Diagnosis and treatment of primary hyperaldosteronism

OBJECTIVE

To characterize the clinical and laboratory features of primary aldosteronism and to evaluate which diagnostic tests can discriminate surgically curable forms of this syndrome.

DESIGN

Retrospective analysis of the following data from 82 patients with primary aldosteronism: blood pressure, serum electrolytes, urinary aldosterone and electrolytes, computed tomographic scans, plasma renin and aldosterone before and during upright posture, atrial natriuretic peptide, and adrenal vein aldosterone and cortisol. Clinical outcomes assessed after treatment included blood pressure, serum electrolytes, and plasma renin activity.

RESULTS

Drug therapy was discontinued before diagnostic tests were done in 56 of 82 patients (34 with adenomas and 22 with hyperplasia). Compared with patients with hyperplasia, those with adenomas had higher systolic (184 mm Hg and 161 mm Hg, respectively; P < 0.001) and diastolic blood pressures (112 mm Hg and 105 mm Hg; P = 0.03), lower serum potassium levels (3.0 mmol/L and 3.5 mmol/L; P < 0.001), and higher serum CO2 (P = 0.001), atrial natriuretic peptide (P = 0.008), and urinary 18-methyl oxygenated cortisol metabolite levels (P = 0.02). In patients with adenomas, aldosterone secretion lateralized to one adrenal gland and did not increase during the postural stimulation test; preoperative urinary aldosterone levels were correlated with diastolic pressures (r = 0.58; P = 0.001). Hypertension was "cured" postoperatively in approximately 35% of patients with adenomas and those with hyperplasia (P > 0.2) but was "improved" more frequently in those with adenomas (P = 0.002). Cured patients from both groups were younger than those not cured (mean ages, 43 years and 54 years, respectively; P = 0.002) and had lower preoperative mean plasma renin activity (0.17 ng/mL per hour and 0.50 ng/mL per hour; P < 0.001). All patients with adenomas in whom aldosterone secretion lateralized were either cured or improved.

CONCLUSION

Of the 51 patients with primary aldosteronism who had adrenalectomy (43 patients with adenomas and 8 with hyperplasia), those most likely to be cured were younger and had lower plasma renin activity. In patients with adenomas who were cured or improved, aldosterone secretion was more likely to lateralize. Tests that distinguished adenomas from adrenal hyperplasia included the postural stimulation test, urinary excretion rates of 18-oxocortisol and 18-hydroxycortisol, and adrenal vein sampling.

Testicular dysfunction in systemic disease

The testis is the most accessible endocrine organ to clinical examination and is highly responsive to environmental factors, including systemic illness. The clinical management of any disorder warrants consideration of the effects of illness and its treatment of male reproductive function. Testicular physiology and clinical evaluation are reviewed, as are the mechanisms of reproductive disruption by systemic disease. Specific diseases and disorders, including renal, liver, respiratory, neurologic, and gastrointestinal diseases, and their effects on the testes are discussed also.

Calcium-channel entry blocker therapy for hypertensive patients with concomitant renal impairment: a focus on isradipine

In the treatment of hypertension in renally impaired patients, normalization of blood pressure alone may not be sufficient to prevent significant morbidity to the kidneys. Treatment must reduce pressure in the renal vasculature, otherwise glomerular filtration rate and renal plasma flow will continue to deteriorate. Isradipine a dihydropyridine calcium-channel blocker, has been investigated as a suitable treatment in this setting. Isradipine maintains glomerular filtration rate, preserves or enhances renal plasma flow, decreases renal vascular resistance, maintains or reduces filtration fraction, and exerts a sustained natriuretic effect, all of which may enable isradipine to slow the rate of progression of renal deterioration. In addition, isradipine may decrease proteinuria and may decrease glomerular capillary pressure by dilating both the efferent and afferent arterioles. Unlike older calcium-channel blockers, isradipine exhibits minimal cardiodepressant activity and is not associated with any negative inotropic effects. It is metabolized in the liver and dosage adjustments may not be necessary when administered to patients with renal insufficiency. Isradipine has a favorable renal effect profile and also has several properties that meet the requirements of other patient populations where an extra measure of antihypertensive safety is required, such as diabetics, dialysis patients, and transplant recipients. Side effects with isradipine are usually mild and transient, occurring in a dose-dependent manner.

Hypertension in pregnancy: the incidence of underlying renal disease and essential hypertension

The objective of this study was to ascertain the likelihood of underlying renal disease or essential hypertension in women diagnosed antepartum as having pre-eclampsia. One hundred eighty-six women (antepartum diagnosis of pre-eclampsia in 87 women and gestational hypertension, also known as "mild pre-eclampsia" by other definitions, in 99 women) in whom no underlying disorder was apparent during pregnancy or the early puerperium were entered into the study. Women were reviewed between 3 and 60 months postpartum. All patients were assessed by measurement of blood pressure, urinalysis, and phase-contrast urine microscopy, and those with pre-eclampsia also had plasma urea, electrolyte, and creatinine concentrations determined and underwent renal imaging with either intravenous pyelography or ultrasound. The kidneys were also imaged in the gestational hypertension group if there was any clinical suspicion of underlying renal disease on review. Essential hypertension was diagnosed if systolic blood pressure was higher than 140 mm Hg and/or diastolic blood pressure was higher than 90 mm Hg after 3 months postpartum and the results of other investigations were normal. Renal disease was diagnosed in the presence of abnormal findings on urinalysis, urine microscopy, or renal imaging, or by elevated plasma creatinine concentration. Seven (8%) of the 87 women with pre-eclampsia had underlying disease (essential hypertension, five patients; renal disease, two patients [one with reflux nephropathy and one with medullary sponge kidney]), as did 16 (16%) of the 99 women with gestational hypertension (essential hypertension, 14 patients (14%); renal disease, two patients (2%) [one with medullary sponge kidney and one with thin basement membrane disease]).(ABSTRACT TRUNCATED AT 250 WORDS)

Nephrocalcinosis, cholelithiasis, and umbilical vein calcification in a premature infant

A case of calcification of the umbilical vein in a premature infant with nephrocalcinosis and cholelithiasis is described. Such an association might have resulted from prematurity, bronchopulmonary dysplasia, umbilical vein catheterization, total parenteral nutrition, and furosemide therapy. Follow-up ultrasound examination at 9 months of age revealed spontaneous resolution of calcification of both the gallbladder and the umbilical vein but not of the kidneys.

Gentamicin vestibulotoxicity

We reviewed 36 patients with gentamicin vestibulotoxicity to determine its relationship to gentamicin dosage, serum gentamicin levels, and the development of gentamicin nephrotoxicity. Thirty of the patients had received intravenous or intramuscular gentamicin; six had received intraperitoneal gentamicin. Sixteen of the 30 patients treated with intramuscular or intravenous gentamicin had received less than the recommended maximum dose of 5 mg/kg/day for less than the recommended maximum period of 10 days. Nephrotoxicity as well as vestibulotoxicity developed in 16 of these 30 patients. Gentamicin vestibulotoxicity was not recognized before discharge from hospital in 32 of the 36 patients. We conclude that as far as the vestibular system is concerned there is no safe gentamicin dose and no safe serum gentamicin level, and there is an increased risk of vestibulotoxicity in patients in whom nephrotoxicity develops. Physicians who use gentamicin should become more aware of the clinical features of vestibulotoxicity because stopping gentamicin as soon as symptoms of vestibulotoxicity appear could prevent permanent impairment of vestibular function.

Pharmacokinetics and pharmacodynamics of the alpha 1-adrenergic antagonist bunazosin retard in hypertensives

The pharmacokinetics and pharmacodynamics of an alpha 1-blocker a sustained release formulation of bunazosin (Detantol R, E1015, 4-amino-2-(4-butyrylhexahydro-1H-1,4-diazepin-1-yl)-6,7- dimethoxyquinazoline hydrochloride, CAS 52712-76-2), were investigated in hypertensive patients with normal renal function (NRF) and those with impaired renal function (IRF). The subjects were hospitalized and placed on a constant sodium diet (NaCl 7 g/day) throughout the study. A 6 mg dose of bunazosin was administered orally once a day for 8 days. Measurement of blood pressure (BP) and sampling of blood and urine specimens were made on the first and last days of treatment. A significant decrease in both systolic and diastolic BP was observed after consecutive dosing of bunazosin compared to baseline values over 24 h in the NRF and for 8 h in the IRF. There were no significant differences in plasma profiles of bunazosin in both groups after single and consecutive dosing. The pharmakokinetic parameters of bunazosin in the NRF and IRF groups did not differ after the single and the consecutive dosing, except for plasma peak levels (Cmax) which were significantly higher in the IRF than those in the NRF. There were, however, neither prolongation of apparent elimination half-life (t1/2), nor increase in Cmax, nor area under the plasma concentration-time curve (AUC0-24) after consecutive dosing in both groups. Cumulative urinary excretion rates of bunazosin were less than 1.1% of dose in both groups, and those did not differ significantly between the NRF and IRF groups in both single and consecutive studies.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of renal sarcoidosis showing central necrosis and abnormal expression of angiotensin converting enzyme in the granuloma

We describe a 66-year-old man who developed renal failure related to granulomatous renal sarcoidosis without systemic manifestations. Renal failure was severe enough to require hemodialysis transiently. Renal biopsy of this patient revealed the central necrosis of the granuloma which is usually absent in sarcoid granuloma. Serum level of angiotensin converting enzyme (ACE) was not helpful for diagnosis in this patient because serum ACE level is often elevated in the condition of chronic renal failure. Immunohistochemical detection of ACE was of diagnostic value in this patient. Subsequent course in which glucocorticoid was used for therapy was consistent with the diagnosis. This is the first report of identification of ACE in renal sarcoid granuloma.

Viral hepatitis in children with renal disease

Specific and sensitive diagnostic tests are now available to identify type A, B, C, D and E hepatitis. Hepatitis A and E which cause only acute, very rarely fulminant, hepatitis are spread largely by the faecal-oral route, having a brief viraemic phase. Hepatitis B, C and D which are transmitted parenterally and via secretions are often associated with chronic viraemia. Patients with chronic renal disease are at particular risk. Impaired immunity due to disease or drugs increases the propensity to develop a chronic carrier state which may progress to cirrhosis and hepatocellular carcinoma. Limited reports indicate that hepatitis C infection may cause cirrhosis more rapidly than hepatitis B. The emergence of mutants to both hepatitis B and C is a cause for concern. Treatment with interferon is of limited efficacy. Screening of blood products for viral markers and prudent handling of potentially infected materials to avoid contamination of damaged skin or mucous membrane are the best strategies to prevent infection. Hepatitis B vaccination of all newborns, young adolescents and those at risk is the most effective means of reducing the carrier frequency.

Epidemiology of primary glomerular diseases in a French region. Variations according to period and age

Between January 1, 1976 and December 31, 1990, histological diagnosis of primary glomerular diseases (PGD) was made in 480 patients born and living at the time of diagnosis in a region of France, comprising 410,664 inhabitants, of whom 390,574 were aged from 10 to 80 years. The prevalence of PGD during a 70 year exposure to risk (10 to 80 years of age) was evaluated to 5.7 in 1000 (7.6 in 1000 males and 3.8 in 1000 females). The most common PGD was IgA nephropathy with a prevalence of 1.9 in 1000 (3.3 in 1000 males, 1 in 1000 females). The annual incidence of the disease was evaluated separately for three consecutive five-year periods: period A (1976-80), period B (1981-85), and period C (1986-90). Within each of these three periods the number of patients with PGD was 179, 170 and 131, respectively, and annual incidence was 9.3, 8.8 and 6.7 in 100,000. The incidence of IgA nephropathy remained the same throughout the three periods: 2.6, 3.1 and 2.5 in 100,000. The incidence of membranoproliferative glomerulonephritis decreased from 1981 onward (0.9, 0.5 and 0.15 in 100,000), while that of membranous nephropathy increased slightly (1.2, 1.6 and 1.7 in 100,000). Acute streptococcal glomerulonephritis virtually disappeared during periods B and C. Lipoid nephrosis was less frequent in period C and idiopathic proliferative glomerulonephritis with crescents slightly increased (0.3, 0.4 and 0.6 in 100,000). There was no significant difference between the three periods regarding the incidence of other PGD.(ABSTRACT TRUNCATED AT 250 WORDS)

Periarticular hyperostosis and renal disease in six black lemurs of two family groups

Proliferative periosteal disease was identified in 6 black lemurs (Eulemur macaco macaco) of 2 family groups. Bilaterally symmetric formation of periosteal new bone at the metaphyseal regions of major long bones was first detected at the stifle and tarsal areas and was detected later at the carpal areas. Bony changes were accompanied by progressive renal disease. The syndrome progressed for 6 to 16 months before the lemurs were euthanatized because of debility. Necropsy revealed changes confined to the skeleton and kidneys. Formation of new bone was detected at all affected joints, and chronic renal disease was evident in each lemur. A specific cause was not identified. Although indistinguishable histologically from hypertrophic osteoarthropathy, several important differences were apparent. Distribution of the periosteal new bone was in the metaphyseal rather than diaphyseal areas. Thoracic or gastrointestinal lesions, typically seen with hypertrophic osteoarthropathy, were not detected, and substantial renal disease was evident. A genetic component may be involved in the development of this condition.

Loin pain-hematuria syndrome: how effective is renal autotransplantation in its treatment?

OBJECTIVES

To evaluate our experience with renal autotransplantation in the management of loin pain-hematuria (LPH) syndrome after relatively long follow-up (30 to 35 months).

METHODS

Four patients with LPH syndrome of 3 to 18 years' duration underwent technically successful autotransplantation. All patients preoperatively had normal radiologic investigations, including renal arteriography and biopsy. All required narcotic analgesia for pain control. Patients were followed for 30 to 35 months.

RESULTS

All 4 patients were pain and narcotic free for 6 months postoperatively. At 18 months after surgery, 3 of the 4 had recurrence of the pain and at 30 months, 2 required nephrectomy. Only 1 patient of 4 had sustained pain relief at 35 months.

CONCLUSIONS

Renal autotransplantation certainly offers temporary relief from LPH syndrome, but in our experience this was not durable in the majority of our patients.

[Surgical aspects of renal transplantation]

Expansion of donor criteria and more efficient use of the donor pool are needed to address the current organ shortage. Results of renal transplantation in older patients support broader recipient selection. To improve intraoperative donor and recipient management, and decrease the rate of delayed graft function, and refine surgical techniques to address more complicated patients are also attempts to expand donor pool. Use of hepatitis-C-positive donors is not safe in hepatitis-C-positive recipients for non-life-saving organs.

New familial nephropathy involving glomerular and tubular basement membranes

We describe two siblings, an 8-year-old boy and a 9-year-old girl, with severe mental retardation, dwarfism, optic atrophy and nephropathy. Laboratory examination showed beta 2-microglobulinuria, decreased creatinine clearance, hypercholesterolaemia and elevated serum levels of muscle enzymes. Renal biopsy from one of the patients demonstrated characteristic ultrastructural changes involving both the glomerular and tubular basement membrane. This group of symptoms and laboratory findings is quite distinct and differs from those of other reported familial nephropathy syndromes. We conclude that this disorder may represent a new syndrome of autosomal recessive inheritance.

Pediatric ureteropelvic junction obstruction treated with retrograde endopyelotomy

OBJECTIVES

To determine the feasibility of retrograde endopyelotomy in the management of pediatric ureteropelvic junction (UPJ) obstruction.

METHODS

We treated 2 boys aged 4 and 6 years with the Acucise endopyelotomy device for symptomatic ureteropelvic junction obstruction. The Acucise device was placed over a Lunderquist guide wire with fluoroscopic guidance only and routine Double J catheters were left in situ for 6 weeks after the procedure. The morbidity of the treatment and the short-term outcome were assessed.

RESULTS

There were no acute complications and short-term follow-up results were satisfactory as determined by intravenous urography and diuretic renography.

CONCLUSIONS

Ureteropelvic junction obstruction in children may be treated by retrograde endopyelotomy with the Acucise device. The principal potential advantage of this procedure is reduced morbidity. Our findings suggest that further evaluation is warranted.

Differentiation of glomerular and non-glomerular hematuria in children by measurement of mean corpuscular volume of urinary red cells using a semi-automated cell counter

Urine samples from 110 children and adolescents with micro- or macrohematuria were compared using phase-contrast microscopy and a semi-automated cell counter to differentiate glomerular from non-glomerular hematuria. Glomerular hematuria, defined by clinical criteria from biopsy and standard chemical evaluation, was observed in 73 patients (group 1): non-glomerular hematuria was found in 37 patients (group 2). The latter group underwent urological operation and had normal urine before operation. Mean corpuscular erythrocyte volume (MCVU) and percent of dysmorphic erythrocytes were determinated. To exclude the influence of mean erythrocyte volume of blood erythrocytes (MCVB), MCVB was determined and additionally the quotient of MCVU/MCVB was calculated (MCVUB). The percentage of dysmorphic erythrocytes differed significantly between the two groups ((75 +/- 13% in group 1 versus 38 +/- 27% in group 2 (mean +/- SD); p < 0.01), MCVU (34.0 +/- 11.1 fl in group 1 versus 55.5 +/- 16.3 fl in group 2; p < 0.01) and MCVUB (0.41 +/- 0.14 in group 1 versus 0.67 +/- 0.20 in group 2; p < 0.01). When glomerular hematuria was defined on the basis of more than 80% dysmorphic erythrocytes, the sensitivity of phase-contrast microscopy was 0.52, specificity versus 0.96 and efficiency 0.64. When glomerular hematuria was defined as < 50 fl MCVU, sensitivity was 0.92, specificity 0.57 and efficiency 0.80 and as < 0.06 MCVUB, sensitivity was 0.89, specificity 0.62 and efficiency 0.80. The correlation coefficient between MCVU and dysmorphic erythrocytes was -0.71 (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasonic diagnosis of renal cell carcinoma in hemodialysis patients

From April 1985 to December 1992 abdominal ultrasonic examination was performed in 1,603 hemodialysis patients at our hospital. Renal cell carcinoma was found in 41 patients (2.6%), confirmed by nephrectomy as well as histology. This rate was 32 times greater than that of the general population (22 patients with renal cell carcinoma were detected among 27,933 at our health care center). Renal cell carcinoma was found in 18 patients with a contracted kidney, 19 with acquired cystic disease of the kidney and 4 with a native kidney after renal transplantation. Among 19 patients with acquired cystic disease of the kidney 8 had unilateral multiple tumors and 5 bilateral multiple tumors. The detection rate of renal cell carcinoma was 100% by ultrasonography, 67% by computerized tomography and 56% by angiography. Ultrasonography was the most accurate examination for the diagnosis of renal cell carcinoma in hemodialysis patients.

Hematuria in children

A work-up of a child with suspected hematuria should be undertaken once the primary physician has determined that there actually are red blood cells in the urine and that the hematuria is persistent. Evaluation of a child with persistent microscopic hematuria is facilitated with the determination of whether the blood originates from the glomeruli or whether it comes from elsewhere in the urinary tract. Clues to a glomerular origin include the presence of other manifestations of glomerular disease such as significant proteinuria, RBC casts, and dysmorphic erythrocytes in the urinary sediment, hypertension, and renal insufficiency. Clues to the blood originating from the lower urinary tract include blood clots in the urine, normal erythrocyte morphology, and a pertinent history pointing to the lower tract such as that of trauma, urolithiasis, urological or vascular abnormality, or symptoms of bladder inflammation. The initial evaluation should include a detailed patient history and family history as well as a careful physical examination looking for clues to the presence of a familial, hereditary, or chronic kidney disease. A logical, stepwise initial work-up should follow with the goal of ruling out life-threatening and treatable diseases. If there are no indications for immediate further intervention and the cause of the hematuria remains unclear after the initial work-up has been completed, the parents and patient should be reassured that there are no life-threatening conditions and that although the etiology of the blood in the urine is yet unknown, there is time to follow the patient and plan for additional studies if and when they are indicated. The family's concerns (ie, "Is this cancer?," "Will my child require dialysis and transplantation?") should be addressed frankly, and the physician should mention those diagnoses that may lead to renal failure, but have not been absolutely ruled out yet before a kidney biopsy has been performed, such as Alport's syndrome and IgA nephropathy. The child with isolated microhematuria should be evaluated regularly with urinalyses looking for persistence of the hematuria and appearance of proteinuria, blood pressure measurements, and renal function tests. If the microhematuria persists for 6 to 12 months, a kidney biopsy should be considered.(ABSTRACT TRUNCATED AT 400 WORDS)

Malignant hypertension in north west India. A hospital based study

One hundred and thirty-five patients with malignant hypertension seen over a period of 11 years (1979 to 1989) at a referral hospital were analyzed to characterize the clinical features and etiology of this disease. Ninety male and 45 female patients with an average age of 38.2 +/- 1.4 years were studied. Malignant hypertension was the presenting feature in 68 patients. The etiology included essential hypertension in 88 patients and a secondary cause in 47 patients. Secondary causes included a renovascular etiology in 20 patients, renal parenchymal disease in 19, pheochromocytoma in 6 and Conn's syndrome and adrenal carcinoma in one patient each. Among the 20 patients with renovascular hypertension, Takayasu's arteritis was seen in 15 (75%). The mean age of patients with essential hypertension was 41.7 + 1.14 years while the mean age in patients with secondary hypertension was 33.2 + 1.96 years. Duration of preexisting hypertension was longer in essential hypertensives (2.42 + 0.45 years) than in patients with secondary hypertension (1.27 + 0.41 years, p < 0.05). Raised serum creatinine was seen in 93 patients. Seventy-seven patients had left ventricular hypertrophy on ECG. Ninety-six patients were followed for a period ranging from 18 months to 10 years (mean 32 months). Sixteen patients died during hospital stay while 6 patients died during the follow-up period. The deaths were related to the effects of uncontrolled hypertension including, renal failure (11), stroke (6), congestive cardiac failure (3) and myocardial infarction (1).(ABSTRACT TRUNCATED AT 250 WORDS)

Role of interleukin-1 and the therapeutic potential of interleukin-1 receptor antagonist in sepsis

Clinical trials of anticytokines in sepsis have not been as straightforward as had been anticipated from results in animal models of sepsis and the role of cytokines in sepsis is now in question. Retrospective analysis of the results of a phase III trial of interleukin-1 (IL-1) receptor antagonist suggests that sepsis-induced adult respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), renal dysfunction, and shock are valuable markers of patients in whom IL-1 is a pathogenic mediator and in whom IL-1ra can reduce mortality. A re-examination of the effects of IL-1ra in animal models of sepsis supports the validity of this analysis. A new phase III clinical trial will confirm or disprove the hypothesis that IL-1 is a mediator of pathology, and IL-1ra is a valuable therapy for sepsis complicated by ARDS, DIC, renal dysfunction, or shock.