Direct infusion of ascites into the blood circuit during hemodiafiltration in uremic patients with cirrhosis

Two chronic dialysis patients with massive ascites caused by cirrhosis were treated by infusion of their ascites directly into the blood circuit. This stabilized their hemodynamics during dialysis, facilitating the control of weight gain and ascites, and thus markedly improving their general condition. Long-term use of this therapy was able to prevent the accumulation of ascitic fluid. Interestingly, fever occurred when this therapy was performed with hemodialysis, but not with hemofiltration or hemodiafiltration, suggesting that a pyrogen in the ascites was removed by filtration.

A case of CREST syndrome and myeloperoxidase-specific anti-neutrophil cytoplasmic autoantibody-associated glomerulonephritis

We report the first case of myeloperoxidase-specific anti-neutrophil cytoplasmic autoantibody (MPO-ANCA)-associated glomerulonephritis in a patient with CREST syndrome. A 74-year-old Japanese man with CREST syndrome (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) developed rapidly progressive renal failure without elevation of blood pressure. Renal biopsy revealed glomerular sclerosis and fibrous crescents. The MPO-ANCA titer was elevated to 145 EU/ml. When patients with collagen diseases develop rapidly progressive glomerulonephritis, the possibility of MPO-ANCA-associated glomerulonephritis should be kept in mind.

Stimulation of tumour necrosis factor-alpha production by recombinant human erythropoietin may contribute to failure of therapy

Although the mechanism of unresponsiveness to recombinant human erythropoietin therapy in dialysis patients has been studied extensively in recent years, many aspects remain unclear. We previously found that administration of erythropoietin induces interleukin-1beta, a cytokine that inhibits erythropoiesis. The present study investigated the involvement of tumour necrosis factor-alpha, another cytokine which inhibits erythropoiesis. Peripheral blood mononuclear cells were obtained from 18 patients on continuous ambulatory peritoneal dialysis, who were being treated with erythropoietin for renal anaemia, and were cultured with various concentrations of erythropoietin (0, 1, 5, 10, and 50 U/ml). Then the tumour necrosis factor-alpha level in the culture supernatant was assayed. The 18 patients were divided into four groups on the basis of the haematocrit after treatment: group A (n = 3), <23.0%; group B (n = 5), 23.0-24.9%; group C (n = 7), 25.0-26.9%; and group D (n = 3), > or =27.0%. In group A, the tumour necrosis factor-alpha level in the culture supernatant was increased by incubation with erythropoietin, while it was not increased in other groups. The tumour necrosis factor-alpha level was significantly higher in group A than in the other groups at erythropoietin concentrations of 5 U/ml. These results suggested that induction of tumour necrosis factor-alpha is one of the reasons for unresponsiveness to recombinant human erythropoietin.

Two cases of hypothyroidism complicated by renal dysfunction

We report two patients in whom hypothyroidism was considered to cause renal dysfunction. Case 1 was a 65-year-old woman who stopped taking levothyroxine sodium for hypothyroidism. After 6 months, she developed proteinuria, edema, weight gain, and renal dysfunction. Renal biopsy revealed focal segmental proliferative glomerulonephritis. After re-administration of levothyroxine sodium, thyroid function and renal function both recovered. Case 2 was a 51-year-old man who presented with edema, difficulty in swallowing, muscular weakness, and fatigue. We diagnosed hypothyroidism, and focal segmental proliferative glomerulonephritis was revealed by renal biopsy. After administration of levothyroxine sodium, his symptoms resolved and his thyroid function and renal function both improved. Our experience suggests that hypothyroidism should be taken into consideration as one of the causes of renal dysfunction.

Lipid-lowering therapy and coagulation/fibrinolysis parameters in patients on peritoneal dialysis

Patients on continuous ambulatory peritoneal dialysis (CAPD) often have abnormalities of lipid metabolism or coagulation and fibrinolysis, these patients may thus be more susceptible to atherosclerosis than those on hemodialysis. It has been reported that hypercoagulability and hyperfibrinolysis are correlated with abnormalities of lipid metabolism. Therefore, we investigated the effect of a decrease in lipids on the coagulation and fibrinolysis system in CAPD patients with hyperlipidemia who received lipid-lowering therapy. The patients included 5 men and 13 women, with a mean age of 52.5 years. Pravastatin sodium (10 mg/day) and ethyl icosapentate (1800 mg/day) were administered concomitantly for 8 weeks. Lipid levels and coagulation/fibrinolysis parameters were measured before and after therapy. The patients were divided into two groups depending on their response to therapy: responders showed a decrease in total cholesterol or triglycerides by at least 20% and non-responders showed less improvement. In the responders, the levels of protein C, tissue plasminogen activator/plasminogen activator inhibitor-I complex, factor XIII, alpha2-plasmin inhibitor, and D-dimer were significantly lower after therapy than before therapy. Protein C, factor XIII, and alpha2-plasmin inhibitor were also significantly decreased after therapy in non-responders, but the extent of the decrease was smaller. The plasminogen level was significantly increased after therapy in non-responders. These findings suggest that a decrease in lipid levels and/or some other action by lipid-lowering agents may correct abnormalities of coagulation and fibrinolysis in CAPD patients.

Up-regulation of gap junctional intercellular communication by hexamethylene bisacetamide in cultured human peritoneal mesothelial cells

Gap junctional intercellular communication (GJIC) is believed to be an important means of regulating cell growth and the malignant potential of tumors. This study examined the effect of hexamethylene bisacetamide (HMBA), a hybrid polar compound and a potent differentiation inducer, on GJIC in cultured primary human peritoneal mesothelial cells. The redistribution of fluorescence after photobleaching was used to detect GJIC. After the incubation of confluent cell cultures with 3 or 6 mM HMBA for 3 and 6 days, GJIC was significantly increased in a concentration-dependent manner compared with cultures without HMBA. Western blotting showed that connexin 43 (Cx43), the major functional protein of gap junctions in peritoneal mesothelial cells, was present in unphosphorylated and phosphorylated forms in control cell cultures. The addition of HMBA to cultures induced a significant increase of total Cx43 protein because of an increase of the phosphorylated forms. Immunofluorescence studies showed that HMBA increased the intensity of fluorescence for Cx43 at cell membrane borders. Quantitative reverse transcription and PCR analysis revealed that the addition of HMBA to cultures resulted in the concentration-dependent up-regulation of mRNA for Cx43. These results indicate that HMBA induces the enhancement of GJIC in peritoneal mesothelial cells through both the up-regulation of Cx43 messages and an increase of post-translational phosphorylation. HMBA may contribute to the maintenance of cellular homeostasis through the up-regulation of GJIC.

Relationship between erythropoietin and chronic heart failure in patients on chronic hemodialysis

In the present study, the relationship between the blood erythropoietin level and cardiac function was investigated in 15 patients on chronic hemodialysis who developed chronic heart failure. Another 45 patients without cardiac dysfunction were selected as a control group that was matched for gender, age, and the duration of dialysis. The erythropoietin level was 256.3 +/- 481.8 mU/ml in the heart failure group, which was significantly higher than that in the control group (17.0 +/- 10.0 mU/ml, P < 0.01). Eight of the 15 patients in the heart failure group maintained a hematocrit of more than 30% without receiving recombinant human erythropoietin therapy, whereas 29 of the 45 patients in the control group required erythropoietin. In the heart failure group, the erythropoietin level was significantly correlated with the levels of atrial natriuretic peptide and brain natriuretic peptide (P < 0.01). These results suggest that heart failure can increase the erythropoietin level in proportion to the severity of cardiac dysfunction, even in patients on long-term dialysis.

Clinicopathological study of myeloperoxidase anti-neutrophil cytoplasmic antibody-associated glomerulonephritis

AIMS

To investigate the potential prognostic factors for myeloperoxidase anti-neutrophil cytoplasmic antibody- (MPO-ANCA) associated glomerulonephritis.

MATERIALS

The clinical and pathological findings were reviewed in 17 patients with this type of glomerulonephritis.

METHODS

The relationship between the outcome and various clinical and pathological factors were assessed. The relationship between the blood MPO-ANCA level and cellular crescent formation was also investigated.

RESULTS

Patients who died had a significantly lower serum albumin and creatinine clearance than those who survived, but there were no differences of age, blood MPO-ANCA, urinary protein, and serum creatinine levels or cellular crescent formation between the two groups. There was a close relationship between blood MPO-ANCA levels and cellular crescent formation.

CONCLUSIONS

Hypoalbuminemia and renal dysfunction may be indicators of a poor prognosis in MPO-ANCA-associated glomerulonephritis. Patients with high blood levels of this antibody and increased cellular crescent formation appear to have active disease, but these factors are not statistically associated with a fatal outcome. Therefore, aggressive treatment may be indicated in patients with active disease initially.

Apolipoprotein E polymorphism in IgA nephropathy

BACKGROUND/AIM

To clarify the role of the apolipoprotein E (Apo E) phenotype in IgA nephropathy, we investigated its relationship with histological damage and clinical factors.

METHODS

The subjects were 104 consecutive patients (41 men and 63 women) with IgA nephropathy. The Apo E phenotype was identified by plasma isoelectric focusing and immunoblotting, and the frequencies of Apo E alleles were calculated.

RESULTS

The frequencies of the phenotypes and the alleles were as follows: 2/2 = 0, 2/3 = 0.086, 3/3 = 0.654, 2/4 = 0. 010, 4/3 = 0.211, 4/4 = 0.010, 3/5 = 0.029, epsilon2 = 0.048, epsilon3 = 0.817, epsilon4 = 0.120, and others = 0.015. There were no significant differences between the IgA nephropathy patients and healthy individuals in the frequencies of Apo E phenotypes and the alleles. However, the Apo E2 phenotype was significantly more common among patients with severe histological damage than in those with mild damage. The serum triglyceride levels were significantly elevated, and the Apo E2 phenotype was significantly more prevalent in patients with severe histological damage as compared with those with mild damage.

CONCLUSION

The Apo E2 phenotype appears to be associated with the severity of histological damage in IgA nephropathy.

Myeloperoxidase antineutrophil cytoplasmic antibody-positive necrotizing crescentic glomerulonephritis and membranous glomerulonephropathy

In September 1997, a 68-year-old woman was found to have proteinuria and renal dysfunction. In December 1997, renal biopsy revealed necrotizing crescentic glomerulonephritis and membranous glomerulonephropathy. We diagnosed myeloperoxidase antineutrophil cytoplasmic antibody-positive necrotizing crescentic glomerulonephritis and membranous glomerulonephropathy because of the presence of necrotizing cellular crescents and spike lesions in the subepithelial region of the glomerular basement membrane. After steroid therapy, the antibody level and the incidence of cellular crescents showed a decrease. This is a rare case of myeloperoxidase antineutrophil cytoplasmic antibody-positive necrotizing crescentic glomerulonephritis associated with membranous glomerulonephropathy.

Evaluation of the PD Adequest Program in Japanese Patients on Peritoneal Dialysis

To perform adequate peritoneal dialysis, it is necessary to individualize the dialysis regimen. PD Adequest is a software program based on the three-pore model that can be used to predict solute clearance and ultrafiltration volume during peritoneal dialysis. We evaluated the ability of this program to predict the solute clearance and ultrafiltration volume in Japanese patients on peritoneal dialysis. The weekly creatinine clearance and weekly urea Kt/V were determined in 45 patients. The PD Adequest was used to simulate their current dialysis regimens and the predicted values of these parameters were calculated. Strong positive correlations were obtained between the actual and predicted weekly creatinine clearance (r=0.993) and weekly urea Kt/V (r=0.991). In conclusion, this program is potentially useful for designing peritoneal dialysis regimens in Japanese patients, even though they have a smaller body mass than Canadians and Americans for whom it was designed.

Evaluation of the PD adequest program in Japanese patients on peritoneal dialysis

To perform adequate peritoneal dialysis, it is necessary to individualize the dialysis regimen. PD Adequest is a software program based on the three-pore model that can be used to predict solute clearance and ultrafiltration volume during peritoneal dialysis. We evaluated the ability of this program to predict the solute clearance and ultrafiltration volume in Japanese patients on peritoneal dialysis. The weekly creatinine clearance and weekly urea Kt/V were determined in 45 patients. The PD Adequest was used to simulate their current dialysis regimens and the predicted values of these parameters were calculated. Strong positive correlations were obtained between the actual and predicted weekly creatinine clearance (r = 0.993) and weekly urea Kt/V (r = 0.991). In conclusion, this program is potentially useful for designing peritoneal dialysis regimens in Japanese patients, even though they have a smaller body mass than Canadians and Americans for whom it was designed.

Correction of CAPD catheter displacement using gastric biopsy forceps: the push-pull method

We corrected malpositioned continuous ambulatory peritoneal dialysis catheters in six patients using a new technique named the "push-pull method". A gastric biopsy forceps was advanced through the catheter to near its tip. After manipulating the tip of the forceps through the abdominal wall, the forceps was opened and pulled out slowly. Repeated insertion and removal of the forceps induced the catheter to return to the pelvic cavity. This push-pull method was successful for Swan neck straight (n=2) and coiled (n=4) catheters in all patients. The time required for the procedure was only 5-10 minutes and there were no complications.

Chronic rheumatoid arthritis complicated by myeloperoxidase antineutrophil cytoplasmic antibody-associated nephritis

We report a myeloperoxidase antineutrophil cytoplasmic antibody-positive rheumatoid arthritis patient who developed necrotizing crescentic glomerulonephritis. Steroid therapy was given combined with an immunosuppressant agent, and double-filtration plasmapheresis was started with the aim of removing antibodies from the blood. This therapeutic regimen was found to be useful.

Effect of pH and glucose on cultured human peritoneal mesothelial cells

OBJECTIVE

We investigated the effects of various pH and glucose concentrations on the growth of human peritoneal mesothelial cells and on coagulation and fibrinolytic factors.

MATERIALS AND METHODS

Cells were cultured at various pH values in Ham's F-12 medium containing 1.0% foetal calf serum and supplemented with D-glucose or D-mannitol at various concentrations. After 4-48 h, cell proliferation and 3H-thymidine incorporation were determined. Coagulation and fibrinolytic factors were measured after 48 h.

RESULTS

Glucose caused concentration-dependent inhibition of cell growth at all pH values, but the deleterious effect of low pH on cell proliferation was faster and stronger than that of high glucose. At a similar osmolality, mannitol caused less inhibition of cell proliferation than glucose. There was a glucose concentration-dependent increase of thrombin-antithrombin III complex production at all pH values. At pH 5.2, tissue-type plasminogen activator production was far lower than at higher pH values, and production of the plasminogen activator inhibitor showed a glucose concentration-dependent increase. At pH 6.5 or 7.3, however, the plasminogen activator inhibitor production decreased and tissue-type plasminogen activator production increased in a glucose concentration-dependent manner.

CONCLUSIONS

Low pH and/or high glucose culture medium had an inhibitory effect on peritoneal mesothelial cells, with the effect of high glucose being partially related to hyperosmolality. These cells may modulate peritoneal coagulant and fibrinolytic activity, with the balance between coagulation and fibrinolysis being disturbed by low pH and/or high glucose.

Localization of transforming growth factors beta1 and beta2 and epidermal growth factor in IgA nephropathy

OBJECTIVE

The localization of transforming growth factor (TGF)-beta1. TGF-beta2 and epidermal growth factor (EGF) was investigated in IgA nephropathy, and was compared with the severity of histological damage (including tubulointerstitial lesions).

MATERIALS AND METHODS

The enzyme antibody method was used to stain paraffin-embedded sections of renal tissue from 42 patients with IgA nephropathy (19 males and 23 females).

RESULTS

There was a significant correlation between glomerular positivity for TGF-beta1 and TGF-beta2 and the severity of histological damage. There was also a significant correlation between positivity for TGF-beta1 and TGF-beta2 in the tubular epithelium and tubulointerstitial lesions. In contrast, there was no relationship between glomerular positivity for EGF and histological damage, although there was a significant correlation between positivity for EGF in the tubular epithelium and tubulointerstitial lesions.

CONCLUSIONS

These findings suggest that TGF-beta1 and TGF-beta2 may be important in the progression of IgA nephropathy, and that the distribution of EGF may also be a useful marker for the progression of renal damage, including tubulointerstitial lesions.

A case of antiphospholipid antibody syndrome diagnosed after thrombosis of an arteriovenous shunt

A 32-year-old male dialysis patient with lupus nephritis was admitted because of shunt obstruction. The arteriovenous fistula was reconstructed, but obstruction recurred twice within several hours after surgery. A high blood level of anticardiolipin beta2-glycoprotein I antibody suggested that shunt obstruction was caused by a thrombotic tendency related to the antiphospholipid antibody syndrome. Accordingly, for the third shunt procedure, antiplatelet therapy (which had been commenced for systemic lupus erythematosus) was combined with dalteparin sodium from before surgery and warfarin was added postoperatively. This regimen prevented shunt obstruction. In conclusion, hemodialysis patients who suffer repeated shunt obstruction should be examined for antiphospholipid antibody syndrome.

Effect of lipoproteins on mesangial cell proliferation

BACKGROUND

Triglyceride (TG)-rich lipoproteins have been reported to promote atherosclerosis, but little is known about their role in kidney disease or about their effects on mesangial cells. Accordingly, the purpose of this study was to investigate which lipoproteins could influence mesangial cell proliferation in vitro. We assessed the effect of various lipoproteins [very low-density lipoprotein (VLDL), intermediate-density lipoprotein (IDL), low density lipoprotein (LDL), oxidized LDL, and high-density lipoprotein (HDL)] on the proliferation of cultured human mesangial cells and also assessed the influence of these lipoproteins on cytokine production.

METHODS

We investigated the effect of various lipoproteins on cultured human mesangial cells using 3H-thymidine incorporation and cell counting assays and investigated the levels of several cytokines [interleukin (IL)-6, platelet-derived growth factor (PDGF), transforming growth factor (TGF)-beta, and tumor necrosis factor-alpha] in mesangial cell culture supernatants after stimulation by the lipoproteins.

RESULTS

Not only LDL but also TG-rich lipoproteins (VLDL and IDL) promoted the proliferation of mesangial cells up to certain concentrations, but cell growth was actually decreased at higher concentrations. Oxidized LDL caused a concentration-dependent decrease of 3H-thymidine incorporation, and HDL had no proliferative effect at any concentration. Exposure to VLDL, IDL, LDL, or a high concentration of HDL enhanced the secretion of IL-6, PDGF-AB, and TGF-beta by mesangial cells, whereas TNF-alpha secretion was stimulated by oxidized LDL.

CONCLUSIONS

TG-rich lipoproteins, LDL, and oxidized LDL may be involved in mesangial cell proliferation and injury in patients with mesangial proliferative glomerulonephritis.

Apolipoprotein E polymorphism and renal disease

BACKGROUND

Lipid abnormalities are frequently found in end-stage renal disease (ESRD), and abnormal lipid metabolism may contribute to the progression of renal disease. Previous investigators have reported that apolipoprotein E (apoE) has an important role in lipoprotein metabolism and that the process of lipoprotein catabolism varies according to the apoE phenotype. In addition, the relative frequency of the apoE alleles is different among the races. In this study, we investigated the allele frequency of apoE phenotypes and evaluated the impact of apoE polymorphism on lipid profile in Japanese patients with renal disease.

METHODS

ApoE phenotypes were determined using isoelectric focusing and Western blotting in 592 Japanese patients with renal disease [86 out of 107 patients with glomerulonephritis had proteinuria of not less than 0.25 g per 24 hr and 485 with ESRD; 448 were on hemodialysis (HD), and 37 were on continuous ambulatory peritoneal dialysis (CAPD)]. The allele frequency and apoE phenotype distribution were estimated by the gene-counting method. Serum lipid parameters related to lipid metabolism were measured after at least a 12-hour fast.

RESULTS

The allele frequency of the three major apoE phenotypes (apoE2, apoE3, and apoE4) in 107 glomerulonephritis patients (epsilon 2; 0.037, epsilon 3; 0.860, epsilon 4; 0.103) was almost identical to that in the normal control population (epsilon 2; 0.036, epsilon 3; 0.848, epsilon 4; 0.115). However, 86 glomerulonephritis patients with proteinuria had higher allele frequency of apoE2 (epsilon 2; 0.052, P < 0.01) and apoE4 (epsilon 4; 0.140, P < 0.001) and lower allele frequency of apoE3 (epsilon 3; 0.808, P < 0.001) than the controls. Furthermore, ESRD patients had higher allele frequency of apoE2 (epsilon 2; 0.058, P < 0.01) and lower allele frequency of apoE4 (epsilon 4; 0.091, P < 0.05) than the controls. Higher prevalence of nephrotic syndrome was found in proteinuric glomerulonephritis patients with apoE2. The impact of apoE polymorphism on serum lipid profile in patients with glomerulonephritis, HD, and CAPD was different from that generally expected.

CONCLUSIONS

The higher frequency of apoE2 in ESRD patients suggests that apoE2 is a possible genetic predisposition to ESRD in a Japanese population. The impact of apoE2 and apoE4 on lipid profile in patients with renal disease was unique and different from that in the normal population.

Hyperimmunoglobulin E syndrome associated with nephrotic syndrome

A 21-year-old man was admitted to Kure National Hospital with nephrotic syndrome in September 1996. He had suffered from an intractable pruritic skin rash and recurrent subcutaneous abscesses caused by the hyperimmunoglobulin E syndrome since the age of 18 months. Renal biopsy gave a diagnosis of membranoproliferative glomerulonephritis. Steroid therapy decreased urinary protein loss and hypoproteinemia, and his pruritic skin rash was improved. Patients with hyperimmunoglobulin E syndrome have a defective immune response, especially to Staphylococcus aureus infection. Continuous antigen stimulation may have caused this patient's renal histological damage as in immune complex glomerulonephritis.

A case of aortitis syndrome and IgA nephropathy: possible role of human leukocyte antigens in both diseases

A 51-year-old woman, who had both aortitis syndrome (Takayasu arteritis) and IgA nephropathy, presented with hypertension, fever, a high erythrocyte sedimentation rate, high C-reactive protein and serum IgG levels, proteinuria, and renal dysfunction. Renal arteriography showed stenosis and poststenotic dilatation at the origin of the right renal artery, as well as tortuosity of the left renal artery branches and marked atrophy of the left kidney. Renal biopsy showed IgA nephropathy with deposits of IgA, C3, and fibrinogen in the glomeruli and arteriolosclerosis. The present patient had human leukocyte antigen (HLA)-B 52, which is reported to be related to the aortitis syndrome, as well as HLA-DR 4, which is possibly related to IgA nephropathy, suggesting that HLA status may be involved in the pathogenesis of both diseases.

Screening for gastroenterological malignancies in new and maintenance dialysis patients

To screen for gastroenterological malignancies in dialysis patients, we used the fecal occult blood test, examined the upper and lower gastrointestinal tract, and used abdominal ultrasonography in 178 patients starting dialysis (171 on hemodialysis and 7 on continuous ambulatory peritoneal dialysis (CAPD)) and 34 patients on maintenance dialysis (27 on hemodialysis and 7 on CAPD). Screening disclosed ten cancers (one esophageal cancer, three gastric cancers, four colorectal cancers, and two hepatocellular carcinomas) in 9 of the patients starting dialysis. Six cancers (one esophageal, three gastric, one colorectal, and one renal) were detected in 5 of the patients on maintenance dialysis. Since an increased incidence of malignancy has been reported in dialysis patients, gastroenterological screening appears to be worthwhile.

Transforming growth factor-beta1 may be involved in shunt obstruction in patients on chronic hemodialysis

Obstructed shunt vessels were studied immunohistochemically to clarify the mechanism of shunt obstruction in hemodialysis patients. The subjects were 12 hemodialysis patients with shunt obstruction, and 8 patients newly started on hemodialysis were used as the controls. Cryosections of shunt tissue were prepared and stained for thrombomodulin as well as transforming growth factor-beta1 using the enzyme antibody method. In the obstructed shunt group, the intima was significantly thicker than in the control group. In addition, staining of the intima for thrombomodulin was decreased in the obstructed shunt group when compared with the controls. Staining for transforming growth factor-beta1 was related to intimal thickening and cell proliferation. These results indicate that release of thrombomodulin occurs with vascular endothelial cell damage and that transforming growth factor-beta1 may be involved in intimal hypertrophic change and shunt obstruction.

Interleukin-6 localization and the prognosis of IgA nephropathy

Various cytokines and growth factors may be involved in IgA nephropathy. To clarify whether interleukin-6 was a prognostic factor for this disease, we investigated interleukin-6 positivity of renal biopsy specimens and its relationship with the prognosis. The subjects were 90 patients with IgA nephropathy (42 males and 48 females with a median age of 32.7 +/- 13.8 years). Renal biopsy specimens were stained for interleukin-6 using an enzyme-antibody method. Fifty-two of 90 patients showed glomerular positivity for interleukin-6. Among the patients positive for interleukin-6, 24-hour urinary protein excretion and serum creatinine levels were significantly higher at the time of biopsy than in the patients without interleukin-6 positivity, while creatinine clearance was significantly lower. In the interleukin-6-positive patients without steroid therapy, serum creatinine increased significantly after 1 year (Deltas-Cr; 1.04 +/- 0.45 mg/dl) and creatinine clearance decreased significantly (DeltaCcr; -11.7 +/- 3.2 ml/min) compared to the interleukin-6-negative patients without steroid therapy. Steroid therapy improved 24-hour urinary protein excretion, serum creatinine, and creatinine clearance in the interleukin-6-positive patients, while these parameters worsened without steroid therapy. On the other hand, the IL-6-negative patients showed no differences of clinical parameters irrespective of the presence or absence of steroid therapy. In conclusion, glomerular interleukin-6 positivity may be a prognostic factor and an indicator of the need for steroid therapy in IgA nephropathy.

Factors influencing arteriovenous fistula dysfunction in Japanese patients on chronic hemodialysis

Arteriovenous fistula dysfunction is a constant problem in chronic hemodialysis patients. We investigated the factors influencing fistula dysfunction in 184 patients on chronic hemodialysis. Stepwise regression analysis and Cox proportional hazards model were used to assess the relationship between fistula dysfunction and age, sex, duration of hemodialysis, diabetes mellitus, hematocrit, serum creatinine, blood urea nitrogen, Kt/V, prothrombin time, blood pressure, anticoagulant therapy, dose of erythropoietin, calcium channel blocker therapy, and angiotensin-converting enzyme inhibitor therapy. Fistula dysfunction showed a significant relationship with a low systolic blood pressure, a low hematocrit, the presence of diabetes mellitus, and angiotensin-converting enzyme inhibitor therapy. These results suggested that treatment with angiotensin-converting enzyme inhibitors may help to prevent fistula dysfunction.

Tissue factor and tissue factor pathway inhibitor in hemodialysis patients

Tissue factor and tissue factor pathway inhibitor are important in extrinsic coagulation. We investigated their clinical significance in hemodialysis patients. We took blood samples, prior to initiation of routine hemodialysis, from 73 patients on hemodialysis (35 men and 38 women aged 56.1+/-11.7 years on dialysis for 82.1+/-61.0 months), and determined tissue factor and tissue factor pathway inhibitor levels by ELISA. In the patients the tissue factor level was 704.5+/-141.6 pg/ml and the tissue factor pathway inhibitor level was 44.5+/-23.3 ng/ml; both values were significantly higher than in normal controls (192.7+/-36.6 pg/ml and 18.6+/-5.7 ng/ml, respectively). In patients with shunt obstruction, tissue factor pathway inhibitor levels were significantly higher than in those without it. Therefore, the tissue factor pathway inhibitor level may be a marker of shunt obstruction.

Plasmapheresis for removal of myeloperoxidase antineutrophil cytoplasmic antibodies: a case report

We report on a patient with myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA) associated glomerulonephritis who had an elevated MPO-ANCA level and necrotizing crescentic glomerulonephritis on renal biopsy. She was treated by double filtration plasmapheresis and immunoadsorption plasmapheresis combined with steroid therapy and immunosuppressive agents. After plasmapheresis, the MPO-ANCA level decreased, and the cellular crescents were reduced. We conclude that plasmapheresis combined with steroid and immunosuppressive therapy may be useful to decrease the activity of MPO-ANCA associated crescentic glomerulonephritis.

Tenascin expression may reflect the activity and chronicity of human IgA nephropathy

BACKGROUND

Tenascin is a large oligomeric glycoprotein component of the extracellular matrix that increases rapidly after inflammation or injury, suggesting that it may be an indicator of renal disease activity. Histological activity and chronicity indices are currently used to evaluate the activity and chronicity of IgA nephrophathy.

PATIENTS AND METHODS

We investigated whether tenascin staining could be an indicator of activity or chronicity in patients with IgA nephropathy using immunohistochemical and in situ polymerase chain reaction methods. Immunostaining for tenascin was done on 58 renal specimens, (51 from IgA nephropathy patients and 7 from normal kidneys), and the in situ polymerase chain reaction was performed on 24 renal specimens (21 from IgA nephropathy patients and 3 from normal kidneys).

RESULTS

Tenascin expression in the glomeruli was correlated with tenascin expression in the tubulointerstitium (protein; r = 0.386, p = 0.0063, mRNA; r = 0.510, p = 0.0225). Tenascin protein staining in the glomeruli was correlated with the chronicity index (r = 0.506, p = 0.0003), and glomerular tenascin mRNA positivity was correlated with the activity index (r = 0.449, p = 0.0448).

CONCLUSION

Tenascin expression was similar in the glomeruli and tubulointerstitium, but glomerular staining more closely reflected the pathological state. Tenascin protein expression may be an indicator of chronicity and tenascin mRNA expression may be an indicator of disease activity in IgA nephropathy.

Vancomycin therapy for treatment of peritonitis in outpatients on peritoneal dialysis

Vancomycin therapy is frequently used for peritonitis in patients on peritoneal dialysis, but the emergence of resistance has been reported. We evaluated the efficacy of a single intraperitoneal dose of vancomycin for peritonitis in peritoneal dialysis patients. We assessed 24 episodes of peritonitis in 16 patients, and compared clinical parameters between responders and nonresponders. Vancomycin was effective for 12 patients (18 out of 24 episodes, 75.0%). Nonresponders had a significantly higher initial C-reactive protein level and dialysis fluid leukocyte count, and the mean serum albumin over three months before onset was significantly lower than in responders. Patients with a serum albumin level 3.0 g/dl or more were significantly more likely to respond than those with a level less than 3.0 g/dl. In conclusion, it seems reasonable for peritonitis patients with a mild inflammatory response and a serum albumin 3.0 g/dl or more to receive intraperitoneal vancomycin on an outpatient basis.

Effects of dialysis membranes on the kinetics of tumor necrosis factor-alpha production by peripheral mononuclear cells in chronic hemodialysis patients

To evaluate the biocompatibility of dialysis membranes, blood samples were collected from 10 hemodialysis patients immediately before dialysis and peripheral blood mononuclear cells were isolated. The 3.0 x 10(5) cells/ml were then passed 30 times through modules made of a polyethylene glycol-grafted cellulose membrane, a polyacrylonitrile membrane, and a polysulfone membrane. Expression of messenger RNA for tumor necrosi factor-alpha (TNF-alpha) was determined. Cells were also cultured for 2 h with and without lipopolysaccharide and TNF-alpha levels in the supernatant were measured. TNF-alpha messenger RNA expression was significantly higher immediately after passage through the polyacrylonitrile membrane compared with the other membranes. Cells cultured without lipopolysaccharide, produced significantly less TNF-alpha after passage through the polysulfone membrane, while lipopolysaccharide significantly increased TNF-alpha production by cells passed through the polyacrylonitrile membrane. These results suggest that biocompatibility differs even among dialysis membranes believed to cause no complement activation.

Nonasthmatic case of Churg-Strauss syndrome with rapidly progressive glomerulonephritis

A 61-year-old man developed mononeuritis multiplex accompanied by eosinophilia in 1993. Approximately 3 years later, acute renal dysfunction, a subendocardial tumor, and a high peripheral anti-neutrophil cytoplasmic antibody titer were also detected. Renal biopsy revealed glomerular crescents and interstitial infiltration of eosinophils, so allergic granulomatosis and angiitis was diagnosed. These clinical abnormalities regressed with steroid therapy. He had no history of asthma. This was therefore considered to be an atypical form of Churg-Strauss syndrome with rapidly progressive glomerulonephritis.

Dose escalation induces tolerance to side-effects of erythropoietin in a patient with dialysis anaemia: case report

A 51-year-old woman began haemodialysis for chronic renal failure in February 1981. Symptomatic anaemia required treatment with recombinant human erythropoietin (rHuEPO) in February 1990 (3000 IU, twice weekly, intravenously). She developed influenza-like symptoms and treatment was withdrawn. In June 1994 rHuEPO was resumed at a very low dose of 100 IU subcutaneously three times weekly, and was increased gradually to 500 IU, without inducing any side-effects. At this dose the haematocrit was maintained at 22.0-25.0% and the symptoms of anaemia improved. In patients like ours, with influenza-like symptoms caused by rHuEPO therapy, dose escalation starting from an ultra-low dose may be effective in avoiding side-effects.

CAPD catheter rupture without deterioration

Continuous ambulatory peritoneal dialysis (CAPD) is associated with various problems, including damage to the CAPD catheter. We encountered catheter rupture around the titanium adaptor in a patient who had been on CAPD for 7 years. The area near the adaptor generally suffers damage secondary to deterioration of the silicon composing the catheter. However, stereoscopic and electron microscopic observation of the surface of the catheter revealed no deterioration. Instead, there were fine scratches around the site of rupture and the broken surface was rough. Since the patient did not protect the catheter with gauze near the titanium adaptor, it was probably damaged by the adaptor and then ruptured by some external force.

Fatal hepatic failure caused by miliary tuberculosis in a hemodialysis patient: case report

A 57 year-old male dialysis patient died soon after the onset of high fever, hypoglycemia, and disturbance of consciousness. Autopsy revealed granulomatous lesions associated with caseous necrosis mainly found in the liver, despite the absence of pulmonary changes on chest radiographs performed during the patients illness. It appears that tubercle bacilli were hematogenously disseminated mainly to the liver causing miliary tuberculosis without producing typical diffuse lesions in the lungs. Since tuberculosis is a common complication in hemodialysis patients, the potential development of atypical miliary tuberculosis should always be borne in mind.

Factors Influencing Arteriovenous Fistula Dysfunction in Japanese Patients on Chronic Hemodialysis

Arteriovenous fistula dysfunction is a constant problem in chronic hemodialysis patients. We investigated the factors influencing fistula dysfunction in 184 patients on chronic hemodialysis. Stepwise regression analysis and Cox proportional hazards model were used to assess the relationship between fistula dysfunction and age, sex, duration of hemodialysis, diabetes mellitus, hematocrit, serum creatinine, blood urea nitrogen, Kt/V, prothrombin time, blood pressure, anticoagulant therapy, dose of erythropoietin, calcium channel blocker therapy, and angiotensin-converting enzyme inhibitor therapy. Fistula dysfunction showed a significant relationship with a low systolic blood pressure, a low hematocrit, the presence of diabetes mellitus, and angiotensin-converting enzyme inhibitor therapy. These results suggested that treatment with angiotensin-converting enzyme inhibitors may help to prevent fistula dysfunction.

Myeloperoxidase-antineutrophil cytoplasmic antibody-associated glomerulonephritis with membranous nephropathy in remission

A 47-year-old woman developed pulmonary hemorrhage and an increase in proteinuria during remission of membranous nephropathy. Renal biopsy revealed crescentic glomerulonephritis. She also had a high perinuclear antineutrophil cytoplasmic antibody level, so a diagnosis of myeloperoxidase-antineutrophil cytoplasmic antibody-associated glomerulonephritis was made. After immunosuppressive therapy was started, the pulmonary hemorrhage resolved and her proteinuria decreased. Renal biopsy was repeated after treatment and showed histological improvement. This case suggests that there may be a relationship between membranous nephropathy and myeloperoxidase-antineutrophil cytoplasmic antibody-associated glomerulonephritis.

Low-density lipoprotein apheresis for focal glomerular sclerosis

We report on a 22-year-old female with focal glomerular sclerosis and hyperlipidemia who did not respond to long-term steroid or immunosuppressant therapy. When low-density lipoprotein (LDL) apheresis was performed, her total daily protein excretion decreased, serum albumin increased, total cholesterol decreased from 1,052 mg/dl to 148 mg/dl after 3 months, and the serum lipoprotein(a) level also decreased from 117.8 mg/dl to 9.1 mg/dl. After this therapy, her clinical course was well maintained. By controlling hyperlipidemia, including oxidized low-density lipoprotein and lipoprotein(a), low-density lipoprotein apheresis may produce clinical improvement in focal glomerular sclerosis.

Localization of hepatocyte growth factor and tubulointerstitial lesions in IgA nephropathy

To investigate the relationship between localization of hepatocyte growth factor (HGF) and tubulointerstitial lesions (TILs) in the cortical area of renal biopsy specimens, a clinicopathological study was performed in 35 patients with IgA nephropathy. HGF was detected by an enzyme-antibody method and TILs were assessed semiquantitatively by light microscopy. HGF was observed mainly on epithelial cells in the tubules, but not in the glomeruli. Fourteen patients had biopsies that were positive for HGF. There was a correlation between HGF positivity and histological damage, the TIL grade, and several clinical parameters determined at biopsy. Thus, HGF is related to TILs in IgA nephropathy, and may be a factor in the exacerbation of this disease.

Myeloperoxidase antineutrophil cytoplasmic autoantibody-associated glomerulonephritis in a very elderly patient with generalized vasculitis at autopsy

An 86-year-old woman was admitted with hemoptysis and rapid deterioration of renal function. Renal biopsy disclosed necrotizing crescentic glomerulonephritis. Based on positivity for serum myeloperoxidase antineutrophil cytoplasmic autoantibody (MPO-ANCA), MPO-ANCA-associated glomerulonephritis was diagnosed. Steroid pulse therapy was performed, but the patient died after the second course. Autopsy revealed renal vasculitis with fibrinoid necrosis extending to the level of the arcuate arteries. Vasculitis was also observed in the liver, adrenal gland, uterus, and spleen, suggesting the presence of microscopic polyarteritis. This case demonstrates the broad spectrum of MPO-ANCA-positive vasculitis and suggests the need for a more effective therapy suitable for very elderly patients.

A case of nephrotic syndrome with rapid spontaneous remission in an elderly patient

In July 1994, a 70-year-old woman was diagnosed as having nephrotic syndrome with proteinuria of 8 to 10 g/day and a serum albumin level of 1.8 g/dl. She was hospitalized in August 1994 for investigation. The urinary findings then normalized, with urinary protein and occult blood both negative and total urinary protein excretion at 0 g/day. A renal biopsy was performed, and spontaneous remission of minimal change nephrotic syndrome was diagnosed. This is an interesting case involving rapid remission of minimal change nephrotic syndrome in an elderly patient.

Role of tenascin in human immunoglobulin A nephropathy

Tenascin is a component of the extracellular matrix that responds rapidly to inflammation or injury. The activity index and chronicity index of immunoglobulin A nephropathy are mainly used to decide whether or not steroid therapy is indicated, but are sometimes difficult to evaluate histologically. We investigated whether tenascin staining of the glomeruli was an indicator of the activity or chronicity indices in patients with immunoglobulin A nephropathy. Tenascin staining was evaluated immunohistochemically in 38 renal specimens, including 32 from patients with immunoglobulin A nephropathy and six from control kidneys, and the extent of staining was scored. Tenascin staining was correlated with the chronicity index (r = 0.643, P < 0.0003) but not with the activity index.