Urinary red cell morphology to detect site of hematuria

We studied the urinary RBC morphology in 87 consecutive cases of significant hematuria by 3 commonly used methods: (a) light microscopy of the unstained urinary sediment; (b) phase contrast microscopy of the unstained urinary sediment; and (c) Wright's staining of the urinary sediment, in order to compare the sensitivity of these methods in detecting dysmorphic RBCs and thus predicting the site of hematuria. The clinical data and the relevant investigations were made available after the morphology of RBCs in the urine was identified. Out of the 87 patients, 45 had a glomerular and 42 had a nonglomerular cause o hematuria. Phase contrast microscopy showed a sensitivity of 91.1%, Wright's stain of 82.2% and light microscopy of 66.7% in detecting a glomerular source of hematuria. Nonglomerular hematuria could be detected in 92.9% cases by each of the 3 methods. It is concluded that phase contrast microscopy is most sensitive for the detection of dysmorphic RBCs in the urine, Wright's stain nearly as sensitive whilst light microscopy of the unstained sediment is least sensitive. Urinary RBC morphology is a useful adjunct in the diagnosis of hematuria and saves the patients from unnecessary investigations.

Case report: acute renal vein thrombosis in patients with spinal cord injury and secondary amyloidosis

Chronic spinal cord injury, when complicated by chronic suppurative infections, has replaced chronic tuberculosis as a leading cause of secondary amyloidosis. Renal involvement with secondary amyloidosis is characterized by the presence of nephrotic range proteinuria and an increased incidence of renal vein thrombosis. Two cases of acute renal vein thrombosis associated with secondary amyloidosis in patients with spinal cord injury are presented. In both cases, a past history of extensive decubitus ulcerations and urinary tract infections preceded the development of nephrotic range proteinuria. In case 1, nonoliguric acute renal failure occurred after the development of acute bilateral renal vein thrombosis. The patient declined dialytic therapy and expired with uremia. In case 2, worsening renal function and increased proteinuria resulted after the development of acute unilateral renal vein thrombosis. These cases include the clinical and anatomic findings of acute renal vein thrombosis that occur as a complication of secondary amyloidosis. Acute renal vein thrombosis should be considered whenever an acute change in renal function or increase in proteinuria is noted in this setting.

Epidemiology of hepatitis C virus infection in patients with renal disease

This study was carried out to determine the prevalence of hepatitis C virus (HCV) antibodies and the epidemiologic factors associated with HCV infection in patients with chronic renal failure before the onset of ESRD. Sex, age, type of renal disease, level of renal function, and history of blood transfusions and invasive procedures were analyzed in 226 patients with renal disease, compared with a population of 1,244 normal subjects and 124 patients with impaired immunity (patients having autoimmune diseases and receiving chemotherapy treatment). Eighteen seropositive patients with renal disease (prevalence, 7.9%) were found, which was significantly higher than the prevalence in the normal population (1.03% in blood donors, 0.98% in pregnant women; P < 0.001, chi 2). There was no significant association of sex, number of blood transfusions, or history of invasive procedures with the presence of HCV antibodies. The prevalence of HCV antibodies was higher (16.6%) in patients with glomerulonephritis compared with patients diagnosed with interstitial nephritis, pyelonephritis, nephrosclerosis, diabetes mellitus, polycystic kidney, and miscellaneous renal diseases (P < 0.01, chi 2). There was a higher prevalence of HCV antibodies in patients with creatinine clearance lower than 30 mL/min (13%) compared with patients with creatinine clearance higher than 30 mL/min (2.7%) (P < 0.01, chi 2). These data suggest that HCV infection may be associated with the pathogenesis of glomerulonephritis. Alternatively, glomerulonephritis or severe renal insufficiency may increase the likelihood of HCV infection.

[Reoperations on valvular disease: an analysis of outcome]

To evaluate risks and complications of reoperation on valvular disease, we reviewed data on 186 patients who underwent reoperations because of prosthetic valve malfunctions, pregression of valvular disease after open mitral commissulotomy and previous valvular replacement. Overall hospital mortality was 4.8% (9/186 patients). The common causes of death was low cardiac output syndrome (3 pts.) and respiratory failure (3 pts.) and others (3 pts). Hospital mortality was different according to the risk factors. There was no significant difference between the operative procedures; AVR (6.2%), MVR (3.2%), DVR (8%), TVR (0%) and MVR + TVR (9%). Furthermore, advanced age, valve position, renal failure, preoperative %FS, LVDd and diagnosis of prosthetic valve malfunction did not appear to be significant risk factor. However, preoperative respiratory failure and emergency operation showed significant increase of hospital mortality in comparison with other factors. On the basis of this reports, hospital mortality and late survival indicated that reoperation should be performed early as the potentially safe condition.

Hypertension and renal disease in patients with acute intermittent porphyria

OBJECTIVES

To assess the association between acute intermittent porphyria (AIP), hypertension and renal disease.

DESIGN

A population-based matched case-control study (1:4) in 50 AIP patients (manifest/latent 25/25), a retrospective study of all individuals who died between the years 1978 and 1990 (2122 including 33 with AIP) and a group of eight patients with severe AIP.

RESULTS

Hypertension was found in 56% of patients with manifest AIP, 33% of their controls (P = 0.041) and 16% of patients with latent AIP (P = 0.004). Renal disease was not more common in patients with AIP than in their controls. Three of the eight patients with severe recurrent AIP had impaired renal function, caused in one by systemic lupus erythematosus (SLE) nephritis. In the other two, no cause other than AIP could be found. In the mortality study, hypertension was registered in 68% of patients with manifest AIP compared to 21% of those with latent AIP (P = 0.008) but death from myocardial infarction and stroke was not more common. Uraemia was cited as the cause of death in 9.1% of AIP patients and 1.0% of those without AIP (P = 0.006).

CONCLUSIONS

Hypertension is more common in patients with manifest AIP than in those with latent AIP or control subjects. Renal disease may be due to hypertension, to AIP or to SLE. AIP may predispose to other renal diseases.

Management of the trauma patient with pre-existing renal disease

Chronic renal disease is associated with fluid retention, electrolyte disturbances, anemia, platelet dysfunction, malnutrition, and, often, underlying disease such as diabetes, hypertension, and coronary artery disease. The mortality and morbidity of trauma increases when the victim has pre-existing renal disease. Special attention must be given to fluid resuscitation in these patients because of their limited or absent ability to excrete solutes and fluids. Invasive hemodynamic monitoring is helpful in guiding the resuscitation efforts because urine output and acid-base balance are unreliable markers. Knowledge of pharmacokinetics and pharmacodynamics is necessary in patients with renal disease. Choice of therapy for solute and fluid removal depends on the patient's hemodynamic status, the presence or absence of coagulopathy, and the type of traumatic injury. Renal replacement therapies are recommended for hemodynamically compromised patients.

Recurrent diseases in the kidney transplant

Virtually all diseases affecting the native kidney recur in the kidney transplant with the exception of Alport syndrome, polycystic kidney disease, hypertension, chronic pyelonephritis, and chronic interstitial nephritis. Fortunately, in the majority of patients, recurrence of the original disease has minimal clinical impact, with only approximately 5% of all graft loss occurring as a result of recurrent disease. The primary renal diseases that commonly recur include membranoproliferative glomerulonephritis type II, IgA nephropathy, and focal and segmental glomerular sclerosis. The most common systemic disease that recurs is diabetic nephropathy. Living-related transplantation should be used with caution in patients with the hemolytic uremic syndrome, recurrent focal and segmental glomerular sclerosis, and membraneous glomerulonephritis. Fabry disease and primary hyperoxaluria type I are no longer absolute contraindications to kidney transplantation.

Secondary polycythaemia associated with bilateral renal lymphocoeles

A patient with a 15 year history of secondary polycythaemia due to renal erythropoietin hypersecretion is presented. Subsequent spontaneous development of bilateral renal lymphocoeles, which contained high erythropoietin levels, was shown by computerized tomography. The lymphocoeles were successfully treated by bilateral peritoneal marsupialization. No cause for the persistent polycythaemia or lymphocoeles was found at laparotomy or on renal biopsy.

Maternal high-risk factors and severity of growth deficit in small for gestational age infants

The relationship between maternal risk factors and severity of fetal growth deficit was evaluated in a population of 613 small for gestational age (SGA) infants and 784 appropriately grown controls. The severity of growth deficit among SGA infants was expressed as 'fetal growth ratio' (observed/expected birthweight, where expected birthweight is the mean birthweight of the Italian population for a given gestational age). In multivariate models, preeclampsia was the only maternal high-risk factor positively correlated with a more severe growth deficit among SGA infants. Chronic cardiac or renal maternal diseases and female fetal sex were associated with mild forms of SGA, thus showing an inverse relationship with severity of growth deficit. Finally, the association between maternal smoking in pregnancy, low (< 0.2 kg/week) maternal weight gain, low (< 50 kg) pre-pregnancy weight, severe (Hb, < 8 g/dl) maternal anaemia, low education (< 6th grade), history of a previous low birthweight infant or recurrent spontaneous abortion, nulliparity and SGA was homogeneous across the severity strata of fetal growth deficit.

Deleterious effect of cyclosporins on the ischemic kidney in the rat and the protection by the calcium antagonist verapamil

Cyclosporine A (CsA) nephrotoxicity has been suggested to be aggravated in the presence of ischemia, as occurs after renal transplantation. Cyclosporine G (CsG) may be less nephrotoxic than CsA. This study evaluated in the rat (1) the effect of CsA and CsG on blood flow and the function of the kidney subjected to 60 min of warm ischemia and (2) the protective effect of the calcium antagonist verapamil (VP). After left nephrectomy, ischemia was induced in the right kidney by the clamping of the kidney pedicle for 60 min, which resulted in a significant increase in serum creatinine (SCr) to 2.30 +/- 0.25 mg/dL by Day 1 with 25% mortality by Day 7. The administration of CsA or CsG (20 mg/kg i.v. daily for 7 days) after 60 min of renal ischemia significantly increased SCr and mortality compared with ischemia alone. In another set of experiments, 60 min of warm ischemia was applied to the right kidney and RBF was measured in both kidneys with a laser Doppler flowmeter. Blood flow in the ischemic kidney returned to the preischemic level by 15 min after the removal of the vascular clamp in the control animals. In contrast, in animals treated with CsA, a significant decrease in RBF was seen in both kidneys; however, blood flow in the ischemic kidney was significantly lower than that in the nonischemic kidney. CsG also decreased RBF in both kidneys, although in the left (nonischemic) kidney, RBF remained significantly higher with CsG than with CsA.(ABSTRACT TRUNCATED AT 250 WORDS)

Medullary renal dysplasia mimicking renal tumor in the Beckwith-Wiedemann syndrome

The known association of Wilms' tumor with the Beckwith-Wiedemann syndrome has prompted a surveillance regimen for children with this problem. Herein we report a case of medullary renal dysplasia that was a new onset by documented ultrasound. The association of medullary renal dysplasia with Beckwith-Wiedemann syndrome is discussed as well as the management of this problem.

Renal manifestations of the antiphospholipid syndrome

Although renal manifestations of the antiphospholipid syndrome (APS) have received scarce attention until recently, the kidney probably is a major target organ in APS. Thrombosis may develop at any location within renal vessels, ie, renal artery trunk or branches, intrarenal arteries or arterioles, glomerular capillaries, and renal vein. The clinical consequences consist of highly variable degrees of proteinuria; systemic hypertension ranging from mild to malignant; cortical necrosis; thrombotic microangiopathy, pregnancy-associated or not; and slowly to rapidly progressive renal failure that may require dialysis. These events occur mainly in the course of systemic lupus erythematosus or of "primary" APS. Renal involvement is a frequent feature of the catastrophic APS. A high prevalence of antiphospholipid antibodies has been reported recently in patients with end-stage renal failure, but their clinical significance remains to be determined.

The pattern of amyloidosis in Malaysia

Congo red screening of routine biopsies at the University Hospital Kuala Lumpur revealed the following categories of amyloidosis: systemic AL (5.9%); systemic AA (3.2%); isolated atrial (14%); primary localized cutaneous (7.5%); other primary localized deposits (3.2%); localized intratumour (58%); and dystrophic (8.6%). Unlike in the West, AA amyloidosis in this population was usually secondary to leprosy or tuberculosis. Liver involvement in AL amyloidosis was shown to exhibit a sinusoidal pattern and differed from the vascular pattern of AA amyloidosis. Within the category of AA amyloidosis, there were two patterns of renal involvement--glomerular and vascular, with the glomerular pattern carrying a more ominous clinical picture. Notable among the localized amyloidoses were isolated atrial amyloidosis complicating chronic rheumatic heart disease, intratumour amyloidosis within nasopharyngeal carcinomas and dystrophic amyloidosis which occurred in fibrotic tissues.

Efficacy and safety of amlodipine in hypertensive patients with renal dysfunction

Amlodipine, a dihydropyridine calcium antagonist, was administered at 2.5-5.0 mg/day for 8 weeks to 35 hypertensive patients with renal dysfunction, and its efficacy and safety were evaluated. The target reduction in blood pressure was achieved in 28 of the 35 patients (80%), while blood pressure was decreased in 4 patients (11.4%) and unchanged in 3 patients (8.6%). A side effect of mild headache was reported by one patient (2.9%). In addition, abnormal changes in laboratory values were observed in five patients, but all of the changes were mild. Blood urea nitrogen and serum creatinine levels both increased in two of these five patients, and serum creatinine levels increased in another two patients. Serum amlodipine concentration was 4.86 +/- 2.57 ng/ml (n = 8) and 3.01 +/- 1.02 ng/ml (n = 8) in patients receiving a daily dose of 2.5 mg for 2-5 weeks and 8-10 weeks, respectively. Serum concentration in patients receiving 5 mg from Weeks 2-6 was 9.72 +/- 6.89 ng/ml (n = 6) after 7-9 weeks, suggesting no tendency for the accumulation of this drug. The drug was rated as of clinical benefit in 27 of the 35 patients (77.1%), and as slightly beneficial in another 5 patients (14.3%). Thus, amlodipine significantly decreased the blood pressure while causing little or no aggravation of renal dysfunction in hypertensive patients with renal impairment.

Glomerular disease as a cause of isolated microscopic haematuria

Microscopic haematuria is a common clinical finding, with reported prevalences of up to 22%. The role of renal biopsy in the investigation of this condition is still debated. Currently urological investigation including cystourethroscopy is often regarded as adequate. We investigated 165 patients (94 male, 71 female; mean age 37.5 years, range 10-71) referred with isolated microscopic haematuria, using renal biopsy and cystourethroscopy. All patients were normotensive with normal serum creatinine, no proteinuria, sterile urine and a normal IVU. Renal biopsy abnormalities were found in 77/165 (46.6%): IgA nephropathy (49), global or segmental mesangial proliferative glomerulonephritis without IgA deposits (16), thin membrane nephropathy (7), vascular changes suggestive of hypertension (3), interstitial nephritis (1), and membranous nephropathy (1). Only five abnormalities were found on cystourethroscopy (cystitis 3, urethral stricture 1, bladder stone 1). Two patients with cystitis also had IgA nephropathy. Biopsy abnormalities were commonest under the age of 20 (69.2%), but 40% of biopsies were abnormal even in the seventh decade of life. Because renal biopsy abnormalities are very frequent in patients with isolated haematuria, renal biopsy is indicated in patients over 45 years of age if renal imaging and cystoscopy are normal. In those under 45 years, renal biopsy should replace cystoscopy as the investigation to follow normal renal imaging.

Early indicators of renal dysfunction in silicotic workers

OBJECTIVES

The aim of this study was to determine whether silicosis is associated with renal alterations detectable in urinary or blood-borne indicators of nephrotoxicity.

METHODS

The study used a cross-sectional design. The subjects comprised 116 male workers who had been exposed to silica for at least two years and had been diagnosed as having silicosis and 61 age-matched referents. The considered outcome measures were the concentrations of beta, -microglobulin and creatine in serum and the urinary excretion of albumin, retinol-binding protein, and beta-N-acetyl-D-glucosaminidase.

RESULTS

Compared with the referents, the silicotic subjects excreted, on the average, slightly higher amounts of albumin, retinol-binding protein, and beta-N-acetyl-D-glucosaminidase. This increase did not correlate with the duration of exposure or the stage of silicosis and was not associated with an elevation in serum creatinine. The concentration of beta2-microglobulin in the serum of silicotic subjects showed a tendency to rise that became significant in the subgroup with pseudotumoral opacities. This effect, which did not correlate with markers of nephrotoxicity, is however more likely the consequence of silicosis-associated inflammatory reactions than of decreased renal filtration.

CONCLUSIONS

The present study confirms that silicosis is associated with some infraclinical renal alterations. However, in the absence of a relationship with length of exposure or severity of silicosis, the implication of silica in their causation needs to be examined further.

Massive retroperitoneal hemorrhage from spontaneous rupture of a renal angiomyolipoma during pregnancy. A case report

We present the case of a 29-year-old, pregnant woman who, at 27 weeks' gestation, suffered an acute abdomen with hypovolemic shock that led to intrauterine fetal death in spite of an emergency laparotomy. The final diagnosis was ruptured renal angiomyolipoma, which caused a massive retroperitoneal hemorrhage.

Renal proximal tubular dysgenesis associated with severe neonatal hemosiderotic liver disease

We report the necropsy findings for three infants with the unusual combination of proximal renal tubular dysgenesis and severe congenital liver disease with excessive iron in several organs resembling neonatal hemochromatosis. Two of the infants were caucasian siblings and one was an Australian aborigine. One died in utero at 35 weeks of gestation and two died at 7 days. The liveborn infants presented with anuria and liver failure. The livers all showed marked loss of hepatocytes and replacement by pseudotubules in the collapsed lobules. The liveborn infants also showed giant cell transformation of hepatocytes, small regenerative nodules, cholestasis, and normal bile ducts. Absence of proximal renal convolutions was confirmed by epithelial membrane antigen positivity in nearly all tubules. In each family there was another sibling with congenital liver disease, fatal in one case, but no renal tubular dysgenesis. No infection or metabolic disease was uncovered in any of our patients, and the cause of the hepatocyte destruction was not determined. The combination in three infants of two rare congenital diseases could be genetic or acquired in utero from the same etiological agent. Alternatively, the absence of proximal convolutions could be secondary to hypoperfusion, perhaps because of shock due to extensive necrosis of hepatocytes.

Severe adverse cardiovascular effects of pulse steroid therapy: is continuous cardiac monitoring necessary?

Pulse steroid therapy (PST) has been used in dermatology to treat a variety of severe inflammatory disorders. Dermatologists have usually recommended that patients be hospitalized for continuous cardiac monitoring during PST administration, although specialists in other fields have administered PST in an outpatient setting. We reviewed the literature concerning serious adverse cardiovascular effects of PST. These were rare and have been mainly reported in nondermatologic patients, typically those with kidney or heart disease. Although outpatient administration of PST may be a safe practice for some dermatologic patients, we cannot make a firm recommendation without a prospective trial.