y.-H. Tzeng, C.-A. Chen and S.-H. Tsai
1Division of Nephrology, Department of Medicine, Cheng-Hsin Rehabilitation Medical Center, 2Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, 3Department of Radiology, Cheng-Hsin Rehabilitation Medical Center, Taipei, Taiwan
The appearance of cloudy peritoneal dialysis effluent in combination with the clinical manifestations of peritonitis usually heralds infectious peritonitis and the diagnosis is established with routine cultures. However, patients may present with culture-negative cloudy dialysate effluent and after ruling out atypical infectious etiologies, other intraabdominal causes should be considered in the differential diagnosis. A 57-year-old male with uremia on continuous ambulatory peritoneal dialysis with a pertinent history of restrictive cardiomyopathy and chronic atrial fibrillation suffered from abdominal pain and persistent culture-negative cloudy peritoneal dialysate. Clinical improvement was limited after empiric antibiotic treatment and all bacteriologic workups were negative. Isolated spleen infarction, a rare cause of culture-negative peritonitis, was disclosed by abdominal computed tomography. Spleen infarction is still an unrecognized cause of culture-negative peritonitis and is frequently overlooked. A high degree of suspicion is needed in CAPD patients with thromboembolism risk who present with unexplained persistent abdominal pain and cloudy PD effluent.
Correspondence to:
S.-H. Tsai, MD
Division of Nephrology, Department of Medicine, Cheng Hsin Rehabilitation Medical Center, Taipei, Taiwan, 45, Cheng-Hsin Street, Peitou 112, Taipei, Taiwan
Email: nephron@ms28.hinet.net
Letter to the Editor
Positive effect of N-acetylcysteine in theophylline intoxication
Abstract
K. Kisters, M. Cziborra, C. Funke, F. Tokmak and M. Hausberg
1Med. Clinic I, St. Anna Hospital, Herne, 2Department of Nephrology, Ruhr University Bochum, and 3Department of Nephrology, University Policlinic, M
Correspondence to:
Prof. Dr. K. Kisters
Med. Clinic I, St. Anna Hospital, Hospitalstrasse 19, 44649 Herne, Germany
Email: kisters@annahospital.de
