Satisfactory control of secondary hyperparathyroidism with low-calcium dialysate in patients not receiving vitamin D

The use of a dialysate calcium concentration of 2.5 mEq/1 for patients not receiving vitamin D is controversial. Therefore, it has been suggested that oral calcium supplements might be sufficient to avoid a negative calcium balance which could result in a worsening of secondary hyperparathyroidism. In order to clarify these aspects, we reduced the dialysis fluid calcium level in 26 patients on chronic hemodialysis with a dialysate calcium concentration of 3.25 mEq/l, all of them receiving low doses of calcium carbonate and aluminum hydroxide. No patient received supplements with vitamin D during the previous 2 years. These patients have been dialyzed using a dialysate calcium concentration of 2.5 mEq/l for 1 year. Gradually we increased the dose of calcium carbonate and decreased the dose of aluminum hydroxide to maintain the predialysis serum calcium and phosphate concentrations between 8-10 and 4-6 mg/dl, respectively. After 1 year of hemodialysis with a low-calcium dialysate (2.5 mEq/l), the oral dose of calcium carbonate was increased from 3.5 +/- 2.6 to 9.2 +/- 5.6 g/day (p < 0.001). In 22 patients (85%) the aluminum hydroxide was stopped, and in the remaining 4 cases the dose was lowered. The reduction in the dialysate calcium concentration did not increase the incidence of hypercalcemia or hyperphosphatemia. In the whole group, we did not observe a significant variation in the levels of intact parathyroid hormone (iPTH; 324 +/- 123 vs. 311 +/- 256 pg/ ml) or alkaline phosphatase (230 +/- 115 vs. 224 +/- 127 U/l), although there was a reduction in the serum aluminum concentration (33 +/- 31 vs. 21.8 +/- 20.2 micrograms/l; p < 0.001). We analyzed the evolution of iPTH in each case. In 15 patients (58%) the iPTH concentration decreased, in 6 cases (23%) it remained stable, and in only 5 subjects (19%) there was an increase (2 of them did not take the oral calcium dosage recommended). In conclusion, a low dialysate calcium concentration (2.5 mEq/l) is safe for most patients not receiving vitamin D. But adherence of patients to high doses of oral calcium supplements is absolutely necessary.

Androgen therapy for anaemia of chronic renal failure. Indications in the erythropoietin era

The high cost of recombinant human erythropoietin has led us to consider the existing indications for androgen treatment of anaemia in patients with chronic renal failure. In the present work, we have tried to identify those patients on haemodialysis for whom androgens could constitute a therapeutic alternative. The evolution of haemoglobin concentration was analysed in 84 patients (67 males and 17 females) treated with a cycle of nandrolone decanoate (200 mg per week given intramuscularly, for six months). In the total group of patients, haemoglobin rose from 69 g/L to 87 g/L (p < 0.01). The increment in haemoglobin was not related to sex, basal haemoglobin, primary renal disease, or dose of nandrolone decanoate corrected by body weight. However, we observed a relationship between this increment in haemoglobin and patient age. Haemoglobin increased by 8 g/L in patients younger than 46 years (n = 29), by 18 g/L in patients aged between 46 and 55 years (n = 28), and by 27 g/L in patients older than 55 years (n = 27) (p < 0.01 between groups). In the last group, haemoglobin concentration at the end of androgen treatment was 101 +/- 16 g/L. The haemoglobin level reached during androgen treatment was maintained for over a year after androgen withdrawal in 55% of the responder patients. A reversible rise in the serum concentration of triglycerides was the main side-effect observed. Nandrolone decanoate therapy was not associated with hepatotoxicity or an increase in blood pressure. Voice change and mild hirsutism were observed in most of the women receiving nandrolone decanoate, and these secondary effects constitute a real disadvantage to its use in females. In conclusion, our results showed that androgens are a useful alternative in the treatment of anaemia in male haemodialysis patients older than 55 years. Furthermore, the response obtained was similar to that observed with erythropoietin, but at a lower cost.

Membranous nephropathy: recurrence after kidney transplantation

BACKGROUND

It is supposed that about 5% of dialysis patients had membranous nephropathy as a cause for their renal failure. Despite of this prevalence, only 33 cases of recurrent membranous nephropathy after kidney transplantation have been reported in the English literature.

METHODS

Among 509 recipients of renal allografts, membranous glomerulonephritis was the cause of renal failure in five patients, who received six transplants.

RESULTS

Recurrence of the disease was observed in three allografts (50%) in three patients, all of them were on treatment with cyclosporin and low-dose prednisone. Proteinuria appeared at 2, 5 and 19 months after grafting. One patient experienced a spontaneous remission after 12 months and he is free from proteinuria and with good renal function after 5 years. The remaining two patients presented progressive renal function deterioration and returned to haemodialysis 24 and 17 months after th appearance of proteinuria. In these patients increasing the immunosuppression did not produce any beneficial effect. One of those patients underwent a second transplant; recurrence of the membranous nephropathy has not been observed after 3 years of follow-up.

CONCLUSIONS

In this study three new cases of recurrence of membranous nephropathy are reported. One patient experienced a spontaneous remission of proteinuria. Recurrence of membranous nephropathy in renal allograft was very high in our series. Its appearance was associated with poor prognosis of the graft in most patients, although spontaneous remission of proteinuria is possible.

Androgen versus erythropoietin for the treatment of anemia in hemodialyzed patients: a prospective study

According to this facility's protocol for the treatment of anemia in hemodialyzed patients, androgens were administered to male patients aged over 50 yr and recombinant human erythropoietin was administered to male patients below 50 yr of age and to female patients. In the study presented here, both therapeutic approaches have been prospectively analyzed. Patients were divided into two groups. Group A was composed of 18 patients, aged 62 +/- 12 yr, treated with nandrolone decanoate (200 mg/wk im) for 6 months; Group B was composed of 22 patients (6 men, 16 women) aged 47 +/- 15 yr, treated with subcutaneous recombinant human erythropoietin (initial dose, 6000 IU/wk) for 6 months. The increases of hemoglobin were similar in both groups; Group A, from 7.3 +/- 0.8 to 10.8 +/- 1.7 g/dL (P < 0.001), and Group B, from 7 +/- 0.6 to 10.4 +/- 1 g/dL (P < 0.001). In Group A, increases of triglycerides (159 +/- 71 versus 267 +/- 153 mg/dL, P < 0.001), serum albumin (3.9 +/- 0.3 versus 4.2 +/- 0.3 g/dL, P < 0.05), and dry weight (62.1 +/- 9.8 versus 64.9 +/- 10.1 kg, P < 0.001) were observed, which remained unmodified in Group B. Blood pressure control worsened in one patient (6%) from Group A, and in ten patients (45%) from Group B (P < 0.05). In conclusion, androgens produced an improvement in anemia in selected patients, similar to that achieved by use of recombinant human erythropoietin but at a lower cost. Androgens also have an appreciable anabolic effect and did not increase the blood pressure.

Antibody level after hepatitis B vaccination in hemodialysis patients: influence of hepatitis C virus infection

Seroconversion after hepatitis B vaccine has been estimated to occur when the level of anti-HBs is higher than 10 IU/1, but recently is has been considered that an antibody titer above 100 IU/1 is necessary to guarantee an efficacious protection. We prospectively studied the evolution of anti-HBs after primary vaccination (3 doses; Engerix B, 40 mu g each) in 56 seronegative and not previously vaccinated hemodialysis patients. Three months after vaccine administration, seroconversion (anti-HBs > 10 IU/1) was found in 43 patients (76.7%), but an adequate response (titer > 100 IU/1) was observed only in 30 (53.5%). At 1 year after vaccination only 1 (3.3%) of the 30 cases with an effective response had lost his anti-HBs, while 12 of the 13 patients (92.3%) with an inadequate response (anti-HBs between 10 and 100 IU/1) had no detectable antibodies (p < 0.01, chi2). Considering that an antibody titer above 100 IU/1 following vaccination is necessary in order to maintain that level of antibody 1 year later, we analyzed the factors which influenced obtaining this level of antibody. Age, time on hemodialysis, serum albumin, Kt/V and protein catabolic rate did not affect the response to the vaccine. Females had a better response than males, and interestingly we found that hepatitis C virus (HCV) infection influenced the level of immunity. 27 out of the 43 HCV-negative cases (62.7%) obtained anti-HBs levels greater than 100 IU/1, but only 3 out of the 13 HCV-infected patients (23%) had an anti-HBs above 100 IU/1 (p < 0.01, chi2). Our results suggest that after hepatitis B vaccine, an antibody titer higher than 100 IU/1 is necessary to maintain the antibody level 1 year later, and that HCV infection may reduce the effectiveness of hepatitis B vaccine in hemodialysis patients.

[Surgical complications in 479 renal transplantations]

Exposition of results obtained from the review of the surgical complications found in a series of 479 renal transplantations performed between 1978 and 1992 in our centre, although some of them lack clinical relevance. There was fluid accumulation in 69 patients, distributed between 31 perirenal haematoma. 17 lymphocele, 13 urinoma, 5 perirenal abscesses and 3 mixed. 27.7% required no action. Frequency of renal rupture was 18 cases, 9 due to acute rejection and 9 to vascular thrombosis. Incidence of urinary obstruction was 4.8% with 5.8% of urinary fistula. With regard to the surgical wound, 9 infections, 7 haematomas, 1 eventration and 1 necrotizing fasciitis were observed. Vascular complications consisted in 10 arterial thrombosis, 10 venous thrombosis, 5 mixed thrombosis and 31 arterial stenosis. Treatment instituted for the various cases, its evolution, and an statistical study of risk factors are illustrated.

[Gastrointestinal complications in renal transplantation]

Seventy-nine gastrointestinal complications in 480 recipients of a renal transplant (RT) (16%) are described. The most frequent complication was high digestive haemorrhage (HDH) (19/480) (2.9%); other complications were: esophagitis, gastroenteritis, diverticulitis, cholecystitis, intestinal tuberculosis, rectal ulcer and colonic polyps. Mortality secondary to gastrointestinal complications was 1.1%. Sixty-seven percent of cases with peptic ulcer developed HDH, an incidence higher than that observed in the general population (20%). Twenty-one percent of transplanted patients with DH had ulcer background. Cholecystitis and diverticulitis were complications with a low incidence (0.2% and 0.6%, respectively) which do not seem to justify aggressive diagnostic and therapeutic manoeuvres prior to the transplant. Prevalence of intestinal tuberculosis in this series (0.4%) was higher to that described in the literature.

Recurrence of focal-segmental glomerulosclerosis in kidney transplant patients on ciclosporin

Two patients on maintenance hemodialysis after terminal renal failure due to nephrotic syndrome and biopsy-proven focal-segmental glomerulosclerosis received three cadaver renal allografts. Immediate recurrence of nephrotic syndrome was observed. In two transplants immunosuppression consisted of ciclosporin A and low-dose steroids. One patient was unsuccessfully treated with immunoadsorption after the second transplant. All grafts were lost because of uncontrolled nephrotic syndrome. Renal allograft biopsy specimens showed findings indicating recurrence of the original disease.

Influence of body iron stores on the serum erythropoietin concentration in hemodialyzed patients

The influence of body iron stores on the concentration of serum erythropoietin was studied in 48 hemodialyzed patients not receiving human recombinant erythropoietin, androgens or iron supplements. The serum erythropoietin concentration was 11.6 +/- 10.4 mIU/ml. There was no correlation between the serum erythropoietin and the hematocrit or hemoglobin concentration; however, there was a correlation between the serum erythropoietin and the log of serum ferritin (r = -0.5699, p < 0.01). Serum erythropoietin levels were higher in the 18 ferropenic patients (serum ferritin < 50 ng/ml) than in the 30 patients with normal serum ferritin concentration (18 +/- 13.8 vs. 7.8 +/- 4.7 mIU/ml, p < 0.01). The administration of intravenous iron to the ferropenic patients resulted in a reduction in serum erythropoietin independent of the response of the anemia (18 +/- 13.8 basal and 7.9 +/- 6.5 mIU/ml at 4 weeks, p < 0.01). Our data would suggest that the concentration of erythropoietin in hemodialyzed patients is influenced by the serum ferritin level.

Expression of adhesion molecules in allograft renal dysfunction. A distinct diagnostic pattern in rejection and cyclosporine nephrotoxicity

We have studied in thirty renal biopsies (from 30 cadaver allograft patients) the expression of both LFA-1 and VLA-4 leukocyte adhesion receptors and their respective ICAM-1 and VCAM-1 endothelial cell ligands, during early allograft dysfunction (24 +/- 5 days after transplantation), reversed either by antirejection therapy (n = 14) or by reduction in CsA dose (n = 16). We have found that the levels of expression of the integrin VLA-4 and the activation signal AIM/CD69 (activation inducer molecule) on interstitial cells were significantly (P < 0.001) higher in rejection than in nephrotoxicity. A main differential expression pattern was observed for VCAM-1, the endothelial cell ligand of VLA-4. Interestingly, a strong staining pattern of the renal vascular endothelium and 35% of tubular epithelium was obtained with anti-VCAM-1 antibody in rejection, as compared with a weak reactivity in endothelium and discrete staining pattern on tubules in nephrotoxicity. On the other hand, we found that the mean percentage of infiltrating cells bearing LFA-1 molecules and the intensity of ICAM-1 (a LFA-1 ligand) expression on endothelium were closely similar in both rejection and CsA nephrotoxicity. Nevertheless, a discrete significant (P < 0.05) "de novo" expression of ICAM-1 was present on tubular cells during rejection. Our results strongly suggest that in rejection the interstitial cell infiltrate seems to be facilitated by the contribution of both LFA-1/ICAM-1 and VLA-4/VCAM-1 cell adhesion mechanisms, and also that VLA-4/VCAM-1 leukocyte interaction does not play a role in cases with CsA nephrotoxicity. Furthermore, the differential expression patterns of VLA-4 and VCAM-1 molecules found between rejection and CsA nephrotoxicity could provide valuable immunohistochemical criteria in the diagnosis of allograft dysfunction.

Hepatitis C antibody after kidney transplantation: clinical significance

The prevalence of antibodies to hepatitis C virus (HCV) was investigated in 231 renal transplantation recipients, by a first- and second-generation EIA assay and a second-generation immunoblot assay (4-RIBA). Before transplantation, prevalence of anti-HCV was 22.6% and was related to the time on dialysis (p < 0.01), transfusions (p < 0.01) and previous history of chronic liver disease (p < 0.01. Following transplantation, 32 patients (13.9%) were anti-HCV positive by the first-generation enzyme immunoassay (EIA) and it increased to 57 patients (24.7%) when anti-HCV was measured by the second-generation EIA. The 4-RIBA assay confirmed the positivity in 46 patients (80.7%), 11 patients (19.3%) were indeterminate. Seroconversion after grafting was observed in 7 negative patients, and another 7 patients became negative after the procedure. The presence of anti-HCV antibody after transplantation was determined by the patient status on dialysis, 80% of them being positive before surgery. Twenty-one 4-RIBA-positive transplantation patients (45.7%) had persistently or intermittently abnormalities on liver function tests, suggesting chronic liver disease. A liver biopsy performed on 10 of these patients showed; chronic active hepatitis in 6, chronic persistent hepatitis in 2, and chronic lobular hepatitis in the other 2 patients. Another 23 4-RIBA-positive transplantation patients had normal alanine aminotransferase levels despite long follow-up (66.2 +/- 32.2 months). The prevalence of anti-HCV antibody can be underestimated if the antibody is measured by first-generation EIA alone. About 50% of patients with anti-HCV had chronic liver disease, and the histological findings suggested a possible evolution to cirrhosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Metastatic calcification simulating a sacral tumor in a patient on periodic dialysis]

Renal osteodystrophy is usually a prominent feature in patients undergoing chronic hemodialysis. Metastatic calcifications are a frequent finding when secondary hyperparathyroidism is associated. We present a patient with a sacral soft tissue calcification resembling a malignant tumour.

Kidney transplantation in systemic lupus erythematosus nephritis: a one-center experience

Eight patients with end-stage renal disease secondary to systemic lupus erythematosus (SLE) received 8 cadaveric renal allograft. Patient and graft survival was 100 and 87%, respectively. None of them showed extrarenal manifestations of SLE or recurrence of lupus nephritis after grafting. One graft was lost because of chronic rejection. In another patient, an episode of graft function deterioration due to bad control of arterial hypertension was observed. Three patients were transplanted during their first year on hemodialysis. Two women became pregnant after successful kidney transplantation; one suffered a spontaneous abortion and the other had a successful delivery. In neither of them, was SLE observed during or after pregnancy. Morbidity was low in this series, and infections were the most frequent complication. In summary, our experience with renal transplantation in SLE patients compares, favorably with the general nodiabetic transplanted population.

Dipyridamole thallium-201 perfusion imaging for the study of ischemic heart disease in hemodialysis patients

To assess the usefulness of dipyridamole thallium perfusion imaging in the evaluation of myocardial perfusion in hemodialysis (HD), we studied 29 HD patients divided into three groups: A) 13 patients with clinical angina, B) 8 patients without angina but similar in age, sex, time on HD and hematocrit and C) 8 young asymptomatic patients (mean age 33 +/- 9.7 years). Dipyridamole thallium-201 (Tl-201) perfusion imaging revealed myocardial perfusion defects in 8 patients (61%) from group A, 4 (50%) from group B and 1 (12.5%) from group C. These defects were localized in the inferior, posterior and septal segments of the left ventricle. Abnormal myocardial perfusion was associated with age over 50 years and aortic calcifications (p less than 0.05). Eight patients died within the following four years. All had aortic calcifications (p less than 0.001). Our results show that myocardial perfusion defects are frequent even in non-symptomatic HD patients. This suggests that ischemic heart disease could be more frequent than estimated by clinical symptoms alone. Tl-201 scintigraphy may be a useful non-invasive procedure in cardiological evaluation of HD patients.

[Study of renal function after the administration of a low-osmolarity iodized contrast medium. Prospective study]

We analysed the development of various kidney function parameters in 40 patients on whom an intravenous urography had been carried out with a non-ionic contrast medium of low osmolarity (iohexol). No patient displayed prior renal insufficiency (serum creatinine 0.4-2mg/dl). Twenty-four hours after injection of the iodized contrast no significant variations in urea blood concentrations, creatinine, sodium or uric acid appeared. As a result of the urography an increase in urine osmolarity and a decrease in fractional sodium excretion took place.

IN CONCLUSION

in patients without renal insufficiency intravenous urography with iohexol does not give rise to a significant alteration in the renal excretory function.