Originals
Renal function in children with sickle cell anemia
A. Karabay Bayazit, A. Noyan, B. Aldudak, A. Özel, A. Anarat, Y. Kilinç, I. Sasmaz, E. Gali, R. Anarat and N. Dikmen
Volume 57 (2002) p. 127 - 130
Abstract
A. Karabay Bayazit, A. Noyan, B. Aldudak, A. Özel, A. Anarat, Y. Kilinç, I. Sasmaz, E. Gali, R. Anarat and N. Dikmen
1Department of Pediatric Nephrology, 2Department of Pediatrics,
3Department of Pediatric Hematology, Çukurova University School of Medicine, 4Antakya State Hospital, 5Biochemistry Laboratory, Adana Hospital, Baskent University, and 6Department of Biochemistry, Çukurova University School of Medicine, Balcali, Adana, Turkey
Background: Patients with sickle cell anemia have various forms of renal dysfunction. Subjects, materials and methods: The purpose of this study is to demonstrate the abnormalities of HbSS patients’ renal function in childhood. Renal function studies were performed in 55 patients with homozygote sickle cell anemia and compared with 13 healthy children. The blood and timed urine samples were obtained for hematological and biochemical determinations. Results: Mean serum creatinine, sodium, phosphorus and calcium levels were not statistically different between patients and controls. Mean serum potassium and uric acid levels were significantly higher in patients than in controls. Mean tubular phosphate reabsorption (p < 0.001) and fractional excretion of potassium (p < 0.05) were lower in patients than in the control. There were no significant differences in fractional excretion of sodium and uric acid between patients and controls. Patients had significantly higher urine pH and significantly lower specific gravity and osmolality than controls. Also, there were no significant differences in urinary protein/ creatinine, urinary N-acetyl-b-D-glucosaminidase/creatinine and urinary malondialdehyde/creatinine between patients and controls. Conclusion: Thus, significant proximal tubular dysfunction is not a common feature but distal tubular abnormality is the most consistent renal functional derangement of patients with SCA in childhood.
Originals
Calcium-sensing receptor gene polymorphism affects the parathyroid response to moderate hypercalcemic suppression in patients with end-stage renal disease
K. Yokoyama, T. Shigematsu, T. Tsukada, S. Hara, A. Yamada, Y. Kawaguchi and T. Hosoya
Volume 57 (2002) p. 131 - 135
Abstract
K. Yokoyama, T. Shigematsu, T. Tsukada, S. Hara, A. Yamada, Y. Kawaguchi and T. Hosoya
1The Division of Nephrology and Hypertension, Jikei University School of Medicine, Tokyo, 2Nephrology and Dialysis Unit, Department of Internal Medicine, Sakura National Hospital, Chiba, 3Department of Clinical Physiology, Toranomon Hospital, Tokyo, 4Kidney Center, Toranomon Hospital, Tokyo, Japan
Aim: The basic mechanism of secondary hyperparathyroidism is still unclear, but a change in Ca2+ sensing by parathyroid cells is possibly involved in this uremic complication. A rightward shift of the calcium set-point and an increase of the minimum secretion rate have been found in secondary hyperparathyroidism, indicating abnormal calcium sensing. Methods: We evaluated the effect of calcium sensing receptor (CaR) gene polymorphism (codon G990R) on the response of the parathyroid gland to moderate hypercalcemic suppression in 77 ESRD patients on regular hemodialysis (HD using 2.5 mEq/l Ca2+ dialysate). All patients underwent an HD session with 3.0 mEq/l Ca2+ dialysate to suppress parathyroid hormone (PTH). Then we investigated the effect of CaR gene polymorphism on the parathyroid response to hypercalcemic stimulation. Results: Patients were divided into 3 groups on the basis of genotype (GG = 33 patients (42.9%), GR = 39 patients (50.6%), RR = 5 patients (6.5%)). Baseline intact PTH levels in patients without the R allele were not significantly different from those in patients with the R allele (GG group, 181.4 ± 31.1 pg/ml vs. GR and RR groups, 230 ± 51.2 pg/ml: mean ± SEM). The significant effect of moderate hypercalcemic suppression on the intact PTH level was observed in the GG group (p < 0.01) but not in the GR and RR groups, despite the identical increase in Ca2+. Conclusion: Our results suggest that CaR gene polymorphism (codon G990R) influences the responsiveness of the parathyroid gland to changes of extracellular Ca2+ in ESRD patients. The glands of patients with the GG genotype of the CaR gene may be more sensitive to extracellular Ca2+ changes.
Originals
Reduction in erythropoietin doses by the use of chronic intravenous iron supplementation in iron-replete hemodialysis patients
C.-H. Chang, C.-C. Chang and S.-S. Chiang
Volume 57 (2002) p. 136 - 141
Abstract
C.-H. Chang, C.-C. Chang and S.-S. Chiang
Department of Internal Medicine, Division of Nephrology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
Background: Iron deficiency is the most common cause of suboptimal response to recombinant human erythropoietin (rHuEPO) in chronic hemodialysis (HD) patients. Iron supply can correct this situation, however, optimal dosage, route of administration, and monitoring of iron status during rHuEPO therapy in maintenance HD patients remains controversial. Methods: We conducted a 12-month intravenous iron substitution trial in 149 iron-replete chronic HD patients receiving subcutaneous rHuEPO therapy. The available iron pool was maintained with 100 mg iron every 2 weeks or 1 month depending on serum ferritin and transferrin saturation levels, the rHuEPO dosage titrated depending on hematocrit (Hct) levels. Results: After 12-month protocol, the Hct increased (28.7 ± 4.1 vs 27.7 ± 2.6, p = 0.003), rHuEPO requirement reduced 25% (46.1 ± 28.9 vs 61.5 ± 67.8 U/kg/week, p = 0.006), serum ferritin increased (1383 ± 727 vs 930 ± 857 ng/ml, p < 0.001), so did the transferrin saturation (36.1 ± 12.7 vs 27.5 ± 12.8%, p < 0.001). The serum albumin decreased slightly but reached statistical significance (4.1 ± 0.48 vs 4.2 ± 0.36 g/dl, p = 0.006), so did the cholesterol levels (166 ± 41 vs 173 ± 38 mg/dl, p = 0.044) and pre-dialysis creatinine (11.3 ± 2.3 vs 11.5 ± 2.4 mg/dl, p = 0.015). Besides, the iPTH levels did not interfere with the rHuEPO dosage reduction and Hct increment in our patients. Conclusion: We conclude that maintaining high levels of serum ferritin and transferrin saturation could further reduce the requirement of rHuEPO in chronic HD patients, but the long-term effect of iron overloading to patients’ nutritional status must be further evaluated in contrast to the economic saving.
Case reports
Renal involvement in sarcoidosis - a report of 6 cases
M. Brause, K. Magnusson, S. Degenhardt, U. Helmchen and B. Grabensee
Volume 57 (2002) p. 142 - 148
Abstract
M. Brause, K. Magnusson, S. Degenhardt, U. Helmchen and B. Grabensee
1Department of Nephrology and Rheumatology, Heinrich Heine University, 2Evangelisches Krankenhaus, Düsseldorf and
3Department of Pathology, University Hamburg, Germany
This report concerns 6 patients with renal involvement in sarcoidosis. Two of the patients had no clinical symptoms at all. In 3 patients, no extrarenal organ manifestation was found. All 6 patients had elevated levels of serum creatinine, 2 were hypercalcemic. Five patients manifested with mild proteinuria, but in none of the cases was a nephritic sediment with erythrocytes found. Kidney biopsies in 5 patients showed epitheloid cell granulomatous interstitial nephritis, and 1 patient presented with nephrocalcinosis. All patients were treated with corticosteroids. The serum creatinine levels decreased significantly in 4 patients (> 50% decrease), and slightly in 2 patients, elevated serum calcium levels were normalized. Thus, even in the absence of other organ manifestations, sarcoidosis can be the cause of renal insufficiency, and it responds well to corticosteroid treatment. These patients demonstrate the importance of kidney biopsy in the unexplained deterioration of renal function.
Case reports
Interstitial nephritis, acute renal failure in a patient with non-fulminant hepatitis A infection
A.-L. Vaboe, S. Leh and T. Forslund
Volume 57 (2002) p. 149 - 153
Abstract
A.-L. Vaboe, S. Leh and T. Forslund
1Renal Research Group, Institute of Medicine, 2Department of Pathology, Gades Institute, Haukeland University Hospital, Bergen, Norway, and
3Department of Medicine, Central Hospital of Jyväaskylä, Jyväaskylä, Finland
This is the first report from Norway of a patient with interstitial nephritis and renal failure due to non-fulminant hepatitis A virus (HAV) infection. HAV infection was confirmed by positive anti-HAV IgM serology. All tests for other virus infections were negative. At admittance serum creatinine (s-Creat) and blood urea nitrogen (BUN) concentration were 539 mmol/l and 32.6 mmol/l increasing the following days to 890 mmol/l and 39.9 mmol/l, respectively. Nine courses of hemodialysis had to be given. Kidney biopsy specimen showed interstitial edema, lymphocytic cell infiltration and acute tubular injury with normal glomeruli. Examination with immunohistochemistry was negative. In contrast to the findings associated with HBV and HCV infection in which glomerular disease is predominantly found, the HAV infection in our patient was associated with interstitial nephritis and acute tubular necrosis. The prognosis of the renal failure due to HAV infection was good although the recovery was substantially delayed.
Case reports
Type I membranoproliferative glomerulonephritis in an HIV-infected individual without hepatitis C co-infection
M. Chidambaram, C.E. Stigant, L.M. Sugar and G.V. Ramesh Prasad
Volume 57 (2002) p. 154 - 157
Abstract
M. Chidambaram, C.E. Stigant, L.M. Sugar and G.V. Ramesh Prasad
1Department of Medicine, 2Department of Pathology, St. Michael?s Hospital, University of Toronto, Toronto, Ontario, Canada
Type I membranoproliferative glomerulonephritis (MPGN) is an uncommon manifestation of human immunodeficiency virus (HIV)-associated renal disease in patients co-infected with hepatitis C virus (HCV). We describe a case of Type I MPGN in an HIV-positive diabetic man with nephrotic-range proteinuria and renal insufficiency who was not co-infected with HCV. Tubuloreticular inclusions were present but there was no evidence for either cryoglobulinemia or cryoglobulin deposits in the kidney. This finding suggests that Type I MPGN may represent a reaction of the kidney to HIV independent of the effects of HCV co-infection. Clinical suspicion must be maintained for Type I MPGN in all HIV infected patients presenting with significant proteinuria regardless of HCV infection status.
Case reports
Hyperhomocysteinemia, low folate status, homozygous
C677T mutation of the methylene tetrahydrofolate reductase and renal arterial thrombosis
G. Queffeulou, C. Michel, F.Vrtovsnik, J.-B. Philit, E. Dupuis and F. Mignon
Volume 57 (2002) p. 158 - 162
Abstract
G. Queffeulou, C. Michel, F.Vrtovsnik, J.-B. Philit, E. Dupuis and F. Mignon
Department of Nephrology, CHU Bichat-Claude Bernard, Assistance Publique Hopitaux de Paris, Paris, France
We report a renal artery thrombosis in a 42-year-old man. Fasting homocysteinemia was at 23 mmol/l 3 months later and at 33 mmol/l 5 months after the vascular event. A homozygous C677T MTHFR was found with low folate status. Active smoking may also have contributed to the pathogenesis of renal arterial thrombosis. The other causes of thrombophilia were ruled out. Homocysteine lowering treament was started: homocysteine normalized at 10.6 mmol/l. There was no recurrence of vascular event within 18 months. We propose mild or moderate hyperhomocysteinemia triggered by low folate status in patients with homozygous C677T MTHFR as a cause of renal arterial thrombosis.
Case reports
Necrotic skin lesions in a
dialysis patient: a multifactorial entity
V. Garrigue, R. Lorho, S. Canet, D. Augias, M.-F. Servel, B. Canaud, B. Albat, G. Mourad and A. Argilés
Volume 57 (2002) p. 163 - 166
Abstract
V. Garrigue1, R. Lorho2, S. Canet1, D. Augias3, M.-F. Servel4, B. Canaud1, B. Albat5, G. Mourad1 and A. Argilés1,2
1Department of Nephrology, University Hospital Lapeyronie, 2Institut de Génétique Humaine – CNRS UPR 1142, 3Department of Dermatology, University Hospital St Eloi, 4Association pour l’Installation à Domicile des Epurations Rénales (AIDER), and 5Department of Cardiovascular Surgery, University Hospital Arnaud de Villeneuve, Montpellier Cedex 5, France
A female dialysis patient with a consistently high serum calcium phosphate product presented with large necrotic skin lesions with ulcers. The clinical course was highly suggestive of calciphylaxis. Parathyroidectomy was followed by the healing of the lesions. New skin lesions appeared following relapse of hyperparathyroidism. Her clinical records included a long past of hypertension, which was the cause of her renal failure. She had a limited walking range and previously had presented bilateral ulcers of vascular origin. This case presents a type of lesion which bears a serious prognosis in dialysis patients. The clinical context and the presentation of the lesions are compatible with multiple etiology: vascular lesions and calciphylaxis. The documented longitudinal follow-up illustrates the importance of treating the different factors known to participate in the appearance of skin lesions in dialysis patients. Particularly, it stresses the benefit of performing parathyroidectomy, even if the parathyroid hormone level is not in the range normally accepted as requiring surgical removal of parathyroid glands.
Case reports
Is continuous veno-venous hemofiltration for acetaminophen-induced acute liver and renal failure worthwhile?
R. Agarwal and M.O. Farber
Volume 57 (2002) p. 167 - 170
Abstract
R. Agarwal and M.O. Farber
Indiana University & Roudebush VA Medical Center, Indianapolis, USA
CVVH for acetaminophen intoxication?
Abstract. We describe a patient with acute liver and renal failure secondary to acetaminophen and chronic alcohol abuse who was treated aggressively with oral acetylcysteine, continuous renal replacement therapy, glucose and branched-chain amino acid intravenous feeding and ventilatory support. The patient had a predicted mortality of > 95% without liver transplantation however, with intensive ventilatory, renal, and nutritional support he made a complete recovery. We discuss the benefits of aggressive supportive therapy and suggest that continuous renal replacement therapy may allow gentle fluid removal, excellent control of cerebral edema and intravenous feeding that may favorably influence prognosis.
Letters to the Editor
Renal involvement in a patient with idiopathic hypereosinophilic syndrome
F. Bulucu, C. Can, V. Inal, Y. Baykal and S. Erik
Volume 57 (2002) p. 171 - 173
Abstract
F. Bulucu, C. Can, V. Inal, Y. Baykal and S. Erik
Letters to the Editor
Focal and segmental glomerulosclerosis and non-Hodgkin?s lymphoma
J.M. Calvo Villas, A. Morales Umpierrez, M.J. Ram
Volume 57 (2002) p. 173 - 174
Abstract
J.M. Calvo Villas, A. Morales Umpierrez, M.J. Ram
Originals
Pneumonia-associated acute glomerulonephritis
T. Srivastava, B.A. Warady and U.S. Alon
Volume 57 (2002) p. 175 - 182
Abstract
T. Srivastava, B.A. Warady and U.S. Alon
Section of Nephrology, The Children?s Mercy Hospital, University of Missouri at Kansas City, Kansas City, USA
Objective: Post-infectious glomerulonephritis typically occurs 7 – 14 days after an infection. However, in
several children we observed acute glomerulonephritis (AGN) to develop concurrently with pneumonia. The objective of the study was to delineate the clinical course and outcome of pneumonia-associated AGN. Study design: The hospital database was searched from 1984 – 1999 for c+hildren admitted with both acute pneumonia and AGN, each diagnosis having been made within 72 hours of each other. Results: 11 boys, age 3.8 –12.7 years, were identified. Ten children had lobar pneumonia and 1 had an interstitial infiltrate. All responded to antibiotic therapy with resolution of fever and respiratory symptoms. Only 1 child developed an empyema. The mean ± SD hospital stay was 5.9 ± 3.9 days. All patients had an abnormal urinalysis with hematuria (gross hematuria in 5), proteinuria and cellular casts. At presentation, 7 children had a serum creatinine > 1.0 mg/dl and creatinine clearance £ 80 ml/min/1.73 m2; in all, serum creatinine returned to normal and the creatinine clearance was > 80 ml/ min/1.73 m2 on follow-up. Nine of the 11 children had a low serum complement C3, 3 of whom also had low complement C4. Anti-streptolysin-O (ASO) titers were elevated in all 10 children tested.Six children developed hypertension and received anti-hypertensive medications. Only 1
child was severely oliguric requiring peritoneal dialysis for 4 days. He underwent a
kidney biopsy, which showed acute proliferative glomerulonephritis without crescents.Neither a biopsy nor dialysis was performed in the other children. At follow-up, blood pressure, urinalysis and serum complements had normalized in the 9 children in whom follow-up was available. Conclusion: Children with pneumonia who are found to have abnormal urinalysis, hypertension, azotemia or oliguria should be evaluated for concomitant glomerulonephritis. In most children, pneumonia-associated AGN runs a benign course and has a good prognosis, however, in some short-term medical intervention may be necessary.
Originals
Bone involvement in idiopathic hypercalciuria
A.M. Misael da Silva, L.M. dos Reis, R.C. Pereira, E. Futata, C.T. Branco-Martins, I.L. Noronha, B.L. Wajchemberg and V. Jorgetti
Volume 57 (2002) p. 183 - 191
Abstract
A.M. Misael da Silva, L.M. dos Reis, R.C. Pereira, E. Futata, C.T. Branco-Martins, I.L. Noronha, B.L. Wajchemberg and V. Jorgetti
1Nephrology Division, 2Immunology Division, and 3Endocrinology Division, University of São Paulo Medical School, São Paulo, Brazil
Background: To evaluate bone involvement in idiopathic hypercalciuria, 40 lithiasic patients and 10 controls were studied. Methods: According to urinary calcium excretion, patients were first classified as hypercalciuric (Hca, n = 22) and normocalciuric (Nca,n = 18). The Hca patients were then subclassified according to bone densitometry (BMD) as osteopenic (HcaO, n = 10) and non-osteopenic(HcaNO,
n = 12). Routine biochemistry, dietary records, bone histomorphometry, and cytokines (IL-1b, IL-6, and TNF) production
by peripheral blood mononuclear cell cultures were studied. Results: There were no differences in routine biochemistry between Hca and Nca groups
except for urinary calcium. Inadequate nutrition was observed in Hca group,showing high protein (80.9% of the patients), carbohydrate (76.2%) and sodium (90%) intake. Calcium intake was low in Hca (57%) and Nca (83%) groups. IL-6 and TNF were not different between the Hca and Nca groups. IL-1b levels were significantly high in both groups when compared to controls. IL-6 and TNF were higher in HcaO than Nca. BMD in femoral neck in HcaO was lower than in HcaNO and Nca groups. Eroded surface (ES/BS) increased in 91% of the Hca group and 36% had a mineralization defect. In the HcaO group serum PTH
correlated negatively with trabecular bone volume (BV/TV) and positively with ES/BS.
1,25(OH)2D3 levels correlated positively with osteoblastic surface.
Calcium intake correlated positively with BV/TV and inversely with ES/BS. A negative
correlation was observed between IL-6 levels and Z score of the femoral neck. Conclusion:Bone involvement was detected in a young population with nephrolithiasis demonstrating that a strict follow-up is necessary in order to control hypercalciuria.
Originals
Hypertension after renal transplantation and polymorphism of genes involved in essential hypertension: ACE, AGT, AT1R and ecNOS
A. Basset El-Essawy, P. Berthoux, S. Cécillon, C.Deprèle, D. Thibaudin, J.-P. De Filippis, E.Alamartine, and F. Berthoux
Volume 57 (2002) p. 192 - 200
Abstract
A. Basset El-Essawy1,2, P. Berthoux1,2, S. Cécillon2, C.Deprèle1,2, D. Thibaudin1,2, J.-P. De Filippis1, E.Alamartine1,2 and F. Berthoux1,2
1Nephrology, Dialysis and Renal Transplantation Department, Hôpital Nord, CHU de Saint-Etienne, 2Research Group on Glomerulonephritides and Renal Transplantation, Faculty of Medicine, Saint-Etienne, France
Background: Arterial hypertension (HT), secondary to cyclosporine A (CsA) used as main immunosuppressive treatment in renal transplantation (RTx), is very frequent (70%), usually severe and explained mostly by vasoconstriction of the glomerular afferent arteriole with secondary sodium and water retention. Material and methods: In a retrospective study, we have analyzed 294 consecutive recipients receiving a first renal cadaveric allograft and all treated with CsA (the majority with triple therapy). We studied, by molecular biology, the polymorphism of genes previously implicated in essential HT such as: angiotensin-converting enzyme (ACE: II, ID and DD), angiotensinogen (AGT: MM, MT and TT), angiotensin II type 1 receptor (AT1-R: AA, AC and CC) and endothelial constitutive nitric oxide synthase (ecNOS: aa, ab and bb), and correlated the data to the prevalence and severity of post-Tx HT. This cohort included 195 (66%) males and 99 females with a mean age of 42 years at time of Tx. The presence and severity of post-Tx HT were indicated by initial persistent blood pressure over 140/90 mmHg with the need for at least one anti-hypertensive drug and by the number of anti-HT medications required to achieve its control. Results: The distribution of the specific alleles and genotypes for ACE, AGT, AT1-R, and ecNOS was not different in transplant recipients compared to 181 controls. At 5 years post-Tx, the prevalence of HT was 72% (169 out of 235) among functioning grafts. There was no significant difference for ACE, AGT, AT1R and ecNOS genotypes distribution between hypertensive vs non-HT recipients. The number of anti-hypertensive drugs prescribed was not different among ACE, AGT, and AT1-R genotypes. However, the a allele and the non-bb genotype (aa + ab) for ecNOS were significantly (p = 0.001) associated with a less severe HT, needing fewer anti-HT drugs. At 10 years post-Tx, the HT prevalence remained high 78% (67 out of 86) among functioning Tx. However, the limited numbers did not allow further correlation. Conclusions: This study produced mainly negative results except for ecNOS-a allele, which seems to protect against severe hypertension. The explanation remains speculative but probably relates to the known cyclosporine-induced upregulation of ecNOS gene and enzyme activity.
Originals
Dyspepsia and gastroparesis in chronic renal failure: the role of Helicobacter pylori
R. Schoonjans, B. Van Vlem, W. Vandamme, N. Van Heddeghem, H. Verdievel, R. Vanholder, N. Lameire and M. De Vos
Volume 57 (2002) p. 201 - 207
Abstract
R. Schoonjans, B. Van Vlem, W. Vandamme, N. Van Heddeghem, H. Verdievel, R. Vanholder, N. Lameire and M. De Vos
1Department of Internal Medicine, Gastroenterology Division, and
2Department of Internal Medicine, Renal Division, Ghent University Hospital, Ghent, Belgium
Aims: Many patients with chronic renal failure have dyspeptic symptoms. In the present study, we assessed the Helicobacter pylori (Hp) status, dyspeptic symptoms and gastric emptying rates in uremic patients. The present study was undertaken to compare chronic renal failure patients not under dialysis therapy (predialysis), hemodialysis (HD) patients and peritoneal dialysis (PD) patients for these variables and to search for a possible causative role of Hp. Methods: We used a standardized questionnaire to assess dyspeptic symptoms. Gastric emptying rates were determined by the 13C-octanoic acid breath test. HD patients were examined outside a dialysis session, PD patients were examined with a ?full? abdomen. Specific Helicobacter pylori IgG was measured by a second-generation enzyme-linked immunosorbent assay. Results: Sixty-six HD patients, 58 predialytic patients and 28 PD patients were included. Prevalences of Hp infection were highest in HD patients (46.2%) and predialysis patients (42.3%) compared to PD patients (28.6%) (p < 0.02). On the contrary, the prevalence of dysmotility-like dyspepsia was higher in PD patients (67.9%) when compared to HD patients (33.3%) (p < 0.01) and predialytic patients (53.6%) (difference not significant). Neither dyspepsia nor delayed gastric emptying were related to the presence of Helicobacter pylori IgG antibodies. Conclusion: A positive Helicobacter status based on serology was not related to the presence of dyspepsia or gastroparesis in uremic patients, whether on dialysis therapy or not. Dyspeptic complaints as well as gastroparesis are most prevalent in patients on peritoneal dialysis. The physiopathological mechanisms and clinical impact of these findings merit further investigation.
Originals
Polycystic kidney disease at end-stage renal disease in the United States: patient characteristics and survival
K.C. Abbott and L.Y. Agodoa
Volume 57 (2002) p. 208 - 214
Abstract
K.C. Abbott and L.Y. Agodoa
1Nephrology Service, Walter Reed Army Medical Center, Washington, D.C., and Uniformed Services University of the Health Sciences, Bethesda, MD, 2NIDDK, NIH, Bethesda, MD, USA
Background: The patient
characteristics and mortality associated with autosomal dominant polycystic kidney disease
have not been characterized for a national sample of end-stage renal disease (ESRD)
patients. Methods: 375,152 patients in the United States Renal Data System were
initiated on ESRD therapy (including patients who eventually received renal transplants)
between January 1, 1992 and June 30, 1997 and analyzed in an historical cohort study of
polycystic kidney disease. Results: Of the study population, 5,799 (1.5%) had
polycystic kidney disease. In logistic regression, polycystic kidney disease was
associated with Caucasian race (odds ratio 3.31, 95% CI, 3.09 – 3.54), women (1.10,
1.04 – 1.16), receipt of renal transplant (4.15, 3.87 – 4.45), peritoneal
dialysis (vs. hemodialysis, 1.37, 1.27 – 1.49), younger age, and more recent year of
first treatment for ESRD. Use of pre-dialysis EPO but not the level of serum hemoglobin at
initiation of ESRD was significantly higher in patients with polycystic kidney disease.
Patients with polycystic kidney disease had lower mortality compared to patients with
other causes of ESRD, but patients with polycystic kidney disease had a higher adjusted
risk of mortality associated with hemodialysis (vs. peritoneal dialysis) compared to
patients with other causes of ESRD (hazard ratio 1.40, 1.13 – 1.75). Conclusions:
Hematocrit at presentation to ESRD was not significantly different in patients with
polycystic kidney disease compared with patients with other causes of ESRD. Peritoneal
dialysis is a more frequent modality than hemodialysis in patients with polycystic kidney
disease, and patients with polycystic kidney disease had an adjusted survival benefit
associated with peritoneal dialysis, compared to patients with other causes of renal
disease.
Originals
Accuracy and clinical utility of dialysis dose measurement using online ionic dialysance
K.P. Katopodis and N.A. Hoenich
Volume 57 (2002) p. 215 - 220
Abstract
K.P. Katopodis and N.A. Hoenich
1Department of Nephrology, School of Clinical Medical Sciences, Medical School, University of Newcastle upon Tyne, and Department of Renal Medicine, University Hospital of Ioannina, Greece, and 2Department of Nephrology, School of Clinical Medical Sciences, Medical School, University of Newcastle upon Tyne, Renal Research Laboratory, Renal Research Institute, New York, and Division of Nephrology and Hypertension, Beth Israel Medical Center, New York
Background: Statistical associations
between urea removal and survival have been described in a number of publications. Urea
removal during treatment may be quantified by the delivered dose of dialysis. Methods in
clinical use to measure delivered dose are retrospective and reliant on accurate blood
sampling. The new generation of single patient proportionating systems incorporate the
facility to automatically measure ionic dialysance throughout dialysis. Methods: In
a prospective study on 9 anuric patients with a stable dialysis prescription, we have
compared the agreement of the dose of dialysis determined from ionic dialysance (Dt/V)
with that derived from equilibriated Kt/V (eKt/V) and Kt/V measured by direct dialysis
quantification (Kt/VDDQ) using 2 types of hemodialysis membrane (hemophan and
low-flux polysulfone). The variability of the delivered dose over a 1-month period was
also determined. Results: Ionic dialysance was independent of membrane type. It was
comparable to that established for plasma urea water clearance for hemophan but lower for
polysulfone (p < 0.001). The mean (± SD) delivered dose of dialysis (Dt/V) was similar
for both membranes (1.18 ± 0.15 (hemophan) and 1.18 ± 0.11 (low-flux polysulfone)).
Bland Altman comparisons showed the limits of agreement between Dt/V and Kt/VDDQ
were ± 0.17 and for Dt/V compared with eKt/V ± 0.15. A 1-month measurement of Dt/V
demonstrated considerable treatment to treatment variability indicating that delivered
dose cannot be considered stable. Conclusion: The availability of online
measurement of ionic dialysance provides a step towards monitoring dialysis more closely
at the time of delivery, and its clinical application will ensure that a more constant
dialysis dose is delivered.
Originals
Lymphopenia in dialysis patients: a preliminary study indicating a possible role of apoptosis
M. Bhaskaran, R. Ranjan, H. Shah, J. Siu, R. Colvin, N. Radhakrishnan, K. Reddy, N. Franki, J.D. Wagner and P.C. Singhal
Volume 57 (2002) p. 221 - 229
Abstract
M. Bhaskaran, R. Ranjan, H. Shah, J. Siu, R. Colvin, N. Radhakrishnan, K. Reddy, N. Franki, J.D. Wagner and P.C. Singhal
Division of Kidney Diseases and Hypertension, Long Island Jewish Medical Center and North Shore University Hospital, New York, NY, USA
Lymphopenia in dialysis patients
Lymphopenia is a common finding in dialysis patients. Since infection rate and mortality associated with infection are high in dialysis patients, lymphopenia may be one of the contributing factors. In the present study, we evaluated the mechanism responsible for lymphopenia in these patients. Lymphocytes isolated from dialysis patients showed increased apoptosis (p < 0.001) when compared to lymphocytes isolated from healthy subjects (healthy subjects, 0.5 ± 0.2% vs. dialysis patients, 8.8 ± 0.7% apoptotic cells/field). Sera from dialysis patients promoted lymphocyte apoptosis in a time- and dose-dependent manner. These sera also enhanced lymphocyte DNA fragmentation into multiple integers of 180 base pairs in the form of a ladder pattern. Cellulose acetate membranes promoted T cell apoptosis when compared to polysulfone membranes and to control. Cellulose acetate dialysis membranes also appear to promote lymphocyte FasL expression. Similarly, dialysis sera enhanced T cell Fas as well as FasL expression. Neither the cellulose acetate nor polysulfone membranes could induce FasL expression on B cells. Similarly, dialysis sera failed to induce FasL expression on B cells. On the other hand, anti-FasL antibodies attenuated dialysis sera-induced apoptosis in T as well as B cells. Interestingly, dialysis serum showed a 5-fold increase in FasL content when compared with control serum. These results suggest that dialysis-associated factors can induce autocrine death in T cells but the help of activated T cells is required to induce death in B cells.
Originals
Ultrasound changes of the carpal tunnel in patients receiving long-term hemodialysis: a cross-sectional and longitudinal study
T. Takahashi, A. Kato, N. Ikegaya, T. Takita, Y. Maruyama, A. Hishida and M. Takahashi
Volume 57 (2002) p. 230 - 236
Abstract
T. Takahashi, A. Kato, N. Ikegaya, T. Takita, Y. Maruyama, A. Hishida and M. Takahashi
1Maruyama Hospital, 2First Department of Medicine and 3Orthopedics Surgery, Hamamatsu University School of Medicine and 4Shizuoka University, Hamamatsu, Shizuoka, Japan
Background: Carpal tunnel syndrome
(CTS) is one of the major problems of long-term hemodialysis (HD), but sometimes difficult
to distinguish from uremic or diabetic neuropathy by clinical symptoms. Patients and
methods: To evaluate the diagnosis of CTS more precisely, we examined the
ultrasonographic alterations of the carpal tunnel and tendons of 90 wrists from 45
patients undergoing HD for more than 5 years. We measured the thickness of the palmar
radiocarpal ligament (PRL), corresponding to the posterior wall of the carpal tunnel (CT),
and the width of the CT, and compared those values with sensory (SCV), motor conduction
velocity (MCV) of the median nerve and clinical symptoms. In addition, we longitudinally
measured CT and PRL in the same patients for 5 years, and compared ultrasonographic
changes and clinical parameters. Results: A linear positive relationship was found
between HD duration and PRL thickness (r = 0.43, p < 0.01) or CT width (r = 0.53, p
< 0.01). CT diameter was negatively correlated with MCV (r = –0.30, p < 0.01)
and SCV (r = –0.33, p < 0.04). PRL thickness was also inversely correlated with
MCV (r = –0.44, p < 0.01) and SCV (r = –0.46, p < 0.01) of the median
nerve, respectively. The wrists with clinical CTS and/or previous CTS surgery had
significantly greater CT and PRL values compared to patients without CTS (CT: 6.1 ± 0.2
vs. 8.0 ± 0.3 mm, p < 0.01; PRL: 1.9 ± 0.1 vs. 3.6 ± 0.2 mm, p < 0.01). There was
a significant increase in CT width from 6.2 ± 0.2 to 7.1 ± 0.2 mm (p < 0.01) and PRL
thickness from 2.4 ± 0.2 to 2.8 ± 0.2 mm (p < 0.01) during the 5-year observation,
respectively. PRL thickness was constantly increased at the rate of 0.4 mm during the
study. However, no significant association was found between the 5-year increases in CT
and PRL distance and age, gender, the prevalence of diabetes, or laboratory parameters
such as blood b2-microglobulin,
pentosidine and Kt/Vurea. Conclusion: Our data suggest that echographic evaluation
of the wrist tissue thickness was useful to assess the progression of CTS. Serial
measurements of the wrist by echography may be helpful to clarify the advance of
subclinical CTS in patients receiving long-term HD.
Originals
Factors associated with progression of IgA nephropathy are related to renal function – A model for estimating risk of progression in mild disease
V. Rauta, P. Finne, J. Fagerudd, K. Rosenlöf, T. Törnroth and C. Grönhagen-Riska
Volume 58 (2002) p. 85 - 94
Abstract
V. Rauta, P. Finne, J. Fagerudd, K. Rosenlöf, T. Törnroth and C. Grönhagen-Riska
Helsinki University Central Hospital, Department of Medicine,
Division of Nephrology Helsinki, Finland
Background: A number of factors are linked to the outcome of IgA nephropathy (IgAN). However, it has been difficult to compare results of studies since patient populations have varied greatly. There were 3 aims in the study reported here, namely to compare factors associated with renal outcome in IgAN patients with different levels of renal function on diagnosis; to determine factors which were independently associated with progression of renal disease in initially mild IgAN; and to create a model for the estimation of the risk of progression in individual IgAN patients with normal renal function on diagnosis. Methods: Two hundred and fifty-nine IgAN patients who had been followed on average for 9.1 (SD 4.5) after diagnosis were divided into 2 groups on the basis of renal function on diagnosis. In group 1 (98 patients), Ccr (creatinine clearance, estimated by the Cockcroft-Gault formula) was < 85 ml/min, in group 2 (161 patients) ³ 85 ml/min. Univariate analyses were used to find significant differences between progressors and non-progressors in both groups. Logistic regression analysis was used to determine factors independently associated with progression in group 2. Results: Several factors were found to be associated with outcome in both groups, such as hypertension, level of Ccr, serum cholesterol, proteinuria, and also histopathological changes. Factors associated with progression in patients with initially decreased renal function (group 1), were predictable, such as male sex, absence of episodes of macroscopic hematuria, serum urate level and degree of tubular atrophy. Surprisingly, in patients with initially normal renal function (group 2), numbers of urinary erythrocytes were associated with outcome. The factors independently associated with progression in this group were number of urinary erythrocytes, existence of hypertension and in histopathology arteriolosclerosis and the level of glomerular score. A model for estimating risk of progression on the basis of various combinations of factors found to be independently associated with outcome is presented. Conclusions: We concluded that association between variable and outcome in IgAN depends partly on renal function at the time of assessment of the factor. Since there are factors which are independently associated with the outcome of early and apparently mild disease, early diagnosis of IgAN is desirable: outcome in mild IgAN can be predicted reliably on the basis of factors found to be independently associated with outcome.
