Volume 69, No. 3/2008(March)
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 Clinical Nephrology
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Invited Editorial
The third World Kidney Day: Looking back and thinking forward
Abstract
S.V. Shah and J. Feehally
Correspondence to:
S.V. Shah, MD, FACP; Professor of Medicine and Director, Division of Nephrology, UAMS College of Medicine, 4301 West Markham, Slot 501, Little Rock, AR 72205, USA
Email: shahsudhirv@uams.edu
Review
Hepatitis C virus-related kidney disease: an overview
Abstract
N. Kamar, J. Izopet, L. Alric, C. Guilbeaud-Frugier and L. Rostaing
1Department of Nephrology, Dialysis, and Multiorgan Transplantation, CHU Rangueil, 2Department of Virology, 3Department of Internal Medicine, Fédération Digestive, CHU Purpan, and 4Department of Histopathology, CHU Rangueil, Toulouse University Hospital
Hepatitis C virus (HCV)-infection leads to chronic liver disease, but also to extra-hepatic manifestations, including kidney disease. We provide an overview of HCV-related kidney diseases in non-transplanted and in kidney transplant patients, and their therapies. Membranoproliferative glomerulonephritis, associated with Type 2 cryoglobulinemia, is the predominant Type of HCV-related glomerulonephritis. Membranous glomerulonephritis and focal segmental glomerular sclerosis are less commonly described. HCV infection seems to be linked to Type 2 diabetes mellitus, and might alter the progression of diabetic-related nephropathy. Patients infected by HCV should be annually screened for markers of kidney disease and, similarly, patients with membranoproliferative or membranous glomerulonephritis should be screened for HCV infection. After transplantation, cryoglobulinemia is frequent and is associated with HCV markers. HCV-related kidney disease requires specific treatment. In non-kidney-transplant patients, treatment relies on either only anti-HCV therapy in cases of moderate renal disease, or combined anti-viral and immunosuppressive therapies in cases of severe renal disease, i.e., nephrotic syndrome and/or progressive renal failure, and in diseases that are refractory to anti-HCV therapy. In kidney transplant patients, ribavirin monotherapy could be used cautiously, whereas rituximab might be a treatment of choice in the presence of cryoglobulinemia. In liver-transplant patients, in addition to anti-HCV therapy, rituximab might be also used.Correspondence to:
N. Kamar MD, PhD; Department of Nephrology, Dialysis, and Multi-Organ Transplantation Unit, CHU Rangueil, Toulouse University Hospital, 1 Avenue J.Poulhès, TSA 50032, 31059 Toulouse Cedex 9, France
Email: kamar.n@chu-toulouse.fr
Originals
Clinical manifestation of gadodiamide-related nephrogenic systemic
fibrosis
Abstract
P. Marckmann, L. Skov, K. Rossen and H.S. Thomsen
1Department of Nephrology, Copenhagen University Hospital Herlev, 2Department of Dermatology, 3Department of Pathology, Copenhagen University Hospital Gentofte, Hellerup, 4Department of Diagnostic Radiology, Copenhagen University Hospital Herlev, Denmark
Aims: To further characterize the clinical signs and symptoms of nephrogenic systemic fibrosis, a new and serious disease affecting renal failure patients and caused by some Gd-containing contrast agents, including gadodiamide. Material: 22 cases of gadodiamide-related nephrogenic systemic fibrosis followed at the nephrology department of Copenhagen University Hospital Herlev. Method: Retrospective cohort study based on medical records, personal interviews and physical examinations. Results: Typical first signs of the disease were skin discoloration, induration and warmth, itching, constant pain and other neuropathic symptoms localized to the lower legs. First sign appeared in a median of 14 days (range 0 – 53 days) after gadodiamide exposure. Associated early symptoms included sleeplessness and transient, diffuse hair loss. The predominant late symptom was symmetrical skin stiffness of extremities with or without restricted joint motion. Ten of 22 patients (45, 95% CI: 27 – 66%) were severely disabled due to contractures on the average of 29 months after being exposed to gadodiamide. Four patients died (18, 95% CI: 6 – 41). Patients perceived that intensive physiotherapy was effective in limiting disabling contractures. Conclusions: Signs and symptoms of nephrogenic systemic fibrosis vary over time and between patients. The disease leads to severe disability in a significant proportion of affected patients. Intensive physiotherapy may limit the development of contractures.Correspondence to:
P. Marckmann, MD, DMSc; Department of Nephrology Copenhagen, University Hospital Herlev, 2730 Herlev, Denmark
Email: peter.marckmann@dadlnet.dk
Originals
Renal protection in diabetes: Is it affected by glucose control or inhibition of the renin-angiotensin pathway?
Abstract
A.K. Mandal and L.M. Hiebert
1University of Florida, Jacksonville, FL, USA and 2Department of Veterinary Biomedical Sciences, University of Saskatchewan, Saskatoon, Canada
Background: Recent reports indicate increased risk of renal failure with long-term use of angiotensin-converting enzyme inhibitors (ACEI) in diabetes. End-stage renal disease (ESRD) in diabetes has increased despite ACEI and angiotensin receptor blocker (ARB) use. This study questions renal protection by ACEI or ARB. Our hypothesis is that uncontrolled hyperglycemia is central to diabetic ESRD while tight glucose control is renoprotective. Cultured endothelial cells show morphological damage that increases with duration of exposure to high glucose and is prevented by insulin and more so by a combination of insulin and heparin. Methods: Findings from individual patients are compared to clinical trial results wherein ACEI or ARB was emphasized as the prime therapy to prevent progression of diabetic nephropathy to ESRD. Serum creatinine (Scr) changes were the main indicator of renoprotective effects in clinical trials. Creatinine clearance (Ccl), an important marker of glomerular filtration rate, was seldom reported. Results: Our observations show that ACEI-treated patients develop progressive renal failure, whereas renal function remains stable with optimum glucose control. Clinical trials showed that reduction of proteinuria, with ACEI, reduces the risk of ESRD. Our studies show that reduction of proteinuria with use of ACEI or ARB parallels a reduction in Ccl, suggesting that a change in proteinuria is related to Ccl changes. Scr changes are small, giving a deceptive view of renal protection. Conclusions: Our observations find no evidence of renal protection with ACEI or ARB use in diabetes. Laboratory studies and clinical observations suggest that adequate glucose control is the key to renal protection in diabetes.Correspondence to:
A.K. Mandal, MB, BS; Medical Specialists, 240 Southpark Circle East, St. Augustine, FL 32086, USA
Email: amandal@med-spec.com
Originals
Effect of oral mizoribine pulse therapy for frequently relapsing steroid-dependent nephrotic syndrome
Abstract
M. Fujieda, M. Ishihara, T. Morita, A. Hayashi, Y. Utsunomiya, T. Ohta, T. Sakano and H. Wakiguchi
1Department of Pediatrics, Kochi University Medical School, Kochi,
2Department of Pediatrics, Tottori University, Nishimachi, Yonago,
3Department of Pediatrics, Tottori Prefectural Central Hospital, Edu, Tottori and 4Department of Pediatrics
Aim: To evaluate the efficacy of oral mizoribine (MZB) pulse therapy given twice a week for frequently relapsing steroid-dependent nephrotic syndrome (FR-SDNS). Subjects: 16 patients with FR-SDNS with a median age of 11.6 years (range 5.1 – 17.8 years) were enrolled in the study. This study was a Phase II trial. Methods: The dose of MZB was adjusted to achieve a peak blood level of about 3 mg/ml (10.0 – 19.7 mg/kg/d, maximum total dose 750 mg) in two divided doses given 2 days a week before a meal. The therapeutic benefits of MZB pulse therapy were assessed based on a comparison of the incidence of relapse (times/year) and the required daily dosage of prednisolone (PSL) before and after therapy. Results: The incidence of relapse after therapy was significantly lower than that before therapy (2.4 ± 1.6 vs. 3.4 ± 1.1 times/year, p < 0.05), and the required daily dosage of PSL after therapy was lower than that before therapy (0.39 ± 0.26 vs. 0.47 ± 0.24 mg/kg/d; not significant). During the follow-up period, discontinuation of PSL was possible in 6 of 12 patients who showed a decreased rate of relapse after therapy. The age at entry into the study and the peak blood concentration of MZB of these patients were significantly higher than in four patients who did not show a decreased rate of relapse (12.3 ± 4.3 vs. 7.9 ± 2.6 years, p < 0.05; 3.00 ± 0.93 vs. 1.97 ± 0.36 mg/ml, p < 0.005, respectively). No adverse effects were observed in any patients. Conclusion: Our results show that MZB pulse therapy is effective in decreasing the frequency of relapse and reducing the required PSL dosage in older pediatric patients with FR-SDNS.Correspondence to:
M. Fujieda, MD; Department of Pediatrics, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi 783-8505, Japan
Email: fujiedam@kochi-u.ac.jp
Originals
Switch of ESA therapy from darbepoetin-α to epoetin-β in hemodialysis patients: a single-center experience
Abstract
P. Biggar, M. Ketteler, H. Hennemann and R. Dömling
KfH Dialysis Center Coburg in affiliation with Klinikum Coburg, Germany
Aims: No study has previously investigated a switch from darbepoetin-α to epoetin-β in unselected dialysis patients. Our study determined the intravenous epoetin-β dose necessary to maintain or to achieve hemoglobin targets after switching from darbepoetin-α. Methods: In our dialysis center, all eligible dialysis patients (n = 90) were switched from darbepoetin-α i.v. to epoetin-β i.v. in 2005. The epoetin-β dose was calculated according to the recommended European equimolar conversion factor (1 : 200 µg darbepoetin-α corresponds to 200 IU epoetin-β). The intraindividual evaluation compared 12 weeks before with 16 weeks after the switch. The dose of the erythropoiesis-stimulating agents (ESA) and the hemoglobin levels were analyzed for the whole period and for the last 4 weeks of both treatment periods. Results: During treatment with darbepoetin-α, 71% of a total of 90 patients achieved a hemoglobin level >= 11.0 g/dl. After switching to epoetin-β, the mean hemoglobin level decreased significantly from 11.4 ± 1.0 g/dl to 11.1 ± 0.9 g/dl (p = 0.0016) and the percentage of patients with hemoglobin levels >= 11.0 g/dl fell to 50% (p = 0.00138). Furthermore, the mean required ESA dose increased by 13% from 4,335 ± 3,217 IU/week darbepoetin-α to 4,885 ± 3,077 IU/week epoetin-β (p = 0.0001). Comparing the last 4 weeks, the ESA dose increased by 17% from 4,583 ± 3,391 IU/week darbepoetin-α to 5,372 ± 3,672 IU/week epoetin-b (p = 0.0003). Conclusions: After switching from darbepoetin-α i.v. to epoetin-β i.v., the equimolar epoetin-β dose was not sufficient to maintain hemoglobin levels with the same efficacy above 11.0 g/dl. Significantly less patients achieved hemoglobin target values as suggested by the EBPG guidelines.Correspondence to:
Dr. P. Biggar; Klinikum Coburg, Abteilung Nephrologie, Ketschendorfer Straße 33, 96450 Coburg, Germany
Email: patrick.biggar@kfh-dialyse.de
Originals
Patient and technique survival of diabetics on peritoneal dialysis:
one-center’s experience and review of the literature
Abstract
W. Fang, X. Yang, J. Kothari, M. Khandelwal, D. Naimark, S. Vanita Jassal, J. Bargman and D.G. Oreopoulos
1Peritoneal Dialysis Program, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada, and 2Renal Division, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
Background: Diabetes is the leading cause of end-stage renal disease (ESRD). This retrospective study investigated the long-term patient and technique survival and sought to identify the predictors of mortality in diabetic patients receiving PD. Methods: Patients, aged 17 years or more who commenced home PD between January 31, 1994, and December 31, 2001 were included. Clinical data were available for 358 patients out of 418 total patients who started PD during this period. They were followed until cessation of PD, death, or to January 31, 2003. Survival probabilities were generated according to the Kaplan-Meier method, and multivariate Cox proportional hazards models were used to assess predictors of survival. Results: A total of 358 patients were enrolled in the study. Among them, 139 patients (38.8%) were diabetics. The 1-, 2-, 3- and 5-year patient survival rates were 91%, 76%, 66% and 47% in diabetics and 94%, 89%, 84% and 69% in non-diabetics, respectively. Median actuarial patient survival for diabetic patients (51.8 months; 95% CI 36.0 – 67.5 months) was significantly shorter than that of non-diabetic patients (log rank 14.117, p < 0.001). Death-censored technique survival rates at 1-, 2-, 3- and 5-year were 90%, 83%, 67% and 58% in diabetic, and 94%, 87%, 77% and 70% in non-diabetic patients, respectively. Similar to patient survival, the median technique survival time was significantly shorter for diabetic patients (63.9 months; 95% CI 35.7 – 92.2 months) than that of non-diabetic patients (log rank 4.884, p = 0.027). Multivariate Cox regression analysis showed that advancing age was the only independent predictor of death in the diabetic patients, whereas higher age and wider pulse pressure were associated with mortality in non-diabetic patients. Conclusion: Long-term patient and technique survival for diabetic patients on PD seem to be improved compared to our previous report and other studies. The mortality of diabetic patients was predicted predominantly by advancing age. PD remains a viable form of long-term renal replacement therapy for diabetic patients with ESRD.Correspondence to:
D.G. Oreopoulos; 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada
Email: dgo@teleglobal.ca
Originals
Patient perceived barriers to treatment of depression and anxiety in hemodialysis patients
Abstract
S. Johnson and A. Dwyer
University of Louisville School of Medicine, Louisville, KY, USA
Untreated psychiatric illness correlates with increased mortality, reduced quality of life and increased risk of suicide in renal failure patients, but little is known about why these patients fail to seek mental health care. The purpose of this study was to identify the perceived barriers to mental health services in the hemodialysis patient population. The Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) were used to identify the prevalence and severity of depression and anxiety in a group of 179 hemodialysis patients. Of the 103 patients who completed the surveys, 73.8% were African-American and 62.1% were male. Of the 54.4% of patients identified with depression by scoring 10 or greater on the BDI, 34.0% had mild-to-moderate, 12.6% had moderate-to-severe, and 7.8% had severe depression. Only 13.6% of respondents met criteria for anxiety. Each patient was asked to choose from a list of possible barriers, and 71.4% of patients meeting criteria for depression or anxiety identified a barrier to mental health treatment. Of these, over 70% of patients were unaware of symptoms of depression/ anxiety or did not perceive the need for help. Our results indicate a high prevalence of untreated depression in hemodialysis patients. Patient perceptions of the need for therapy present the most significant barriers to identification and treatment.Correspondence to:
A. Dwyer, MD; Kidney Disease Program, 615 S. Preston Street, University of Louisville, Louisville, KY 40202, USA
Email: amy.dwyer@louisville.edu
Case Reports
Acute renal failure after antibiotic-impregnated bone cement treatment of an infected total knee arthroplasty
Abstract
S. Dovas, V. Liakopoulos, L. Papatheodorou, I. Chronopoulou, V. Papavasiliou, E. Atmatzidis, M. Giannopoulou, T. Eleftheriadis, T. Simopoulou, T. Karachalios and I. Stefanidis
1Department of Nephrology, 2Department of Orthopedics, School of Medicine, University of Thessaly, Larissa, Greece
Antibiotic-impregnated cement is used frequently in revision procedures of infected total hip and knee arthroplasties. Local antibiotic treatment is as effective as the use of systemic antibiotics. The purpose of such treatment is to provide high tissue concentrations of antibiotics and minimize systemic toxicity, especially nephrotoxicity. Though antibiotic-impregnated cement is considered safe in terms of nephrotoxicity, two cases that have implicated aminoglycoside-impregnated cement in acute renal failure (ARF) after surgery for an infected total knee arthroplasty (TKA) have been reported [Curtis et al. 2005, Van Raaij et al. 2002]. Two more cases of postoperative ARF after use of combined tobramycin- plus vancomycin-impregnated cement, this time in total hip arthroplasty, have been recently reported [Patrick et al. 2006]. We report a case of ARF in a 61-year-old patient with a history of diabetes mellitus and hypertension after treatment of a febrile infection of a TKA with combined gentamicin- plus vancomycin-impregnated cement. The ARF could not sufficiently be attributed to other causes and though serum concentrations of antibiotics obtained from the 8th postoperative day and thereafter were far below the trough levels associated with nephrotoxicity, gentamicin and vancomycin seem to have contributed significantly to ARF in our case.Correspondence to:
I. Stefanidis, MD, PhD; Associate Professor of Medicine/Nephrology
Chief of the Department of Nephrology, School of Medicine, University of Thessaly, 22 Papakyriazi street, 41222, Larissa, Greece
Email: stefanid@med.uth.gr
Case Reports
Therapeutic management of a new case of LCAT deficiency with a multifactorial long-term approach based on high doses of angiotensin II receptor blockers (ARBs)
Abstract
P. Aranda, P. Valdivielso, L. Pisciotta, I. Garcia1, C. García-Arias, S. Bertolini, G. Martín-Reyes, González-Santos and S. Calandra
1Nephrology and Pathology, Hospital Carlos Haya, SAS, 2Lipid Unit, Hospital Virgen de la Victoria and University of Málaga, Spain, 3Department of Internal Medicine, University of Genoa and 4Department of Biomedical Sciences, University of Modena and Reggio Emilia, Italy
Familial lecithin cholesterol acyltransferase (LCAT) deficiency (FLD) is characterized by the appearance of corneal opacity, anemia, proteinuria progressing to chronic renal failure and abnormalities in the composition of plasma lipoproteins. No established therapy currently exists for this condition. We report here a new case of FLD caused by two novel mutations in the LCAT gene in which, for the first time, aggressive therapy with angiotensin II receptor blockers and lipid-lowering drugs showed benefit in blood pressure, lipid abnormalities, proteinuria and also kidney function, probably delaying progression to renal failure.Correspondence to:
P. Valdivielso, MD; Department of Medicine, University of Malaga, Blvd Luis Pasteur, 29010 Malaga, Spain
Email: valdivielso@uma.es
Case Reports
Headache during hemodialysis – an uncommon cause for a common problem
Abstract
M.S. van Brussel, P.W. Koppius and N.H. Schut
1Departments of Internal Medicine and 2Ophthalmology, Kennemer Gasthuis, Haarlem, The Netherlands
A hemodialysis patient is described who was suffering from headache during his dialysis sessions. This was due to a neovascular glaucoma causing an increase in intraocular pressure (IOP) during dialysis sessions. After several months his headache decreased but his IOP measurements remained high with almost similar pre- and post dialysis values. Headache during hemodialysis may be due to glaucoma, but this can disappear with time, along with a disappearance in the increase in IOP during dialysis sessions.Correspondence to:
N.H. Schut, MD, PhD; Kennemer Gasthuis, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands
Email: schutn@kg.nl
Case Reports
Spontaneous bladder rupture in a chronic hemodialysis patient
Abstract
S. Chung, D.-E. Choi, J.S. Lim, K.-R. Na, Y.-T. Shin and K.W. Lee
1Department of Internal Medicine and 2Department of Urology, Chungnam National University Hospital, Daejeon, South Korea
Spontaneous bladder rupture is very rare. A 67-year-old woman who was nearly anuric and had been on chronic hemodialysis therapy for diabetic end-stage renal disease for 6 years complained of severe low abdominal pain and fever for 2 days. Abdominal computerized tomography and retrograde cystography revealed the extraperitoneal leakage of contrast medium, confirming bladder perforation. Partial cystectomy around the perforation site and repair of the bladder rupture were performed. Microscopic examination of the excised bladder tissue revealed that the bladder mucosa was ulcerated. Severe suppurative inflammation was observed throughout the bladder wall. Antibiotic treatment was continued for 3 weeks postoperatively, and repeated retrograde cystography showed no evidence of contrast extravasation. She was discharged, with no other complications.Correspondence to:
K.W. Lee, MD; Renal Division, Department of Internal Medicine, Chungnam National University Hospital, 640 Daesa-Dong, Chung-Ku, Daejeon, 301-040, South Korea
Email: kwlee@cnu.ac.kr
Case Reports
Clear cell renal carcinoma presenting as a bleeding cyst in pregnancy: inaugural manifestation of a von Hippel-Lindau disease
Abstract
I. Simon, S. Rorive, C. Kirkpatrick, T. Roumeguere and J.L. Nortier
Departments of 1Nephrology, 2Pathology, 3Gynecology and 4Urology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
Von Hippel-Lindau (VHL) disease is a dominant autosomal disorder inducing the development of many tumors, such as hemangioblastomas in the central nervous system and retina, cysts or tumors (benign or malignant) in the kidneys and/or the pancreas. We report the case of a pregnant woman who presented with a voluminous hemorrhagic cyst of the right kidney with an exophytic lesion detected in the lower median part of the cyst wall. As an anamnestic inquiry resulted in a familial history of VHL disease, a screening imaging was performed and detected three medullary hemangioblastomas. Considering the active bleeding of the renal cyst and its potential malignancy, a unilateral nephrectomy was carried out after pregnancy interruption. Histological analysis confirmed a multilocular clear cell renal carcinoma. This case underlines the importance of screening procedures such as abdominal ultrasonography and medullary magnetic resonance imaging in all pregnant women with a familial history of VHL disease.Correspondence to:
J.L. Nortier, MD, PhD; Nephrology, Dialysis and Renal Transplantation, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
Email: jnortier@ulb.ac.be
Letters to the Editor
Hyperphosphoremia in kidney failure- salivary phosphate as a marker and possible target
Abstract
V. Savica, L.A. Calò, P.A. Davis 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, Italy and 4Department of Nutrition, University of California
Correspondence to:
L.A. Calò MD, PhD; Department of Clinical and Experimental Medicine,
Clinica Medica 4, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
Email: renzcalo@unipd.it
Letters to the Editor
T wave alternans testing before and after hemodialysis
Abstract
J.E. Madias
Mount Sinai School of Medicine of the New York University and the Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, USA
Correspondence to:
Dr. J.E. Madias; Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY 11373, USA
Email: madiasj@nychhc.org
Letters to the Editor
Cinacalcet improves bone mineral density in a renal transplant recipient with persistent hyperparathyroidism
Abstract
P.-Y. Decleire, J.-P. Devogelaer and E. Goffin
Departments of 1Nephrology and 2Rheumatology, Université Catholique de Louvain, Brussels, Belgium
Correspondence to:
Prof. E. Goffin; Cliniques Universitaires St-Luc, Av Hippocrate 10, 1200 Brussels, Belgium
Email: goffin@nefr.ucl.ac.be
