Cyclosporine nephrotoxicity in lung transplant recipients

End-stage lung disease has been treated successfully by lung transplantation (LTXP) at our institution since 1983. We report on the renal function of 30 LTXP recipients who were followed for at least 6 months (mean, 39 months; range, 6-60 months). All patients received quadruple immunosuppressive therapy including cyclosporine A, with a trough serum level (RIA) between 150 and 250 ng/ml for the first 6 months between 125 and 150 mg/ml after 6 months. The mean serum creatinine (SeCr) increased from a baseline value of 75 +/- 3.5 to 182 +/- 13.9 microM at the end of the follow-up. The greatest change in SeCr occurred within the first 6 months post LTXP. Fifteen of 30 patients who were initially normotensive required at least one antihypertensive medication post LTXP. By the end of the follow-up, 9 patients had SeCr > 200 microM. Two patients in this institution have progressed to end-stage renal disease requiring dialytic therapy. CsA nephrotoxicity has emerged as a major source of morbidity in the lung transplant population. Nephrotoxicity occurs early, and there does not appear to be any trend toward reversibility despite a lowering of the dose. Renal parenchymal injury may be progressive, despite an apparent plateau of the SeCr in some patients.

A randomized controlled trial of prednisone in patients with idiopathic membranous nephropathy

We conducted a prospective randomized study in which patients with biopsy-confirmed idiopathic membranous nephropathy were assigned to receive either a six-month course of prednisone given on alternate days (45 mg per square meter of body-surface area; n = 81) or no specific treatment (n = 77). The mean duration of follow-up was 48 months. Patients in the prednisone group (median age, 46 years) entered with a mean disease duration of 15 months, a median creatinine clearance of 1.2 ml per second per 1.73 m2 (range, 0.25 to 2.6), and a median rate of urinary protein excretion of 6.8 g per day (0.3 to 26). The annual change in the corrected creatinine clearance at six months did not differ between the prednisone group and the control group (0.10 vs. 0.06 ml per second; P = 0.8), or at the last follow-up evaluation (-0.07 vs. -0.02 ml per second; P = 0.2; 95 percent confidence interval on the difference, -0.03 to 0.13). The proportion of patients with complete remission of proteinuria was also similar in the groups at 6 and 12 months and after a mean of 48 months. Outcomes were similar in the two groups with respect to progression to renal failure (3 vs. 4 patients), death (3 vs. 1 patient), complete remission of proteinuria at 36 months (16 vs. 19 patients), and a decline of 25 percent or more in the creatinine clearance at 60 months (32 vs. 25 percent of patients). A multivariate analysis, which adjusted for differences at entry in sex distribution, urinary protein excretion, and creatinine concentration, as well as other prognostic variables, failed to provide an explanation for the lack of effect of prednisone. We conclude that a six-month course of therapy in which prednisone is given on alternate days is of no benefit to patients with idiopathic membranous nephropathy.

Early function as the principal correlate of graft survival. A multivariate analysis of 200 cadaveric renal transplants treated with a protocol incorporating antilymphocyte globulin and cyclosporine

We examined the factors determining graft survival in 200 consecutive cadaveric renal transplants managed on a quadruple-therapy protocol: Minnesota antilymphoblast globulin, cyclosporine, azathioprine, and low-dose prednisone. Perioperative central venous pressure monitoring and volume expansion were emphasized. To avoid CsA nephrotoxicity in the early posttransplant period, patients were treated with ALG until renal function was established (a mean of 7 days). Therapeutic CsA levels were achieved before ALG was discontinued. Azathioprine was used to supplement CsA in patients with nephrotoxicity or rejection. Twelve-month graft survival was 85% (first transplants 86%, retransplants 79%), with patient survival of 95%. ALG was not associated with excessive clinical cytomegalovirus infections, which occurred in 5% of patients, or with malignancy. When 3 technical failures were excluded, an analysis of numerous factors in the pretransplant and peritransplant period revealed that the strongest correlate of one-year graft survival was early renal function. Grafts with delayed function (DF) had 75% survival, compared with 91% for grafts with good early function (EF). A multivariate analysis confirmed this association: the relative risk of graft loss was increased 2.86 times for DF compared with EF. The mechanism of the deleterious effect of DF was apparently multifactorial: the DF group, by definition, contained all the kidneys that never functioned, but some risk also persisted in kidneys that achieved function. One reason for this may be that DF kidneys that achieved function had higher mean serum creatinine values at 1 month: elevated serum creatinine values at 1 month were strongly associated with increased risk of graft loss regardless of initial function. There was also a higher number of rejection episodes diagnosed in the DF group. These observations suggest that early renal function is a major determinant of graft outcome and should be a target for efforts to further improve renal graft survival.

Effect of ciclosporin on active Heymann nephritis

The effects of ciclosporin on active Heymann's nephritis starting at different times after induction was studied. When given at the time of antigen injection, ciclosporin blocked both free antibody and circulating immune complex formation. Immunopathology and renal function tests remained normal in this group despite a rise in both these parameters to control values after ciclosporin was discontinued. When given at a later stage of the disease process, despite suppression of both antibody and complex formation, neither pathology nor functional parameters were modified. This suggests either a limited time frame for immunologically mediated injury in Heymann's nephritis or that early treatment with ciclosporin may permanently alter a vital primary step in the immunopathogenesis.

Nutritional assessment of continuous ambulatory peritoneal dialysis patients

This study revealed the following. Malnutrition was frequent (41.6%) in patients on CAPD for less than three months and was present in 18.1% of patients on CAPD for longer than 3 months. Fifty percent of these malnourished patients returned to normal on conventional nutritional management within 2 to 6 months, but 10% remained malnourished throughout the study period. There was increased mortality among malnourished patients, but we were unable to demonstrate that the state of nutrition was an independent risk factor, because of the increased prevalence of other co-morbid risk factors known to influence survival and because of the limitation of a small sample size. The influence, if any, of nutritional state as an independent risk factor on the survival of CAPD patients should be answered, because malnutrition is potentially reversible with aggressive nutritional interventions, such as enteral, parenteral, or intraperitoneal supplementation.

Plasmapheresis and antiplatelet agents in the treatment of the hemolytic uremic syndrome secondary to mitomycin

Four patients with the hemolytic uremic syndrome secondary to mitomycin therapy were treated with intense plasmapheresis and antiplatelet agents. All four patients had a hematologic response and three had slow, but steady, improvement in renal function. These results suggest an important role for these agents in mitomycin-induced hemolytic uremic syndrome.

Results of a controlled drug trial in membranoproliferative glomerulonephritis

A prospective randomized drug trial was carried out on 59 patients with confirmed membranoproliferative glomerulonephritis (MPGN). The treatment group (27 patients) received cyclophosphamide, coumadin, and dipyridamole for 18 months, and the control group (32 patients) received no specific therapy. Complications of the renal disease such as hypertension and fluid retention were treated similarly in both groups. Entrance criteria included confirmed renal pathology demonstrating either types I or II MPGN, a corrected creatinine clearance (CCr) of less than 80 ml/min/1.73 m2, and/or proteinuria greater than 2 g/day. Actuarial survival was not different between the treatment and the control groups in either MPGN type and was 85% in type I and 90% in type II at 2 years. The change in renal function, as measured by both the slope of CCr and the plasma creatinine reciprocal (1/Cr) at 6, 12, and 18 months was not significantly different between treatment and control groups in either types I or II when tested by both parametric and nonparametric analysis. The age, sex, and initial level of CCr did not influence the rate of decline. Control and treatment group proteinuria was not different at any time point in either types I or II MPGN. The small numbers of type II MPGN cases do not give sufficient power to allow conclusions regarding this therapy in type II. We can conclude that this treatment is ineffective in altering the natural history of type I MPGN.

Adult hemolytic-uremic syndrome: successful treatment with plasmapheresis

Two adult patients with the hemolytic-uremic syndrome were treated successfully with intense plasma exchange. One patient had recurrent episodes and, with each relapse, both their thrombocytopenia and acute renal failure were reversed with plasma exchange therapy alone. These cases demonstrate the useful role of plasma exchange in the therapy of severe idiopathic hemolytic-uremic syndrome in adults.

Ribonuclease inhibition of erythropoiesis in anemia of uremia

The anemia of chronic renal failure was studied by assessing the effect of uremic serum on proliferation of human marrow erythroid stem cells into colonies in vitro. Of 50 sera tested, 46 inhibited "CFU-E" colony formation by a mean of 72%, and 42 inhibited "BFU-E" colonies by a mean of 53.5%, compared to normal sera. Analysis of the uremic sera revealed a striking increase of ribonuclease activity in every patient. Mean activity in the study group was 17,346 U/ml serum (range 6,700-36,250) compared to control mean of 1,047 +/- 247 U/ml. Purified ribonuclease added to marrow cultures in concentrations simulating uremic serum produced a dose-dependent decrease in CFU-E colonies suggesting that the substance has a role in the production of anemia of renal failure.

Anemia of chronic renal failure: inhibition of erythropoiesis by uremic serum

The pathogenesis of anemia in patients with end-stage renal disease was studied by assessing the effect of uremic serum on the proliferation and maturation of erythroid progenitor cells, BFU-E and CFU-E, into colonies in vitro. Nucleated peripheral blood cells from 10 anemic patients produced normal or increased numbers of BFU-E colonies in response to added erythropoietin when cultured in control serum, but declined a mean of 63% when autologous uremic serum was substituted. Uremic sera from 90 patients cultured with normal human marrow produced a mean decrease in BFU-E colony growth of 72%, and of CFU-E colony growth of 82%, compared to control serum. Neither hemodialysis nor peritoneal dialysis was effective in removing the inhibitor. We conclude that patients with uremia have adequate circulating erythroid progenitors that respond to erythropoietin normally when removed from the uremic environment, and that uremic serum is toxic and inhibitory to erythropoiesis. This may be an important mechanism in the anemia of chronic renal failure.

Symptomatic exacerbation of peripheral vascular disease with chronic ambulatory peritoneal dialysis

Details of five patients with exacerbation of the symptoms of peripheral vascular disease on chronic ambulatory peritoneal dialysis (CAPD) are presented. The mechanisms of their vascular complications are discussed and the peripheral arterial sequelae of hypotension induced by CAPD are emphasized. These patients are compared with the other patients in the series of 121 patients. Suggestions for diagnosis and treatment of exacerbations of peripheral vascular disease in patients on CAPD are given.

Monthly plasmapheresis for systemic lupus erythematosus with diffuse proliferative glomerulonephritis: a pilot study

Twelve patients with systemic lupus erythematosus and biopsy-proved diffuse proliferative glomerulonephritis were randomly allocated to a control group (to continue receiving conventional therapy only) or to a plasmapheresis group (to receive conventional therapy along with one 4-I plasma exchange a month). The six patients treated with plasmapheresis had better preservation of renal function, reduced disease activity, fewer admissions to hospital and less need for steroid and immunosuppressive therapy than the six control patients. The patients treated with plasmapheresis also showed evidence of reduced immunologic activity and had no side effects attributable to the plasma exchange. These results suggest that monthly plasma exchange should be assessed in a controlled randomized trial as a possible therapeutic adjunct in patients with systemic lupus erythematosus and diffuse proliferative glomerulonephritis.

Dialysis hyperlipemia: response to dietary manipulations

The effects of dietary manipulations on plasma lipid concentrations were studied over a 3 month period in 8 stable uremic patients on dialysis. Each of the 4 diets was of 3 weeks' duration, and consisted of the following periods: Control (regular diet), high carbohydrate (60% of total calories ingested), control, and a low carbohydrate diet (20% of total calories ingested). The patients' weight remained stable throughout the study. A 33% reduction in plasma triglyceride concentration was observed during the low carbohydrate period (P less than 0.05, paired analysis), and a 33% increase above control values was observed during the high carbohydrate period (P less than 0.05, paired analysis). Cholesterol concentrations did not vary and remained within normal limits throughout the study. There was no significant correlation observed between either insulin or glucagon levels and variations in triglyceride concentration. Reduction in the proportion of carbohydrate in the diet of dialysis patients, may be an effective long-term therapeutic approach to their hypertriglyceridemia.

Circulating anti-tubular basement membrane antibody in a variety of human renal diseases: detection and significance

Serum specimens from 99 selected renal patients were examined over a 3-year period by both a hemagglutination technique (HA) and an indirect immunofluorescent (IIF) method for the presence of circulating antibody against tubular basement membrane (TBM). 11 patients were found with anti-TBM antibodies. 6 of them also had antibody against glomerular basement membrane (GBM). The other 5 with anti-TBM antibody alone, had a unique natural history and response to therapy which suggested that the antibody was important in the pathogenesis of their disease. The variation seen in end organ damage may indicate that other factors, possibly genetic, are involved in the pathophysiology.

Hyperlipidemia after renal transplantation: natural history and pathophysiology

Twenty-five patients had their lipid profile monitored sequentially for up to 3 years post-transplant. All patients had a good graft function throughout the study. Forty-four percent remained hypertriglyceridemic. The lipid level was not due to diet or excessive weight gain. Triglyceride turnover studies showed that overproduction was the predominant defect in patients receiving massive steroids to reverse rejection and in stable long-term recipients. Repeat metabolic investigations in the latter group, after changing to alternate-day, equal-dose steroid therapy showed improvement in both the absolute triglyceride concentration and the triglyceride production rate. The correlation observed between basal insulin level and triglyceride concentration suggests the drug may act through this hormone, stimulating hepatic triglyceride production. A change to alternate-day steroid therapy should be considered in post-transplant patients who are hyperlipemic while receiving minimal daily prednisone therapy.

Initial experiences with continuous ambulatory peritoneal dialysis

Continuous ambulatory peritoneal dialysis (CAPD) has been initiated on 51 patients: 27 females (mean age -- 43.9 years) and 24 males (mean age -- 46.4 years). This group has been observed for a total of 1420 patient weeks of treatment (27.3 patient years). Thirty-six episodes of peritonitis have been noted among 19 patients. The overall incidence was one episode per 39.4 patient weeks. Recurrent episodes of peritonitis resulted in discontinuation of CAPD in five (9.8%) of the patients. Three (5.9%) of the patients were unable to continue with CAPD because of its inability to control extracellular fluid balance. In the patients who transferred from intermittent peritoneal dialysis to CAPD, there was a 4.5 mg/dl drop in serum creatinine and a 34 mg/dl drop in mean BUN values. There was a rise of approximately 2 gm in the hemoglobin levels of this group of patients. If the problem of peritonitis can be solved, CAPD will become the dialytic treatment of choice for the majority of patients with end-stage renal disease.