Focal segmental glomerulosclerosis with and without nephrotic syndrome in children

The clinical presentation, initial laboratory and renal biopsy findings, and course of focal segmental glomerulosclerosis (FSGS) were studied retrospectively in 57 children in order to compare findings in those with and without nephrotic syndrome and to establish factors of prognostic significance. All patients had proteinuria. Eleven patients were otherwise asymptomatic, and nephrotic syndrome did not develop (group 1); 14 patients had asymptomatic proteinuria, but nephrotic syndrome subsequently developed (group 2); 32 patients had nephrotic syndrome (group 3). There were no differences between these three groups with regard to sex, age, initial renal function, incidence of hypertension and hematuria, and pathologic findings. At the latest follow-up, five group 1 patients, six in group 2, and 14 in group 3 had chronic renal failure; the incidence was similar for those with asymptomatic proteinuria and those with nephrotic syndrome. The location of the sclerosis within the glomerulus proved to have prognostic significance. All 12 patients with peripheral FSGS maintained normal renal function, whereas in 25 of the 44 with hilar FSGS chronic renal failure developed.

Glomerular podocyte vacuolation in focal segmental glomerulosclerosis

An electron microscopic study of the nonsclerotic glomeruli or nonsclerosed segments of affected glomeruli was made in 34 children with nephrotic syndrome and focal segmental glomerulosclerosis (FSGS) and in 34 children with minimal-change nephrotic syndrome. Particular attention was paid to alterations of glomerular epithelium. The most striking glomerular change in FSGS was vacuolation of the epithelial cell. Glomerular epithelial vacuolation was found in 21 of the 34 patients with FSGS. Eleven of these 21 patients with vacuoles developed chronic renal failure, while only one of the 13 patients without vacuoles developed renal failure. In minimal-change nephrotic syndrome only five of the 34 patients showed mild epithelial vacuolation. These observations are consistent with glomerular epithelial vacuolation contributing to the development and progression of the glomerular lesion in FSGS.

[Stimulation of pituitary-adrenocortical system by cepharanthine]

We observed that cepharanthine might exert its anti-allergic action by stimulating the secretion of corticosterone. The present experiments were carried out to investigate stimulation of the pituitary-adrenocortical system by cepharanthine. Administration of cepharanthine to rats produced increases in plasma and adrenal corticosterone levels. Administration of cepharanthine to propranolol pretreated rats also produced increases in plasma and adrenal corticosterone levels and plasma ACTH level. The elevation of corticosterone level induced by cepharanthine was considered to be the specific effect of cepharanthine. Cepharanthine did not increase plasma corticosterone level in rats in the state of dexamethasone suppression of the pituitary-adrenocortical system, in which the level was lowered. Administration of cepharanthine to Bordetella pertussis vaccine induced beta-adrenergic blocked rats also produced increases in plasma and adrenal corticosterone levels. The production and release of corticosterone from an adrenal cell suspension were not influenced by cepharanthine in vitro. These results suggest that cepharanthine stimulates the pituitary-adrenotropic function.

[Changes of lysosomal enzyme activities in experimental type I and type IV allergic models]

Experimental allergy was induced in animals: asthma, a Type I allergy, was induced in guinea pigs by sensitizing them with alpha-amylase (inhalation), and experimental allergic encephalomyelitis (EAE), a Type IV allergy, was induced in rats. Pulmonary, brain and serum lysosomal enzyme activities were measured in normal and allergic conditions. beta-Glucuronidase (beta-G) and arylsulfatase (AS) activities were determined by the fluorescent technique. During the asthmatic attack, pulmonary lysosomal enzyme activities were not different from that in the normal state in guinea pigs. However, brain lysosomal enzyme activities were elevated markedly on the 1 st day of EAE induction. Brain beta-G activity was elevated on the 2nd day, and AS activity had a tendency to be increased. On the other hand, serum lysosomal enzyme activity was not altered significantly. In the experimental allergy, lysosomal enzyme activity was altered in Type IV, but not in Type I.

Glomerular electron-dense deposits in childhood IgA nephropathy

An electron-microscopic study of the glomeruli was made on 154 children with IgA nephropathy and no evidence of systemic disease, in whom immunofluorescence microscopy had shown diffuse mesangial deposition of IgA. Mesangial deposits were observed in all but eight children. Subepithelial deposits were observed in 40 children and were almost always accompanied by both mesangial and subendothelial deposits. Subepithelial deposits were significantly associated with more severe clinical presentations, a worse outcome and more severe light microscopic glomerular changes. These observations support the concept that IgA nephropathy is an immune complex disease.

Membranous glomerulonephritis associated with hepatitis B antigen in children: a comparison with idiopathic membranous glomerulonephritis

The laboratory and pathological findings are reported for 16 children with membranous glomerulonephritis (MGN) associated with hepatitis B virus (HBV) infection and compared with those of 12 children with idiopathic MGN. Serum hepatitis B surface antigen (HBsAg) was found in all children with HBV associated MGN and serum hepatitis B e antigen (HBeAg) in 11 of the 15 examined. Five patients with HBV associated MGN, but none with idiopathic MGN, showed reduced serum C3 values. Otherwise there was no difference in laboratory findings. HBeAg was detected in the glomeruli of all 7 patients with HBV-associated MGN examined but HBsAg was not detected. Of the 14 children with HBV-associated MGN examined by electron microscopy, all but one showed small mesangial deposits and 4 subendothelial deposits, whereas of 9 with idiopathic MGN only 2 showed mesangial deposits and none subendothelial deposits. Thus most of the children with HBV-associated MGN are characterized by some laboratory and pathological features of membrano proliferative glomerulonephritis in addition to those of idiopathic MGN. These observations are consistent with HBV inducing a spectrum of glomerulopathy from typical MGN to typical membranoproliferative glomerulonephritis.

[A case of congenital mesoblastic nephroma growing with a polypoid pattern in the renal pelvis and ureter]

Congenital mesoblastic nephroma (CMN) is an unusual renal tumor, similar in some respects to Wilms' tumor and reported only in infants. We report a case of CMN in a 2-year-old boy. He was referred to us with a right abdominal mass. Excretory urogram, arteriogram and computed tomogram revealed a large malignant renal tumor on the right side. With a clinical diagnosis of Wilms' tumor of the right kidney, he received radiation and chemotherapy. After radiation and chemotherapy, tumor size was decreased. Right nephrectomy was performed on April 22, 1982. The kidney and tumor weighed 270 g and measured 12 X 7 X 5 cm. The tumor extended to the renal pelvis and the ureter with polypoid growth pattern. Microscopically, the tumor was composed of compact interlacing bundles of elongated fibromyomatous cells. Islands of entrapped glomeruli and tubules were also detected within the tumor. He was well and had no signs of recurrence of tumor at the age of 3 years.

Twenty-seven children with focal segmental glomerulosclerosis: correlation between the segmental location of the glomerular lesions and prognosis

Twenty-seven children with focal segmental glomerulosclerosis (FSGS) were studied for clinical and pathological manifestations in order to determine whether the location of the sclerotic lesions bears prognostic implications. There were 11 children with peripheral FSGS and 16 with hilar FSGS. During a mean follow-up period of 6 years, 10 of the 16 with hilar FSGS developed renal failure (GFR less than 20 ml/min/m2) but all of the 11 with peripheral FSGS maintained normal renal function. We suggest that FSGS may be divided into a hilar type with poor prognosis and a peripheral type with benign prognosis. It is conceivable that these two groups represent etiologically different entities.

The thin glomerular basement membrane in children with haematuria

To determine the specificity and significance of widespread attenuation of the glomerular basement membrane on electron microscopy, 240 renal biopsies from 218 children were studied retrospectively. Twenty-three patients showed diffuse attenuation and three of them are cases of hereditary nephritis. The other 20 patients are characterized by persistent microscopic haematuria, absence of proteinuria, normal blood pressure and renal function, and minimal glomerular changes. In 10 of these 20 children, microscopic haematuria was also present in the family. We conclude that widespread attenuation of the glomerular basement membrane is a characteristic of benign familial and non-familial haematuria. The thin glomerular basement membrane may be responsible for the haematuria and may result from incomplete glomerular maturation.

The prevalence of diabetic autonomic neuropathy indicated by abnormal R-R interval variation

The variation in R-R interval in ECG has been reported to decrease in diabetics with autonomic neuropathy. To investigate the diagnostic value of heart rate monitoring and the prevalence of diabetic autonomic neuropathy, R-R interval variations (CVs) were measured, and the relationships between CV and MCV, FCV, SCV, retinopathy, nephropathy, peripheral neuropathy, and duration of diabetes were investigated. 70 diabetics aged 19 approximately 74 were studied. A total of 100 consecutive R-R intervals on ECG were analyzed by computer. 16 patients (22.8%) of 70 had one or more symptoms of autonomic neuropathy, while the prevalence of diabetic autonomic neuropathy indicated by abnormally low CV was 41.4%. Diabetics with retinopathy, nephropathy or peripheral neuropathy had significantly lower CVs than diabetics without these complications (p less than 0.01). The correlation coefficients for CV and duration of diabetes, and CV and SCV were -0.69 and 0.57 respectively (p less than 0.01). CV (%) of R-R interval was a useful parameter for the determination of diabetic autonomic neuropathy and our results showed that autonomic nerve damage was more prevalent than were symptoms of autonomic neuropathy.

[Efficacy of chemo-endocrine therapy for recurrent breast cancer]

Recurrent breast cancer can now be treated more effectively with endocrine therapy, combined with chemotherapy. Between April 1977 and March 1982, 127 breast cancer operations were performed at Kumamoto Municipal Hospital; recurrence was found in 13 cases (approx. 10%). Treatment of 7 of these cases with endocrine therapy (mainly Nolvadex, anti-estrogen) combined with chemotherapy resulted in 6 cases showing either complete response (CR) or partial response (PR). The efficacy of chemo-endocrine therapy was obvious when compared with cases without therapy. Further studies on hormone receptors and the establishment of guidelines for chemo-endocrine therapy as post-operative adjuvant therapy are justified.

Familial hematuria; clinico-pathological correlations

The findings are reported in 38 patients with familial hematuria. In 10 of the 24 families investigated, a familial incidence of hematuria was revealed only by routine urinalysis in first-degree relatives. Where there was either neurosensory deafness of heavy proteinuria in the patient or family, or a history of chronic renal failure in the family, the patient generally ran a progressive clinical course. Light microscopy (LM) of renal biopsy specimens revealed little abnormality in young children, but segmental glomerular sclerosis was frequently observed in older patients. The most characteristic change, observed on electron microscopy (EM) in 27 out of 31 renal biopsies was complex replication of the lamina densa of the capillary basement membrane, to form a "basket weave" pattern. Families with and without deafness (groups 1 and 2) were both considered to fall within the spectrum of Alport's syndrome, although the presence of deafness adversely affected the prognosis. In contrast, patients from families showing neither deafness, heavy proteinuria nor chronic renal failure (group 3) ran a non-progressive course. Their biopsies showed little or no glomerular changes other than attenuation of the lamina densa on EM. In Alport's syndrome, deafness, heavy proteinuria, segmental sclerosis and foam cells were not often present before the age of 10 years, whereas the "basket weave" alteration of the lamina densa was found in all three children biopsied under 5 years of age. We therefore emphasize the importance of EM in the differential diagnosis from benign familial hematuria.

Microfibrils in glomerulopathies of children: an ultrastructural study

Extracellular microfibrils were found in 47 per cent. of 360 renal biopsies performed in children with a variety of nephropathies. They were observed in the mesangial matrix and basal lamina. They are 17 to 35 nm in diameter and a few show cross-striations with a periodicity of about 10 nm. They are different from fibrin or interstitial collagen. Their close association with thinner filaments in the mesangial matrix and basal lamina suggests that they are derived from such filaments.

Ultrastructure of the non-sclerotic glomeruli in childhood nephrotic syndrome

An electron-microscopic (EM) study of the non-sclerotic glomeruli was made in 96 children with the nephrotic syndrome in whom light microscopy had shown minimal change, focal global glomerulosclerosis or segmental glomerulosclerosis. EM showed a variety of alterations. Foot process fusion, duplication and crenation of the lamina densa, and granular and lucent expansion of lamina rara interna were noted in almost all patients in all three groups. Localised ulceration of the podocytes was noted in some patients in each group. There was no difference in the mean thickness of the glomerular basal lamina but there was an increase with age in minimal change. Curious extracellular curved striated bodies, clusters of electron-dense, round microparticles and microfilaments were found in all three, but most frequently in segmental glomerular sclerosis. Electron-dense deposits were seen in all but one of the patients with segmental glomerular sclerosis and usually involved the capillary wall. They were seen in one third of those with minimal change and focal glomerular sclerosis but rarely in the capillary wall. There were no specific features which distinguished segmental glomerular sclerosis although the various types of deposits were more extensive and more frequent than in minimal change and focal glomerular sclerosis. These observations are consistent with common pathogenetic factors operating at different intensities in segmental glomerular sclerosis, focal glomerular sclerosis and minimal change.

The glomerular basal lamina in hereditary nephritis

Characteristic ultrastructural alterations of the glomerular basal lamina have been reported in hereditary nephritis. The basal lamina is irregularly thickened and the lamina densa shows replication with a "basket weave" pattern, enclosing electron-lucent lacunae which frequently contain small dense particles. However there is controversy regarding the specificity of this lesion in hereditary nephritis. To determine the specificity, 366 renal biopsies from 310 children were studied retrospectively. Twenty-four out of 27 patients with hereditary nephritis showed the characteristic changes of the basal lamina and they were widespread in 17. Two patients with recurrent haematuria but no family history of deafness or haematuria showed similar extensive changes and are regarded as new mutant cases of hereditary nephritis. Similar changes were seen in 17 of the 281 patients with other conditions but were always localized to a few capillary loops. We conclude that a widespread "basket weave" pattern appears to be confined to hereditary nephritis and is seen in the great majority of such cases.

Prognostic significance of the glomerular changes in Henoch-Schoenlein nephritis

Eighty-three children with Henoch-Schoenlein nephritis were studied to establish the prognostic significance of the glomerular changes. After a mean follow-up period of 6 years, 44 patients had no demonstrable abnormality, 21 had minor urinary abnormalities, 8 had heavy proteinuria and/or hypertension, and 10 had either died or developed chronic renal failure. Patients presenting with hypertension and/or acute renal insufficiency were more likely to develop chronic renal failure than those with milder presentations. A poor outcome was found to correlate with (1) crescents and segmental lesions affecting a high proportion of glomeruli, (2) the presence of subepithelial electron-dense deposits and (3) the finding of extracellular "lead shot" microparticles. While the clinical presentation is not a good means of predicting the outcome, an acute nephritic onset nevertheless appears to be the best available indication for renal biopsy, which should include both light and electron microscopy in order to increase the precision of prognostication.

Curved striated and round bodies in glomerulopathies of children; an ultrastructural study

Extracellular curved striated bodies and round bodies were found in 62 and 41 per cent, respectively of 360 renal biopsies performed in children with a variety of nephropathies. They were observed in the basal lamina and mesangial matrix. The fact that they commonly occurred together appears to suggest a common aetiology and they are probably derived from altered protein of the basal lamina and mesangial matrix, or from proteins of immune deposits.

Glomerular morphometry I: nephrotic syndrome in childhood

Glomerular morphometry was performed on needle biopsy specimens from 53 children with the nephrotic syndrome with minimal change (MC), focal global glomerulosclerosis (FGS) and segmental glomerulosclerosis (SGS). There were significantly fewer epithelial cells and more mesangial cells in SGS compared with MC and FGS. The number of epithelial cells decreased with age in MC and FGS, but was constantly low at all ages in SGS. There were no significant differences in differential cellularity between MC, with or without focal glomerular obsolescence or focal tubular atrophy, and FGS. Glomerular diameter increased with age in MC and FGS, but not in SGS. These findings support the view that SGS is a distinct entity rather than a variant of MC.

Glomerular morphometry II: familial and nonfamilial haematuria

Differential glomerular cell counts and measurements of glomerular diameter were made in 13 children with Alport's syndrome (AS), four with benign familial haematuria (BFH) and 15 with nonfamilial haematuria (NFH). Mesangial cellularity was increased in the six cases of NFH with diffuse mesangial deposits of IgA (IgA +). In AS, IgA + and -NFH, epithelial cellularity decreased with age while glomerular diameter increased. In AS mesangial and endothelial cellularity also decreased with age. These findings support the view that AS, IgA + and -NFH are three distinct entities. BFH, although similar in several respects to IgA -NFH, should nevertheless be retained as a separate category by virtue of its familial incidence of haematuria.