Showing papers in "Clinical Nephrology in 1989"

Atherosclerotic renovascular disease causing renal impairment--a case for treatment.

Abstract: Renovascular disease is a potentially curable cause of renal failure. In a prospective survey over an eighteen month period atherosclerotic renal artery disease was the cause of renal failure in 14% of patients over the age of fifty years accepted for renal replacement therapy at this hospital. Ten patients were found to be suffering from atherosclerotic renovascular disease causing renal failure but in only one was treatment able to reverse renal failure. The major problem with this group of patients is the widespread nature of their disease affecting many other organs. Significant morbidity is associated with their investigation. Although potentially curable, atherosclerotic renovascular disease is a frequent cause of renal failure in patients over the age of fifty years but is also difficult to treat.

Long-term prognosis of chronic idiopathic membranous glomerulonephritis. An analysis of 334 cases with particular regard to tubulo-interstitial changes.

Abstract: A retrospective long-term study (average follow-up time 5.2 years) of 334 patients with idiopathic membranous glomerulonephritis (MGN) was carried out with the following results: 1) MGN was found to have a relatively good prognosis when all cases were considered together: 5-year kidney survival rate (KSR) -88%, and 10-year KSR -77%. 2) Univariate survivorship analysis showed the following morphological and clinical parameters to be associated with an increased risk of terminal renal insufficiency or death from renal disease: a) tubulo-interstitial changes; b) glomerular stage III as opposed to stages I and II; c) elevation of serum creatinine concentration at the time of the biopsy; d) arterial hypertension at the time of the biopsy. 3) Multivariate analysis showed that only tubulo-interstitial changes (interstitial fibrosis and/or acute renal failure) found at the time of the biopsy and their clinical correlate, serum creatinine concentration, were significant and therefore of definite prognostic importance. 4) Unsystematic therapy with steroids and/or cytostatic agents does not improve the long-term prognosis of MGN. 5) The cause of disease in the tubulo-interstitial system in MGN is discussed. Interstitial fibrosis is considered to develop possibly as a consequence of unresorbed interstitial edema which can develop during an episode of acute renal failure. Coexisting T-cell-mediated disease in the region of the intertubular capillaries is also considered as a possible factor in the development of interstitial fibrosis.

Treatment of IgA nephropathy with eicosapentanoic acid (EPA): a two-year prospective trial.

Abstract: Thirty-seven patients with biopsy proven mesangial IgA nephropathy were prospectively allocated to either two years of treatment with eicosapentanoic acid (EPA) 10 g per day or no treatment. At entry treated and untreated patients with renal dysfunction (Group A) or patients with normal serum creatinine less than 0.12 mmol/l (Group B) did not differ in serum creatinine, creatinine clearance, urinary protein excretion, or quantitative urinary red cell counts. Compliance with EPA therapy was excellent as assessed by plasma fatty acid profiles. At the end of the trial creatinine clearance in treated patients had gone from 80 +/- 16 to 57 +/- 17 ml/min (p less than 0.05) and in untreated patients from 76 +/- 18 to 55 +/- 14 (p less than 0.05). There were no beneficial effects in either Group A or Group B patients. The only two patients who had improvement in renal function were in the EPA treatment group. Although no side effects of treatment were noted, EPA does not alter the course of established mesangial IgA nephropathy.

Improved sexual function in hemodialysis patients on recombinant erythropoietin: a possible role for prolactin.

Abstract: As it was reported that correction of anemia in long-term hemodialysis patients by recombinant human erythropoietin (r-HuEPO) is associated with improved sexual function, we conducted the present study to further delineate the mechanism(s) by which this is brought about. Serum prolactin, testosterone, and parathyroid hormone (PTH) levels were followed during 4 months of r-HuEPO therapy. Within 4 months of treatment with r-HuEPO, hematocrit values rose from 23.7 +/- 1.2 to 35.7 +/- 0.2% and hemoglobin increased from 7.3 +/- 0.3 to 11.3 +/- 0.4 g/100 ml. In parallel, serum prolactin values decreased significantly from 66.9 +/- 9.3 to 9.6 +/- 2.6 ng/ml in females and from 39.5 +/- 10.5 to 10.3 +/- 1.0 ng/ml in male dialysis patients. Testosterone concentrations were low in male patients and remained unchanged during r-HuEPO therapy. Baseline PTH values were elevated (1,880 +/- 220 pg/ml) in patients of both sexes and declined to 1,410 +/- 180 pg/ml during treatment with r-HuEPO. However, this difference did not reach statistical significance. Sexual function improved in 4 out of 7 males and 5 out of 9 female patients began to menstruate regularly again. It appears that treatment of anemia in end-stage renal disease by r-HuEPO improves sexual function via normalization of elevated serum prolactin concentrations.

Echocardiographic findings in patients on maintenance hemodialysis substituted with recombinant human erythropoietin.

Abstract: Cardiomegaly and impaired myocardial function are frequent in patients on maintenance hemodialysis. One important reason is probably severe renal anemia. Substitution with recombinant human erythropoietin (rhEPO) results in long-term correction of renal anemia. We investigated the changes in cardiac function under rhEPO therapy using echocardiography. 13 patients with severe renal anemia (hct less than 26%) but independent of regular blood transfusions during the last six months were treated with 40-120 IU/kg rhEPO intravenously three times/week. Echocardiographic studies were performed in the anemic state and when hematocrit values were stable at levels above 30%. Left ventricular end-diastolic diameter (LVEDD) and end-systolic diameter (LVESD) were reduced (LVEDD: 53.9 +/- 4.2 mm vs. 51.4 +/- 5.8 mm; LVESD: 35.7 +/- 5 mm vs. 32.8 +/- 5 mm). Mean end-diastolic volume (LVEDV) and end-systolic volume (LVESV) were also diminished (LVEDV: 141.9 +/- 25.4 ml vs. 128.1 +/- 32.5 ml; LVESV: 54.8 +/- 18.6 ml vs. 45.1 +/- 17 ml). Stroke volume (SV) fell slightly from 87.1 ml to 83 ml resulting in a decrease of cardiac output (CO) from 6.9 +/- 1.6 l/min to 6.2 +/- 1.7 l/min. The thickness of the left ventricular posterior wall (LVPW) and of the septum interventriculare (IVS) remained constant. Myocardial contractility indicated by ejection fraction (EF), fractional shortening (FS) and the velocity of circumferential fiber shortening (VCF) frequently improved. Our data indicate that correction of renal anemia by rhEPO can improve myocardial function in patients on maintenance hemodialysis.

Long-term outcome of Schönlein-Henoch nephritis in the adult.

Abstract: Sixteen adult patients with Schonlein-Henoch nephritis, selected by strict inclusion criteria, were studied retrospectively. At the time of discovery of the nephropathy, 11 patients had normal plasma creatinine and 5 other patients had renal insufficiency. All patients had renal biopsies, which were studied by both light and immunofluorescence microscopy. After a mean follow-up of 90.5 +/- 59.1 months (range 16-261), 3 patients were in chronic dialysis (18.7%), 8 other patients had renal function deterioration (50%), with creatinine clearance ranging from 31 to 60 ml/min. Four other patients had mild urinary abnormalities with normal plasma creatinine (25%) and only 1 patient was in complete clinical remission (6%). No clinical features at onset were predictive for the clinical outcome of the disease, while in the biopsies the percentage of crescents was higher in patients who developed renal insufficiency. High IgA serum levels were correlated (p = 0.0242) with a favorable course. It is concluded that Schonlein-Henoch nephritis of the adult carries a high long-term risk of renal dysfunction.

Sequential development of systemic vasculitis with anti-neutrophil cytoplasmic antibodies complicating anti-glomerular basement membrane disease

Abstract: Anti-neutrophil cytoplasmic antibodies (cANCA) were detected in 3 patients with anti-glomerular basement membrane (anti-GBM) disease. All 3 cases presented late in their clinical course, with severe renal involvement and alveolar hemorrhage. Anti-neutrophil cytoplasmic antibodies were associated with clinical features outwith the lungs and kidneys; in one case cANCA were initially absent but subsequently developed concurrently with the clinical appearance of systemic vasculitis as the anti-GBM antibody titer was falling. These findings confirm that cANCA can complicate anti-GBM disease and suggest that cANCA may identify a distinct subset of patients with anti-GBM disease, supporting a pathogenic role for cANCA in the development of systemic vasculitis.

Staphylococcus aureus skin carriage and development of peritonitis in patients on continuous ambulatory peritoneal dialysis.

Abstract: We conducted a 15-month prospective study to investigate the skin carriage of Staphylococcus aureus and the development of peritonitis in 43 patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Sixteen of 43 patients (37%) were chronic carriers of S. aureus in the anterior nares and/or in the exit-site of the catheter; 12 patients (28%) were intermittent carriers, and 15 (35%) were noncarriers. Fifty episodes of peritonitis occurred during a total of 422 patient-months of observation. S. aureus was responsible for 16 episodes of peritonitis diagnosed in 15 patients. All episodes of S. aureus peritonitis occurred in chronic and intermittent carriers. Phage typing was performed on isolates from 8 patients with S. aureus peritonitis, and they were found to have the same phage type as that previously carried in the skin. We conclude that CAPD patients who are chronic or intermittent carriers of S. aureus are at higher risk of development of peritonitis than noncarriers.

The acute effect of growth hormone on GFR is obliterated in chronic renal failure.

Abstract: Recombinant human growth hormone (rhGH) has become available for treatment of growth failure in uremic children. Since GH raises the glomerular filtration rate (GFR) in healthy individuals, there has been concern that treatment with rhGH, by its action on glomerular hemodynamics, may adversely affect the progression of renal failure. To further address this issue, inulin clearance (enzymatic steady-state infusion technique) was measured in 7 healthy normotensive adult volunteers and 7 patients with chronic renal failure from glomerular or non-glomerular causes. Subjects were given 4.5 U bid of rhGH by s.c. injection for 3 days. In volunteers, a significant increase in Cin was noted 72 h after start of rhGH administration from 120 ml/min/1.73 m2 (range 91-158) to 133 (108-167) (p less than 0.02). In contrast, no significant increase in Cin was noted in patients with chronic renal failure (baseline Cin 21 ml/min/1.73 m2, 15-32; after rhGH 22 ml/min/1.73 m2, 15-32) despite pronounced effects of GH on S-cholesterol and urea excretion rate. The results show that stimulation of GFR by short-term administration of rhGH is obliterated in chronic renal failure.

Severe pulmonary hemorrhage and systemic vasculitis in association with circulating anti-neutrophil cytoplasm antibodies of IgM class only.

Abstract: We report an association of severe pulmonary hemorrhage with circulating autoantibodies to neutrophil cytoplasmic antigens (ANCA) restricted to IgM class in three patients with systemic vasculitis. ANCA were detected by indirect immunofluorescence and isotype specific solid phase radioimmunoassay (SPRIA). Institution of immunosuppressive therapy was accompanied by an isotype switch to IgG ANCA and recovery in all three patients. In an associated study, ANCA activity was found in eluates from the washed glomeruli of two postmortem cases, with the same isotype distribution as was present in the sera.

Acute renal failure secondary to oral ciprofloxacin therapy: a presentation of three cases and a review of the literature.

Abstract: The fluoroquinolones represent a new class of antimicrobial agents with a broad spectrum of activity. We report three cases of acute renal failure following ciprofloxacin in patients without a previous history of renal insufficiency. The average baseline creatinine was 1.1 mg/dl and rose to an average of 4.0 mg/dl during therapy. The length of antecedent ciprofloxacin therapy ranged from several days to several weeks. Other causes of acute renal failure and postobstructive uropathy were excluded. Kidney size was normal-to-increased. Gallium scans were positive in one of two patients studied. Peripheral eosinophilia developed in one case, suggesting an acute hypersensitivity reaction to the drug. The acute renal failure in all cases was non-oliguric and was completely reversed after discontinuation of ciprofloxacin. In two of the three reported cases there was an increased creatinine to BUN ratio, but increased production of creatinine (i.e., rhabdomyolysis) was unlikely with a normal serum creatinine phosphokinase (CPK). In addition, we performed in vitro studies which eliminated the possibility of methodological artifact. The nephrotoxicity of the quinolones has been linked to the development of crystalluria in experimental animals. However, in humans, crystalluria is unlikely and renal damage has not been noted. There have been only two previous case reports of acute renal failure due to oral ciprofloxacin therapy. In one, biopsy showed acute interstitial nephritis. We conclude that oral ciprofloxacin therapy may lead to acute renal failure secondary to tubulointerstitial nephritis characterized by an increased creatinine to BUN ratio. Patients placed on ciprofloxacin therapy need to be followed closely.

Pregnancy-related acute renal failure.

Abstract: From 1958 to 1987, 81 cases of pregnancy-related acute renal failure (PR-ARF) were observed (9% of the total number of acute renal failure [ARF] needing dialysis). In the three successive ten-year periods (1958-67, 1968-77, 1978-87) the incidence of PR-ARF fell from 43% to 2.8% with respect to the total number of ARF, and from 1/3,000 to 1/15,000 with respect to the total number of pregnancies. Maternal mortality was high (32%), with 5 cases of death in the last ten years. Irreversible renal damage was recorded in 11.6% of PR-ARF, and, in particular, in 26.3% of cases in preeclampsia-eclampsia (PE-E). Worse maternal and renal prognosis occurred in PE-E complicated by abruptio placentae. Neither disseminated intravascular coagulation (DIC), microangiopathic hemolytic anemia nor prostacyclin imbalance were significantly related to the severity of renal damage. Heparin therapy did not modify DIC evolution and renal outcome and was aggravated by severe hemorrhagic complications. In conclusion, PR-ARF has become a rare, but still critical occurrence, and the most effective measures would be a program of careful prevention.

Glucose intolerance in uremic patients: the relative contributions of impaired beta-cell function and insulin resistance.

Abstract: Glucose tolerance and tissue sensitivity to insulin were examined in 19 renal failure patients on chronic regular hemodialysis (group U) and in 6 matched control subjects with normal renal function (group A). Based on glucose tolerance as assessed by an oral glucose tolerance test (OGTT), glucose tolerance was normal in 5 (group U:N), borderline in 5 (group U:BL) and decreased in 9 uremic subjects (group U:D). Compared with group A the uremics demonstrated significantly (p less than 0.01) impaired insulin sensitivity as assessed by a continuous mixed infusion of somatostatin, insulin and glucose (SIGIT). In addition 19 non-diabetic subjects with normal fasting blood glucose and normal renal function, matching the uremic patients with respect to glucose tolerance as assessed by OGTT, were studied (group B). In group B impairments in both insulin secretion and insulin sensitivity tended to be more pronounced in subjects with decreased OGTT as compared with those with borderline OGTT. In contrast, insulin resistance was present to a similar degree in uremic subjects of group U:N, U:BL and U:D. During SIGIT endogenous insulin, glucagon and growth hormone (GH) were suppressed in both uremic and control subjects. This implies that insulin resistance in uremia is most likely not due to hyperglucagonemia or abnormal GH metabolism. During OGTT subjects of group U:N had significantly higher insulin response than subjects of group U:BL (p less than 0.02) and group U:D (p less than 0.01). Insulinogenic index was significantly higher in group U:N than in group U:BL (p less than 0.02) and group U:D (p = 0.01) and was higher in group U:BL than in group U:D (p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of renal transplantation on the radiological signs of dialysis amyloid osteoarthropathy.

Abstract: We have assessed the fate of amyloid bone cysts after a successful renal transplantation in 5 patients who had been on dialysis for 7 to 15 years. The size of 34 cysts, typical of amyloid osteoarthropathy, was monitored on annual X-rays for 29 to 75 (mean 47) months after TP. In sharp contrast to their progression during dialysis, cysts did not increase in size and no new cysts appeared during follow-up. However, despite a successful graft, none of the 34 cysts regressed significantly. The stability of the bone cysts may reflect either the poor solubility of the beta 2-m amyloid deposits or the limited accessibility of bone deposits to lytic factors. A longer follow-up will perhaps be necessary to document a significant regression of the cysts. Strikingly, transplantation resulted within a few days in an almost complete relief of articular complaints; in the absence of evidence of amyloid regression, this probably reflects the anti-inflammatory effect of steroids.

Continuous arteriovenous hemofiltration in the treatment of 100 critically ill patients with acute renal failure: report on clinical outcome and nutritional aspects.

Abstract: The clinical outcome for 100 consecutive patients with multiorgan failure including acute renal failure (ARF) was studied. Fifty-eight of the patients had acute renal failure due to complications during and after major surgery. Seventy-three of the patients had a urine output of less than 400 ml/24 hours. The majority of the patients also had complications such as septicemia or respiratory insufficiency and required vasopressor infusions. All patients were treated with continuous arteriovenous hemofiltration (CAVH). The duration of the CAVH treatment varied between a few hours and 90 days, with a mean of 8 days. The mean ultrafiltration volume per 24 hours was, on the average, 12 liters. CAVH resulted in adequate uremic control in 89 cases, but additional treatment with intermittent hemofiltration was necessary in 11 patients. The total survival rate was 45% including survival rates as high as 54% in patients with ARF complicating abdominal aortic surgery. Only three patients were referred for chronic dialysis therapy. In a subgroup of 17 patients with ARF complicating abdominal aortic surgery the nutritional aspects during CAVH were studied. It is concluded that during CAVH therapy it is possible to give adequate nutritional support even to hypercatabolic and anuric patients.

Thin membrane nephropathy: a clinico-pathological study.

Abstract: Thin membrane nephropathy is common, representing approximately 11% of non-transplant renal biopsies. A family history of renal disease is present in at least 40% of patients. Electron microscopy is essential for its diagnosis. There are no immunofluorescence markers but light microscopic changes, usually mild, are invariably present and predict the ultrastructural findings although there is no correlation with their degree. The extent of the morphological changes bears no obvious relationship either to clinical or familial features. Immunogold studies indicate that there is reduction or loss of the subepithelial portion of the basement membrane, which apparently contains normal amounts of type IV collagen. Unnecessary urological investigations may be avoided by awareness of the condition and microscopic examination of urine for dysmorphic red blood cells. Prospective long-term studies are necessary to determine the nature and consequences of the condition.

Nephrotic syndrome associated with chronic lymphocytic leukemia: an immunological and pathological study.

Abstract: Three patients with B chronic lymphocytic leukemia and the nephrotic syndrome had atypical membranous glomerulonephritis or lobular membranoproliferative glomerulonephritis with subepithelial and subendothelial deposits containing IgG1 kappa, IgG1 lambda or IgM and IgG by immunofluorescence, respectively. A monoclonal cryoglobulin was intermittently found in the serum in one case. In two patients, kidney deposits were made of organized microtubular structures. Intracytoplasmic immunoglobulin inclusions in the two patients' lymphocytes showed a very similar electron microscopic pattern. The immunologic phenotype of leukemic lymphocytes was analogous in the three cases (with expression of CD2) and suggestive of a late maturation step. A complete remission of the nephrotic syndrome was observed after therapy with chlorambucil (and prednisone). These observations suggest a direct role of monoclonal immunoglobulins in kidney disease.

Irreversible ocular toxicity from single "challenge" dose of deferoxamine.

Abstract: Deferoxamine is a chelating agent used in the treatment of transfusional iron overload and more recently in the diagnosis and treatment of increased aluminum body stores in chronic renal failure patients. High dose chronic and short-term treatment has been associated with ocular toxicity. We present a case of irreversible visual loss that occurred with a single small "challenge" dose of deferoxamine.

Spontaneous rupture of the quadriceps tendon in patients on maintenance hemodialysis--report of three cases with clinicopathological observations.

Abstract: Three patients receiving maintenance hemodialysis therapy for end-stage renal failure presented with spontaneous rupture of the quadriceps tendon(s). Biochemical data and the skeletal roentgenograms were compatible with secondary hyperparathyroidism. Histological examination of the excised quadriceps tendon specimens suggested that repeated minor avulsion fractures of the bone cortex at the tendon insertion site had preceded the final total tendon rupture and that osteitis fibrosa was responsible for these minor fractures. Serum alkaline phosphatase level had been increasing continuously for approximately five years prior to the tendon rupture in all three patients, indicating that uncontrolled osteitis fibrosa due to secondary hyperparathyroidism over these years preceded the tendon rupture.

Idiopathic acute interstitial nephritis associated with anterior uveitis in adults.

Abstract: Concomitant renal and ocular lesions have been described in a few systemic diseases. The association of acute interstitial nephritis (AIN) and anterior uveitis without determined cause was first described in children. Recently, the same clinical association has been reported in adults. We report 3 cases of this association and present a review of the literature. Including our 3 patients, 7 cases of this association have been reported in adults. All patients were females aged 27-74 years. Initial symptoms were either ocular, or pseudoviral (fever, myalgia and fatigue). Histological renal studies revealed acute interstitial nephritis with tubular lesions. Immunofluorescence and electron microscopy were not contributive. Ocular prognosis was always good. In 5 patients, the evolution of renal function was excellent with complete resolution of acute renal failure within a few weeks. Chronic renal failure developed in two of the four patients who did not receive systemic steroid therapy (with evolution towards terminal renal failure in one patient). Three of the patients received 60 mg per day of prednisone and none of them developed chronic renal failure. Despite the small number of patients reported and the possibility of spontaneous regression, these data suggest a beneficial effect of systemic steroid therapy to prevent or reduce interstitial inflammation and subsequent fibrosis.

Energy expenditure in postoperative multiple organ failure with acute renal failure.

Abstract: The provision of an adequate energy supply is of particular importance in patients sustaining long periods of multiple organ failure (MOF). Energy expenditure (EE) and hypermetabolism (measured EE expressed as percent above predicted basal metabolic rate) were investigated in 22 artificially ventilated patients with MOF during the second to fourth postoperative weeks. Eleven of these patients had severe acute renal failure (ARF) necessitating extracorporeal renal replacement therapy, whereas eleven patients had normal or only moderately impaired renal function (serum creatinine less than 200 mumol/l). The average EE in all patients was 124 +/- 17 (SD) kJ/kg x 24 h and the average hypermetabolism was 35 +/- 12%. Patients with MOF including ARF had significantly (p less than 0.01) lower EE (114 +/- 12 kJ/kg x 24 h) and hypermetabolism (28 +/- 7%) than patients with normal or only moderately impaired renal function (133 +/- 17 kJ/kg x 24 h and 42 +/- 12%, respectively). The results confirm that patients with MOF have only a moderate hypermetabolism and indicate that hypermetabolism is even less pronounced in MOF patients with ARF. The results suggest that the presence of ARF in MOF is associated with a more extensive reduction in aerobic metabolism than may be attributed to the loss of renal function. The marked interindividual variation in EE emphasizes the importance of EE monitoring as a guideline for nutritional support.

Red blood cell destruction in single-needle dialysis

Abstract: A high incidence of hemolytic episodes has been documented by increased lacticodeshydrogenase levels after dialysis. When symptomatic, these episodes presented frequently with nausea and abdominal or back pain occurring typically in the last hour of the dialysis session. A prospective study, comparing two different access devices (needle and catheter) and three double-pump systems, demonstrated the critical role of the access device configuration. In addition, the neccessity to monitor the pressures in the arterial and venous lines when working with high blood flow rates is also stressed. By comparison, red blood cell destruction is negligible in conventional double-needle dialysis.

Baroreceptor, not left ventricular, dysfunction is the cause of hemodialysis hypotension.

Abstract: Many patients with chronic renal failure experience profound hypotension during hemodialysis. This has been attributed both to autonomic and ventricular dysfunction. In an attempt to distinguish which, if either, is important in this role, we assessed both autonomic and left ventricular function in 10 such patients. Cardioactive medication was stopped 24 hours prior to the investigations. Autonomic function was assessed from day/night blood pressure and heart rate variation and from the hemodynamic response to tilting and the Valsalva maneuver using an intra-arterial ambulatory monitoring technique. Left ventricular function was assessed scintigraphically both before and during hemodialysis. Day/night variation was significantly reduced in the patients with chronic renal failure (BP 13/7 +/- 8/6 mmHg, HR 5 +/- 4) compared with a control population (BP 36/28 +/- 10/5 mmHg, HR 19 +/- 6). Nine patients had a "square wave" response to the Valsalva maneuver. Both of these abnormalities are usually seen in patients with heart failure and are attributed to volume overload and a consequent failure of baroreceptor response. Blood pressure fell during hemodialysis (mean fall 40/22 +/- 20/10 mmHg) in all patients, but heart rate did not change (-2 +/- 16) despite the hypotension. All patients had a normal or high resting ejection fraction (mean 66%, range 55-79%), and there was no change during dialysis. This indicates that the hypotension was not due to left ventricular dysfunction in this group of patients, but to a failure of the baroreceptor response to volume depletion during hemodialysis.

Postprandial alterations in arterial pressure control during hemodialysis in uremic patients.

Abstract: To test the hypothesis that eating may adversely affect the hemodynamic response to ultrafiltration-dialysis, we studied the effect of a standard snack (about 400 Kcal) in 13 patients on RDT. Each patient was studied in random order during two standard hemodialysis sessions (snack-HD and control-HD) performed at identical UF rate. Arterial pressure fell significantly (p less than 0.01) during both the Control-HD (from 135 +/- 8/76 +/- 3 to 121 +/- 10/68 +/- 5 mmHg) and the Snack-HD (from 137 +/- 7/77 +/- 3 to 105 +/- 8/59 +/- 4 mmHg). The rate of fall, however, was significantly higher (p less than 0.01) after the snack than during the corresponding period in the control HD. Consequently, there were more hypotensive episodes requiring saline infusion during Snack-HD (23 in 10 patients) than during Control-HD (12 in 6 patients) (p less than 0.025). In spite of the greater number of interventions, the average fall in arterial pressure after a snack (-22 +/- 3/-13 +/- 2 mmHg) was more marked than during the corresponding period in the control-HD (-13 +/- 3/-9 +/- 2 mmHg). The hypotensive effect of snack was more pronounced in the presence of advanced autonomic neuropathy. Food ingestion impairs the arterial pressure response to UF in patients on RDT. Fasting during hemodialysis may in part prevent hypotension.

Clinical and laboratory features of patients with chronic renal disease at the start of dialysis.

Abstract: We examined clinical and laboratory features retrospectively in 402 patients at the start of chronic hemodialysis in order to define better the "uremic syndrome" in the dialysis era. The information gathered included demographic data, renal diagnoses, uremic symptoms, biochemical values, and prevalences of hypertension (69%), diabetes mellitus (23%) and ischemic heart disease (16%). Unexpected findings were the wide ranges of serum creatinine levels (3.5 to 35 mg/dl) and blood urea nitrogen levels (35 to 345 mg/dl), and the frequency of hyponatremia (27%), hypoalbuminemia (52%), and anion gaps above 25 mg/dl (5%). There were higher hematocrits in males and diabetics, lower serum creatinine levels in females, diabetics and older patients, and lower blood urea nitrogen levels in blacks. The time interval from diagnosis of diabetes mellitus to initiation of dialysis in patients with diabetic nephropathy due to juvenile-onset diabetes mellitus (20.6 +/- 6.8 years) was twice that in adult onset diabetes mellitus (10.3 +/- 8.3 years).

Hemodynamics of patients with renal failure treated with recombinant human erythropoietin.

Abstract: Hemodynamics were evaluated in 8 patients with uncomplicated renal failure on regular dialysis before and after partial correction of anemia by treatment with recombinant human erythropoietin (r-huEPO). Under r-huEPO treatment, mean (+/- SD) hemoglobin increased from 7.51 (0.60) to 10.27 (0.92) g/dl. Mean blood pressure, body weight, total blood volume and extracellular fluid compartment remained unchanged. Cardiac output as measured with a radionuclide method increased significantly from 4622 (1069) to 5393 (1285) units (p less than 0.02) and peripheral resistance decreased from 22 (4) to 19 (3) units (p less than 0.02). 6-keto-1-alpha-prostaglandin decreased from 96.9 (54.4) to 61.6 (18.0) pg/ml (p less than 0.05) but plasma renin activity, noradrenalin and atrial natriuretic peptide remained unchanged comparing pre- and post-treatment levels. This observation suggests that an increase of red blood cell mass can improve heart function in patients undergoing regular dialysis treatment.

Idiopathic lobular glomerulonephritis (nodular mesangial sclerosis): a distinct diagnostic entity.

Abstract: Lobular glomerulonephritis is an entity first thought to have represented a primary disease of uncertain histogenesis, but more recently has generally been considered to represent a morphologic variant of membranoproliferative glomerulonephritis. We have encountered five patients who were found to have a lobular glomerulonephritis by renal biopsy, but in whom features of membranoproliferative glomerulonephritis types I, II, or III, could not be demonstrated and in whom alternate known diagnostic categories could be excluded. We suggest that lobular glomerulonephritis, or alternately, idiopathic nodular mesangial sclerosis, is an uncommon but persistent disease entity with a distinctive pathologic appearance and unknown pathogenesis.

Detection and clinical implication of anti-neutrophil cytoplasm antibodies in Wegener's granulomatosis and rapidly progressive glomerulonephritis.

Abstract: The specificity of anti-neutrophil cytoplasm antibodies (ACPA/ANCA) was investigated in patients suffering from Wegener's granulomatosis (WG), various forms of systemic diseases including vasculitides (non-WG), and different types of biopsy-proven glomerulonephritides. In particular, the diagnostic significance of ACPA/ANCA was assessed in patients affected by rapidly progressive glomerulonephritis with and without systemic manifestations. From 25 patients with active Wegener's granulomatosis 22 showed the classical diffuse finely granular cytoplasmic staining of neutrophils as did 4/31 patients with idiopathic rapidly progressive glomerulonephritis. One patient with biopsy confirmed Wegener's granulomatosis, six patients with microscopic polyarteritis and 3/31 patients with idiopathic rapidly progressive glomerulonephritis showed a focal cytoplasmic staining exhibiting a rosette-like pattern. One further patient with Wegener's granulomatosis displayed a prominent fluorescence of the outer nuclear membrane as well as a punctate-diffuse nuclear staining resembling that of granulocyte specific antibodies. Another patient with active Wegener's granulomatosis did not react in the ACPA/ANCA-test. These findings demonstrate different staining patterns of neutrophils which are related to different clinical entities within the spectrum of small vessel vasculitis. Moreover, they point out that different antigens are involved in the various types of vasculitis. In classical cases of Wegener's granulomatosis, but not in other forms of vasculitis, the titer of ACPA/ANCA showed a close relationship to the number of organs involved.

Apolipoprotein B turnover in dialysis patients: its relationship to pathogenesis of hyperlipidemia.

Abstract: Exogenously labelled Iodine-125-VLDL (very low density lipoprotein) was given intravenously to twelve dialysis patients and four normal controls. Specific activities of I-125-VLDL apoB (apolipoprotein B) and I-125-IDLapoB (intermediate density lipoprotein apolipoprotein B) were measured for forty-eight hours. Synthesis rates (flux) and fractional catabolic rates (FCRs) of VLDLapoB and IDLapoB for hyperlipidemic (n = 8), normolipidemic (n = 4) dialysis patients and controls (n = 4) were calculated. Dialysis patients had lower VLDLapoB FCRs than controls (p less than 0.05); hyperlipidemic dialysis patients had marginally raised VLDLapoB flux over normolipidemics (p = 0.0508), suggesting apoB production might play a greater role in the pathogenesis of hyperlipidemia. Hyperlipidemics had lower IDLapoB FCRs than controls (p = 0.01). IDLapoB flux was similar in all three groups. The discrepancy in VLDLapoB fluxes between hyperlipidemics and normolipidemics with similar IDLapoB fluxes suggested that VLDLapoB could be directly catabolized in hyperlipidemics. ApoB concentration was increased in VLDL, IDL of hyperlipidemics when compared with normolipidemics (p less than 0.05) and controls (p = 0.01). Hyperlipidemic VLDL plasma levels were relatively enriched with cholesterol when compared with controls, p less than 0.01, and normolipidemics, p less than 0.05. These factors might all contribute towards accelerated atherogenesis in hyperlipidemic dialysis patients.

Evidence for an HIV-related nephropathy: a clinico-pathological study.

Abstract: The existence of an HIV-related nephropathy as a distinct disease entity is controversial. We observed a high incidence of renal disease in our AIDS patients. Of 182 patients, 59 patients (32.4%) were found to have heavy proteinuria (greater than 2 g/24 h). Of these, 24 patients had slow progression of renal insufficiency and 2 patients had rapid deterioration to end stage renal disease. There was a notable absence of hypertension in these cases. The incidence of proteinuria was similar in blacks and hispanics; however 22.8% of blacks had renal insufficiency as compared to 6.9% of hispanics. There was no difference in the incidence of heavy proteinuria between intravenous drug abusers (32.3%) and nonabusers (33.3%). Renal morphology when examined showed characteristic changes, including cytomembranous structures and virus-like particles. These changes were similar in patients with heavy or light proteinuria, though they were less severe in the latter. We conclude that a HIV-related nephropathy exist and the presence of cytomembranous structures and virus-like particles in the renal tissue raises the possibility of a viral etiology for this disorder.