Volume 69, No. 5/2008(May)
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 Clinical Nephrology
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Review
Herb-drug interactions in nephrology: documented and theoretical
Abstract
R. Nowack
Center for Nephrology and Dialysis, Lindau, Germany
Renal patients consuming herbal drugs are at risk for herb-drug interactions by various mechanisms. In transplant recipients, toxicity and underdosage of calcineurin inhibitor-based immunosuppression have been linked to phytochemically triggered activity changes of cytochrome P-450 isoenzyme CYP3A4 metabolism and drug transport proteins. This type of interaction might be triggered by many other plant products besides grapefruit juice and St. John’s wort, less well-known for this risk. Other potential herb-drug interactions in renal patients, for example with antidiabetics, anticoagulants or antihypertensives are discussed, although they have not yet been reported. Herb-drug interactions might possibly often go unnoticed, because physicians are not informed about herbal drug consumption by their patients. For better future detection and handling of herb-drug interactions, physicians should expand their knowledge about phytochemicals in herbs and foods.Correspondence to:
Dr. R. Nowack; Dialysezentrum Lindau, Friedrichshafener Straße 82, 88131 Lindau, Germany
Email: nowack@dialyse-lindau.de
Editorial Comment
The continuum home program concept
Abstract
J.A. Diaz-Buxo and T. Crawford-Bonadio
Fresenius Medical Care North America, Waltham, MA, USA
The continuum home program concept aims to promote preservation of freedom for the individual patient, providing the opportunity to administer the therapy of choice in the patient’s own environment. It strives for a continuation rather than a disruption of the patient’s live. Continuum emphasizes matching the prescription to the patient’s metabolic and psychological needs and strong consideration is given to economic realities and the best utilization of resources. Patients should be approached from the time of earliest referral and should be followed throughout their life with renal failure, regardless of therapy selection. The concept incorporates the traditional renal team members, as well as individuals responsible for the creation, manufacturing and delivery of products and services. It addresses patient recruitment, pre-ESRD education, general planning of dialysis, training tools and the timely creation of vascular or peritoneal access. The ideal program should provide a continuous flow of services where consideration for the patient’s autonomy is always a priority.Correspondence to:
J.A. Diaz-Buxo, MD, FACP; Fresenius Medical Care NA, 1001 Morehead Square Drive, Suite 470, Charlotte, NC 28203, USA
Email: jose.diaz-buxo@fmc-na.com
Originals
Inaccuracy of GFR predictions by plasma cystatin C in patients without kidney dysfunction and in advanced kidney disease
Abstract
O. Bakoush, A. Grubb and B. Rippe
Department of Nephrology and 2Department of Clinical Chemistry, University Hospital of Lund, Sweden
Background: In clinical practice there is need for a simple and reliable test for determination of impaired renal function. With reductions in GFR, the plasma cystatin C concentration (C, mg/l) will increase earlier than serum creatinine, and it is generally agreed that plasma cystatin C is only little affected by body weight, age or sex. However, some reports indicate that cystatin C may be influenced not only by GFR, but also by malignancy, inflammation and high doses of corticosteroids. The aim of the present study was to investigate how plasma cystatin C predicts GFR in distinct subcategories of patients with various disorders as well as in organ transplant patients. Methods: Plasma cystatin C was measured in 536 patients (age range 0.3 – 96 years, 262 females, 274 males), consecutively referred to our hospital for determination of GFR by iohexol clearance. Correlations of log GFR vs. log cystatin C were used to compare plasma cystatin C and measured GFR for the following categories: individuals with no known kidney disease (No-KD), malignant patients with (mostly) normal GFR, solid organ-transplanted patients, and patients with native chronic kidney disease (CKD). Results: In patients with normal kidney function and cystatin C level <= 1 mg/l, the cystatin C was poorly correlated with GFR (R2 = 0.13). By contrast, in patients with chronic kidney disease (log) plasma cystatin C was highly correlated with (log) GFR (R2 = 0.87). This correlation was more or less unchanged whether the cause of the reduction in GFR was CKD at Stages 1 – 3 (90 > GFR > 30 ml/min–1 (1.73 m2)–1) or solid organ transplantation (GFR = 84.55 C1.7666 and GFR = 83.95 C–1.5968, respectively). Conclusion: Therefore, for these categories, a common equation for all patients with increased cystatin C, irrespective of cause of renal impairment, could be used, namely that presented by Grubb et al. [2005] (GFR = 83.93 C–1.676). However, at marked reductions of renal function (GFR < 30 or cystatin C > 2), i.e. for CKD Stages 4 and 5, the Grubb prediction equation is less accurate. Based on our data, we suggest the equation GFR = 50.52 C–1.26 for this category of patients.Correspondence to:
O. Bakoush, MD, PhD; Department of Nephrology University Hospital of Lund, 211 85 Lund, Sweden
Email: Omran.Bakoush@med.lu.se
Originals
Acute intermittent porphyria and chronic renal failure
Abstract
J.T. Marsden, P. Chowdhury, J. Wang, A. Deacon, N. Dutt, T.J. Peters and I.C. Macdougall
1Departments of Clinical Biochemistry, 2Renal Medicine and 3Histopathology, King’s College Hospital, London, UK
Despite the little known association between renal damage and the acute porphyrias, limited information is available on the characteristics and pathogenesis of renal disease in this patient group. Previous reports have focused on hypertension as the principal etiological factor. We have studied a series of 9 patients with acute intermittent porphyria (AIP) attending the Porphyria Clinic at King’s College Hospital, London, UK, who were referred to the Renal Unit for investigation and treatment of their renal disease. No evidence of a glomerular lesion was found in any of the patients. In contrast, renal histology showed features of a tubulointerstitial disease, and there was evidence of impaired erythropoietin production. Hypertension and nonsteroidal antiinflammatory drug use were present in about a half of the patients. It is postulated that the nephrotoxic effects of porphyrin precursors may contribute to the etiology of this clinical syndrome.Correspondence to:
Dr. J.T. Marsden; Department of Clinical Biochemistry, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
Email: joanne.marsden@kch.nhs.uk
Originals
Increased erythropoietin-α dose when switching from subcutaneous to intravenous administration: effect of serum albumin
Abstract
H.-H. Chen, D.-Ch. Tarng, Ch.-J. Wu, Y.-W. Chen and J.-T. Ting
1Division of Nephrology, Department of Medicine, Mackay Memorial Hospital, 2Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, 3Institutes of Physiology and Clinical Medicine, Faculty of Medicine, National Yang-Ming University School of Medicine, 4Mackay Medicine, Nursing and Management College, 5National Taipei College of Nursing and 6Graduate Institute of Medical Science, Taipei Medical University, Taipei, Taiwan
Background: Patients on hemodialysis receiving subcutaneous (s.c.) erythropoietin usually require a higher dose if switched to intravenous (i.v.) administration. The factors affecting this dose change are not clear. Methods: From January 2003 to June 2004, patients on hemodialysis who were receiving s.c. erythropoietin were enrolled in this prospective observational study. The s.c. route was continued for the first 2 months and the average weekly dose of erythropoietin to maintain the target hematocrit from that period was the baseline dose. Patients were then switched to i.v. erythropoietin and followed for 6 months, with the dose adjusted monthly to maintain the hematocrit. Biochemistry data were collected throughout the study period. Results: After 6 months, the mean i.v. dose of erythropoietin in 179 patients was 50.9% higher than baseline. The 86 patients requiring a > 50% increase had a significantly lower serum albumin than 93 patients with a < 50% increase in dose (3.64 g/dl vs. 3.78 g/dl, p < 0.005). Each 1 g/dl higher level of serum albumin was associated with a 1237-U lower dose increment (F = 12.47, p < 0.001). Conclusion: Serum albumin is significantly correlated with the increase in erythropoietin dose needed when switching from s.c. to i.v. administration in Taiwanese on hemodialysis.Correspondence to:
Dr. H.-H. Chen; Department of Nephrology, Mackay Memorial Hospital 92, Section 2, Chungshan North Road, Taipei, Taiwan
Email: a2703180@ms1.mmh.org.tw
Originals
The influence of hemodialysis membranes on the plasma insulin level of diabetic patients on maintenance hemodialysis
Abstract
M. Abe, F. Kikuchi, K. Kaizu and K. Matsumoto
1Division of Nephrology and Endocrinology, Department of Medicine, Nihon University School of Medicine, 2Department of Nephrology and Blood Purification, Yamato Hospital, Tokyo, 3Department of Nephrology and Blood Purification, Yokohama Social Insurance Central Hospital, Yokohama, Japan
Aim: The aim of the present study was to evaluate the alteration in plasma immunoreactive insulin (IRI) concentrations due to hemodialysis (HD) treatment by using three types of membranes in diabetic HD patients. Method: We recruited 20 outpatients on maintenance HD with diabetes for this crossover study. HD was performed using membranes made of cellulose triacetate (CTA), polyester-polymer alloy (PEPA), and polysulphone (PS). These membranes were used for 2 weeks (6 HD sessions) in each patient in a randomized order decided by drawing lots. Blood samples were obtained at the beginning and end of the HD session from the blood tubing at the arterial (A) site. At 60 min after the initiation of dialysis, blood samples were obtained from the blood tubing at both the A and venous (V) sites of the dialyzer. Results: The plasma IRI levels decreased significantly at the sites an hour after initiating HD in all membranes. The clearance of IRI was significantly higher in the case of the PS membrane when compared with the CTA and PEPA membranes. Conclusions: It was concluded that plasma insulin is cleared by HD, and the rate differs for each membrane. Plasma insulin clearance with the PS membrane is higher than that with the PEPA and CTA membranes.
Correspondence to:
M. Abe, MD; Division of Nephrology and Endocrinology Department of Medicine, Nihon University School of Medicine, 30-1, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
Email: mabe@med.nihon-u.ac.jp
Originals
Vascular complications of the lower extremities in diabetic patients on peritoneal dialysis
Abstract
T. Pliakogiannis, S. Bailey, S. Cherukuri, H. Taskapan, M. Ahmad, T. Oliver, J.M. Bargman and D.G. Oreopoulos
Peritoneal Dialysis Program, University Health Network and University of Toronto, Toronto, Ontario, Canada
Background: Diabetic patients with end-stage renal disease (ESRD) are at high risk for developing foot complications and few have studied this complication in the diabetic patients treated with peritoneal dialysis (PD). The purpose of this study was to examine peripheral vascular disease (PVD) in diabetic patients with ESRD, who are being treated with PD, and to identify those factors that may contribute to its development. Patients: We reviewed retrospectively the charts of 71 diabetic patients who started PD between January 1999 and January 2006, inclusive, and recorded their demographic data, their treatment regimens, their complications and the results of biochemical investigation(s) at the beginning and throughout their follow-up period. All patients were under the care of a chiropodist who examined them at regular intervals and more often when needed. We divided the patients into two groups with respect to the presence of complications in the lower extremities, such as ulcers, open wounds, osteomyelitis, necrotizing or gangrenous lesions, and amputations, intermittent claudication and/or the presence on an imaging examination of changes in the leg vessels consistent with vascular disease. Results: 33 of the 71 patients had some type of a foot lesion. There were 8 amputations in the course of 176 patient-years (2 double amputations), or 1 amputation per 30 PD patient-years. Those patients with foot complications were treated more frequently with CCPD (p < 0.05), more often had peripheral neuropathy (p < 0.002), as well as coronary artery disease (p < 0.044). They had lower serum albumin (p < 0.005), significantly higher serum phosphorus (p < 0.047) and they received higher doses of erythropoietin (p < 0.042). There was no statistically significant difference between the groups regarding sex, age at initiation of PD, type of diabetes, use of insulin, levels of HbA1c, body mass index (BMI), presence of retinopathy, cerebral vascular disease, hyperlipidemia, smoking, rate of transplantation, rate of drop-out from PD, time-averaged Kt/V, creatinine clearance, serum calcium, Ca × P and intact PTH. In a multiple logistics regression model, only peripheral neuropathy and hypoalbuminemia were independently associated with the development of lower-extremity complications (p < 0.0066 and p < 0.026, respectively). One-, two- and three-year cumulative survival of the whole group was 91.5%, 78.8% and 69%, respectively. Patients with foot lesions had a lower survival than those without. Interestingly though, those patients, who had had an amputation, survived as long as those patients, who did not have foot complications at all. Conclusion: In conclusion, compared to reports in the literature, our diabetic patients on PD had a lower rate of foot complications and amputation probably because of early intervention by our chiropodist. This fact stresses the need for constant and expert monitoring of the condition of the diabetic patient’s feet, especially in those with low serum albumin and peripheral neuropathy.
Correspondence to:
D.G. Oreopoulos, MD; Toronto Western Hospital, 399 Bathurst Street, Toronto, M5T 2S8, ON, Canada
Email: dgo@teleglobal.ca
Originals
Removal of gadolinium by peritoneal dialysis
Abstract
M. Murashima, H.R. Drott, D. Carlow, L.M. Shaw, M. Milone, M. Bachman, D.E. Tsai, S.-L. Yang and R.D. Bloom
1Renal Electrolyte and Hypertension Division, Hospital of the University of Pennsylvania, 2Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia, 3Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, 4Hematology and Oncology Division, Hospital of the University of Pennsylvania and 5Department of Kidney Transplantation, Albert Einstein Medical Center, Philadelphia, PA, USA
An association between gadolinium-containing contrast and the development of nephrogenic systemic fibrosis (NSF) has been increasingly recognized. For patients receiving hemodialysis (HD) who are exposed to gadolinium, the Federal Drug Administration (FDA) recommends HD to remove this contrast agent in order to minimize the risk of NSF. This study examines if gadolinium can be removed by frequent exchanges by peritoneal dialysis (PD). Following administration of 0.1 mmol/kg of gadodiamide to a patient with end-stage renal disease, the serum clearance of this contrast agent by automated PD was examined. 10 and 15 exchanges of PD using an automated cycler were respectively performed during the first and second 24-hour periods after gadolinium exposure. Serum gadolinium levels were measured 1 hour after the gadolinium administration, then at 24 and 48 hours after PD was initiated. 90% of the gadolinium was removed from the circulation in 2 days with a regimen of 10 – 15 exchanges per day of PD. For patients on chronic maintenance PD who receive gadolinium, our case suggests that a temporary intensive automated PD regimen, aimed at maximizing clearance of this contrast agent immediately after exposure, could be an effective alternative when institution of HD is problematic.
Correspondence to:
R.D. Bloom, MD; Renal Electrolyte and Hypertension Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
Email: rdbloom@mail.med.upenn.edu
Case Reports
Relapse of membranous glomerulopathy after kidney transplantation: sustained remittance induced by rituximab
Abstract
H. Weclawiak, D. Ribes, C. Guilbeau-Frugier, G. Touchard, N. Kamar, M. Mehrenberger, A. Modesto and L. Rostaing
1Department of Nephrology, Dialysis and Multiorgan Transplantation, 2Department of Histopathology, CHU Rangueil, Toulouse, and 3Department of Nephrology, Dialysis, and Renal Pathology, CHU Jean Bernard, La Milétrie, Poitiers, France
Membranous glomerulopathy (MG) is a rare cause of chronic kidney disease. However, after kidney transplantation (KT), despite immunosuppression, it often relapses on the allograft. Herein, we report on a male kidney-transplant patient, aged 27 years, who developed overt nephrotic syndrome 11 months after KT. This was related to relapsing MG, as evidenced by the allograft biopsy, which, in addition, showed CD3 (+) and CD20 (+) interstitial lymphocyte infiltration. The patient was treated with rituximab: 375 mg/m2/week for 4 consecutive weeks, followed by one additional injection every 3 months for one year. Remission was observed before the third rituximab injection. After a follow-up of 42 months, the patient was still in remission, i.e., microalbuminuria of 107 mg/day.
Correspondence to:
Prof. L. Rostaing; Nephrology, Dialysis, and Multiorgan Transplant Unit, CHU Rangueil, 1 av. Jean Poulhès, 31059 – Toulouse Cédex 9, France
Email: rostaing.l@chu-toulouse.fr
Case Reports
Nail-patella syndrome and renal involvement: Description of three cases and literature review
Abstract
A. Granata, G. Nori, R. Ravazzolo, M. Marini, S. Castellino, E. Sicurezza, C.E. Fiore and R. Mignani
Department of Nephrology, Dialysis and Internal Medicine A.O. “Vittorio Emanuele II”, Catania, 1Department of Nephrology and Dialysis, A.O. Terni, 2Laboratory of Molecular Genetics, G. Gaslini Institute Genova, 3Department of Nephrology and Dialysis, A.O. S. Vincenzo, Taormina and 4Department of Nephrology and Dialysis Infermi Hospital, Rimini, Italy
Nail-patella syndrome (NPS) is a rare, autosomal dominant disorder reported in approximatively 1/50,000 individuals. It is characterized by hypoplastic or absent patellae, dystrophic nails, dysplasia of the elbows and iliac horns. Less frequently renal and ocular damages occur. The abnormal gene in NPS is located at the distal end of the long arm of Chromosome 9. Mutations in the human LMX1B gene have been demonstrated to be responsible for NPS. It encodes a LIM-homeodomain transcription factor which plays an important role in limb development in vertebrates. Extensive mutation analysis of different NPS families by different groups failed to demonstrate any genotype-phenotype correlation. Renal involvement occurs in 30 – 60% of patients and presents with proteinuria and/or microscopic hematuria, edema, hypertension. Progression to nephrotic syndrome occurs in less than 20% of patients, and renal failure in about 10% of NPS patients requiring dialysis and/or transplantation. We report three cases of NPS with different degrees of renal involvement and present a review of the literature on this rare hereditary condition.
Correspondence to:
Dr. A. Granata, MD; Via F. Paradiso 78/a, 95024 Acireale (CT), Italy
Email: antonio.granata4@tin.it
Case Reports
Clinical remission and histopathological resolution of nodular lesions in a patient with γ3 heavy-chain deposition disease
Abstract
J. Soma, Y. Tsuchiya, T. Sakuma and H. Sato
1Department of Nephrology, 2Department of Pathology, Iwate Prefectural Central Hospital, Morioka and 3Department of Nephrology, Hypertension and Endocrinology, Tohoku University, Sendai, Japan
Heavy-chain deposition disease (HCDD) is a rare entity accompanying to nonamyloidotic monoclonal immunoglobulin deposition disease. We report a case of γ3-HCDD in which follow-up biopsy could be done after complete remission was achieved by chemotherapy. Follow-up biopsy 2 years after initial biopsy showed remarkable diminution of both nodular glomerular lesions and IgG heavy-chain deposits. This is the first case report to indicate that the original structure of glomeruli in patients with HCDD could be restored within a few years by an appropriate treatment at an early stage of the disease.
Correspondence to:
J. Soma, MD, PhD; Department of Nephrology Iwate Prefectural Central Hospital, 1-4-1 Ueda, Morioka, 020-0066 Japan
Email: sjun@chuo-hp.pref.iwate.jp
Case Reports
Mycobacterium avium complex-associated peritonitis in a patient on continuous ambulatory peritoneal dialysis
Abstract
E.L. Falcone, A. Alam and N. Tangri
1Faculty of Medicine, McGill University, Montreal, QC, Canada, 2Division of Nephrology, Tufts-New England Medical Center, Boston, MA, USA, and 3Department of Medicine, McGill University Health Center, Montreal, QC, Canada
Continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis remains a major cause of morbidity in the dialysis population. Typically, infection is caused by gram positive bacteria and treated with empiric antibiotics. A subset of patients, however, develop culture negative peritonitis and may be infected with fungal or mycobacterial organisms. We present a case of Mycobacterium avium complex-associated peritonitis in a HIV negative patient on CAPD. Our patient suffered from technique failure and died from unrelated causes before treatment could be completed.
Correspondence to:
Dr. N. Tangri; Division of Nephrology, Tufts-New England Medical Center, 750 Washington St. Box 391, Boston, MA, 02111, USA
Email: ntangri@tufts-nemc.org
Letters to the Editor
Darier’s Disease in hemodialysis
Abstract
G.G. Dimas, H. Kampouris, G. Karkavelas, S. Kapoulas and D.M. Grekas
Letters to the Editor
Falecalcitriol for conventional vitamin D therapy-resistant secondary hyperparathyroidism in a continuous ambulatory peritoneal dialysis patient
Abstract
M. Tokunaga, M. Tamura,N. Kabashima, R. Serino, T. Shibata, M. Matsumoto, T. Miyamoto, M. Miyazaki, Y. Furuno, M. Takeuchi, H. Abe, M. Okazaki and Y. Otsuji
