Early diagnosis of polyomavirus type BK infection in tailoring immunosuppression for kidney transplant patients: screening with urine qualitative polymerase chain reaction assay

Polyomavirus type BK (BKV) nephropathy is increasingly a significant cause of graft dysfunction and even failure. Early diagnosis followed by reduction of immunosuppression has been associated with an improved prognosis. We screened 250 patients with the urine qualitative polymerase chain reaction (PCR) for BKV DNA. We followed with blood BKV PCR if the urine screen was positive and then reduced immunosuppression in viremic patients. One hundred ninety-nine patients (80%) had no viuria; 43 (17%) viuria; and 8 (3%) both viuria and viremia. Graft biopsy performed in three patients (1%) with viremia and impaired graft function all revealed BKV nephropathy. After 6 months of follow-up, seven out of eight viremic patients (88%) had negative repeat blood PCR and stabilized graft function. An early diagnosis of BKV infection with reduction of immunosuppression may reverse viremia and retard progression of BKV nephropathy. BKV screening by PCR assays should be considered in kidney transplant recipients, especially those with impaired graft function.

Predictors of renal function improvement following tacrolimus conversion in cyclosporine-treated kidney transplant recipients

The objective of this study was to evaluate the relationship between variability of cyclosporine (CsA) absorption and tacrolimus (TAC) conversion seeking factors that predict improvement in allograft function after TAC conversion. We performed a retrospective study of 44 adult kidney transplant recipients undergoing conversion from CsA to TAC-based immunosuppression. Before TAC conversion, patients had complete, consecutive, 6 monthly C2 levels and a follow-up duration beyond 6 months after TAC conversion. The patients were divided into 2 groups: one (n=23) with low variability of CsA absorption and one (n=21) with high variability of CsA absorption. At TAC conversion, the estimated glomerular filtration rate (eGFR) was similar in both patient groups. Six months after TAC conversion, eGFR improved in both groups. Stepwise regression analysis revealed the DeltaSCr6 (change in serum creatinine level at 6 months) to be independently associated with the preconversion serum creatinine (SCr; P<.0001) and the percent coefficient of variation (%CV) of SCr (P=.0034). DeltaSCr6 was inversely associated with posttransplantation years (P=.0033), and 6-month TAC blood levels (P=.0053). The DeltaSCr6 was not associated with variability of oral CsA absorption. The cutoff value of baseline SCr at TAC conversion differentiated an increase in or reduction of SCr to be about 1.0 mg/dL. Our study of CsA-treated kidney transplant recipients who underwent TAC conversion showed that a preconversion SCr>1.0 mg/dL, a high variability of SCr, and early TAC conversion predicted greater short-term benefit on graft function.

Effect of pentoxifylline on graft function of renal transplant recipients complicated with chronic allograft nephropathy

BACKGROUND

Chronic allograft nephropathy (CAN) is characterized by a progressive deterioration of renal function with various degrees ofproteinuria. Currently, there is no effective treatment despite the introduction of new generations of immunosuppressants. Pentoxifylline (PTX) is a phosphodiesterase inhibitor that possesses antiproteinuric effect and has been proved to be effective in treating several glomerular diseases. The purpose of the current study was to examine the effect of PTX on renal transplant patients with established CAN.

MATERIALS AND METHODS

Renal transplant recipients with biopsyproven CAN were recruited for the study. All the patients had been on angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for more than 1 year and were on a triple immunosuppressive regimen including corticosteroid, calcineurine inhibitor and mycophenolate mofetil. PTX in a dose of 1,200 mg/day was administered for at least 6 months. The following parameters were assessed at baseline, the 3rd and the 6th month post treatment: systolic and diastolic blood pressure, number of anti-hypertension drugs, serum creatinine (sCr),estimated glomerular filtration rate (eGFR), 24-hour urinary protein excretion (U/P), urinary N-acetylglucosaminidase (NAG) and intracytoplasmic Thl/Th2 cytokines production of peripheral blood CD4+ cells.

RESULTS

A total of 17 (11 male and 6 female) patients were enrolled in the study. The mean duration of follow-up post transplant was 10.6+/- 4.4 years. The baseline data of sCr, eGFR and U/P were 1.83+/-0.46 mg/dl, 38+/-8 ml/min and 2.65+/-2.15 g/day, respectively. Corresponding values at the 3rd and 6th month post treatment were 1.90+/-0.43 mg/dl (p = NS), 33+/-7 ml/min (p=NS), 2.13 +/-1.13 g/day (p < 0.05) and 2.03+/-0.64 mg/dl (p < 0.05), 32+/-10 ml/min (p < 0.05), 2.74 +/-0.93 g/day (p = NS), respectively. When individual data were analyzed, five cases (29.4%) showed a U/P significant reduction of more than 50% of baseline value, while in 10 cases (58.8%) the graft function remained either stable (9 cases) or improved (1 case) at the end of treatment. Urinary NAG was elevated at the 3rd month, but stabilized thereafter. The Thl/Th2 intracytoplasmic cytokine pattern of peripheral blood CD4+ cells showed a significant decrease of cells bearing TNF-alpha (15.0+/-14.4% vs 14.2+/-17.0%, p < 0.05) and cells bearing IL-10 (1.60 +/-1.23% vs 0.90+/-0.66%, p < 0.05) at the 3rd month.

CONCLUSION

In this pilot study, PTX seemed to be temporarily effective in reducing proteinuria. The graft function was stabilized in more than half of patients at the end of follow-up.

Lamivudine is effective for the treatment of reactivation of hepatitis B virus and fulminant hepatic failure in renal transplant recipients

Lamivudine is a potent inhibitor of hepatitis B virus (HBV) replication. The aim of this study is to elucidate the effectiveness of lamivudine for the treatment of HBV reactivation with or without fulminant hepatic failure in renal transplant recipients. Forty-two renal transplant recipients (30 men, 12 women) were enrolled onto this study. Eight patients presented with HBV reactivation without fulminant hepatic failure and were administered lamivudine (group I), 5 patients presented with HBV and hepatic failure and were administered lamivudine (group II), 5 patients presented with HBV and hepatic failure but were not administered lamivudine (group III), and 24 patients were asymptomatic HBV carriers who were not administered lamivudine (group IV). Lamivudine was administered at a dose of 100 or 150 mg once daily. A greater prevalence of recent use of a combination of antilymphocyte immunoglobulin (ALG) and methylprednisolone (MP) occurred in patients with hepatic failure (groups II and III) than those without hepatic failure (30% versus 6.3%; P = 0.043). However, there was no significant difference in the incidence of MP use alone (20% versus 25%; P = 0.746). Mortality rates for groups I, II, and III were significantly different (12.5%, 40%, 100%; P = 0.008). One patient in group I died of sepsis without evidence of HBV DNA, even in the terminal event. In group II, 3 of 5 patients (60%) were rescued by lamivudine therapy. In group III, without lamivudine treatment, there was a 100% mortality rate despite intensive plasmapheresis. HBV DNA was not detectable after lamivudine treatment in 7 of 8 patients in group I and 3 of 5 patients in group II. Creatinine levels did not change significantly during lamivudine treatment. Hepatitis B surface antigen and hepatitis B e antigen seroconversion rates after lamivudine treatment were 7.7% and 37.5%, respectively. We conclude that ALG is a potent trigger of HBV-related fulminant hepatic failure in renal transplant recipients, whereas lamivudine is an effective and lifesaving treatment. Prompt use of lamivudine is recommended in renal transplant recipients with evidence of HBV reactivation to prevent catastrophic fulminant hepatic failure.

A regulatory region rearranged BK virus is associated with tubulointerstitial nephritis in a rejected renal allograft

A renal allograft transplant patient with high serum creatinine presented clinical symptoms of rejection. Sections of renal biopsy tissue showed mononuclear leukocyte infiltration in the tubulointerstitium and nuclear enlargement with inclusions in the tubular epithelium. The morphological characteristics resembled polyomavirus-induced interstitial nephritis. Electron microscopy of the nuclear inclusions showed paracrystalline arrays of naked viral particles with a diameter of 45 nm. Molecular studies revealed that a new variant of BK virus (BKV) with rearrangement at the regulatory region was involved in the nephritis. The BKV regulatory region contained a tandem repeat from the P-block to the Q-block causing duplication of several important transcriptional elements or transcriptional factor binding motifs. This is the first report to show a naturally occurring BKV variant with regulatory region rearrangement associated with tubulointerstitial nephritis.

Evaluation of the severity of traumatic rhabdomyolysis using technetium-99m pyrophosphate scintigraphy

A quantitative scoring method was designed to assess the extent of muscle damage. Technetium-99m pyrophosphate (99mTc-PYP) scintigraphy was performed for 9 patients experiencing crush injury in the Chichi (Taiwan) earthquake. The magnitude of muscle uptake of 99mTc-PYP was graded as follows: grade 0, less than bone radioactivity (BRA); grade 1, equal to BRA; grade 2, higher than BRA; or grade 3, greatly higher than BRA. The area of muscle injury was estimated according to the rule of nines. The sum of the muscle injury size multiplied by its corresponding grading was defined as the anterior or posterior score according to the anterior or posterior images. Each image was interpreted by two physicians and average anterior and posterior scores were calculated. The muscle score was defined as the geometric mean of the average anterior and posterior scores. Significant correlations were obtained between the muscle score and duration of time trapped (r = 0.868, p < 0.01), peak serum creatine kinase level (r = 0.866, p < 0.01), peak serum phosphorus level (r = 0.877, p < 0.01) and number of hospital days (r = 0.875, p < 0.01). A negative correlation between the muscle score and blood pH (r = -0.706, p < 0.01) was also observed. We concluded that this scoring method may be used as an adjunct for evaluating the locations of trauma and the severity of crush syndrome, and for predicting the duration of hospital stay.

Use of pulsed-field gel electrophoresis in the analysis of recurrent Staphylococcus aureus infections in patients on continuous ambulatory peritoneal dialysis

BACKGROUND/AIM

The purpose of this study was to evaluate pulsed-field gel electrophoresis (PFGE) for distinguishing between relapse and reinfection of Staphylococcus aureus infections in patients on continuous ambulatory peritoneal dialysis (CAPD).

METHODS

Between July 1993 and May 1997, 4 patients with recurrent CAPD-associated infections caused by S. aureus we enrolled in this study. There were nine episodes of peritonitis, one episode of temporary double lumen catheter infection, and one episode of Hickman catheter infection. A total of eleven S. aureus isolates were collected from peritoneal fluid (n = 9) and blood (n = 2). PFGE typing was applied.

RESULTS

In our study, from PFGE typing, the 11 S. aureus isolates were classified into seven patterns. Antibiogram profiling classified only four patterns. Patient A had a reinfection by another strain of S. aureus, and patient B had three episodes of peritonitis caused by the same strain of S. aureus due to exit site infections. Patient C had two episodes of CAPD peritonitis caused by two different strains, respectively. Patient D had four episodes of S. aureus infection (three CAPD peritonitis and one bacteremia); the first two episodes of peritonitis were caused by an identical strain of S. aureus, whereas the subsequent two infections were caused by other organisms.

CONCLUSION

PFGE has a high discriminatory power and can be an assistant method to antibiogram profiling for distinguishing relapse from reinfection in CAPD-associated peritonitis.

Assessment of nutritional status in continuous ambulatory peritoneal dialysis patients: a comparison of bioelectric impedance and conventional methods

BACKGROUND

Nutritional status is an important factor in long term continuous ambulatory peritoneal dialysis (CAPD) prognoses. Conventionally, serum albumin is an indicator of nutritional status. More recently, protein catabolic rate and lean body mass have been calculated during peritoneal equilibrium testing to assess nutritional status. These have the advantage of providing an early indication of malnutrition before the serum albumin decreases. Bioelectric impedance analysis (BIA) of nutrition has the advantage of being the simplest procedure among all nutritional assessments. Standard nutritional assessments was compared with the BIA method.

METHODS

The protein catabolic rate and lean body mass was measured by the Keshaviah method. At the same time BIA was used to assess lean body mass, fat mass and fixed percentage of fat in 27 long-term CAPD patients, with and without peritoneal fluids.

RESULTS

Among the 27 patients, the protein catabolic rate was 0.95+/-0.5 g/kg/day and lean body mass was 37.4+/-0.5 kg measured by the conventional method. Using BIA, the lean body mass was 37.8+/-11.0 kg with peritoneal dialysate, which was strongly correlated with the conventional method (p<0.001). BIA of lean body mass was 37.4+/-9.2 kg without peritoneal dialysate, which was also significantly correlated to the conventional method (p<0.001).

CONCLUSIONS

BIA nutritional assessment of lean body mass was comparable to the conventional method of nutritional assessment. The presence or absence of peritoneal dialysate did not influence the BIA method for detection of lean body mass. BIA has the advantage of being a more simple procedure and can be used for the long-term assessment of nutritional status in CAPD patients.

Impact of interleukin-1 receptor antagonist and tumor necrosis factor-alpha gene polymorphism on IgA nephropathy

BACKGROUND

It is evident that cytokines play an important role in the pathogenesis as well as disease progression in IgA nephropathy (IgAN). The level of cytokine production is influenced by different genotypes that reflect gene polymorphism of the pertinent cytokine. Interleukin-1 receptor antagonist (IL-1ra) and tumor necrosis factor-alpha (TNF-alpha) gene polymorphism have been found to affect disease susceptibility and activity in several inflammatory diseases. However, the impact of these polymorphisms in IgAN patients has not previously been thoroughly studied.

METHODS

We investigated 111 cases of biopsy-proven IgAN and 100 healthy, normal controls for their IL-1ra and TNF-alpha gene polymorphism. IL-1ra gene polymorphism was characterized as a variable number of tandem repeats of a 86 bp sequence within intron 2. Five alleles were identified and were designated as IL1RN*1, IL1RN*2, IL1RN*3, IL1RN*4, and IL1RN*5, corresponding to 4, 2, 5, 3, 6 repeats, respectively. A polymorphism in the promoter region of the TNF-alpha gene was also studied. This polymorphism involved a guanidine to adenosine transition at position -308 and was designated as TNF1 (-308G) and TNF2 (-308A).

RESULTS

There were 54 male and 57 female patients with a mean age of 30.3 +/- 12.5 years and a disease duration of 66. 8 +/- 47.2 months. The mean duration of the follow-up period was 47. 3 +/- 32.6 months. In the patient group, the allele frequencies of IL1RN*1, IL1RN*2, IL1RN*3, IL1RN*4, and IL1RN*5 were 89.6%, 9.9%, 0%, 0.5%, and 0%, respectively, whereas the corresponding carriage rates were 100%, 19.8%, 0%, 0.9%, and 0%, respectively. An excessive carriage of IL2RN*2 was found in the patients when compared with normal controls (allele frequency, 9.9 vs. 2.5%, P < 0.0001). The allele frequencies of TNF1 and TNF2 were 94.1 and 5.9%, respectively, and the carriage rates were 99.1 and 10.8%, respectively, in the patients, which was not significantly different from those of normal controls. When the patients were stratified into mild and severe groups according to their initial presentation, none of the studied alleles correlated with the severity. However, patients with gross hematuria were associated with a higher carriage rate of TNF2 when compared with patients without gross hematuria (allele frequency, 15. 4 vs. 4.6%, P = 0.0552; carriage rate, 30.8% vs. 8.2%, P = 0.0272). Renal survival analysis revealed that the TNF2 carrier had a renal survival comparable with TNF2 (-) patients. However, the carriage of the IL1RN*2 allele was associated with a significantly poorer long-term outcome with a median survival time of 72 months, as compared with those without IL1RN*2 (134 months, P < 0.01).

CONCLUSION

IL-1ra and TNF-alpha gene polymorphism may affect disease susceptibility as well as disease activity and long-term outcome in human IgAN. Treatment with an IL-1ra or IL-1 blocking agent may be relevant in those carrying the IL1RN*2 allele.

Prevalence of subclinical cryoglobulinemia in maintenance hemodialysis patients and kidney transplant recipients

We studied the prevalence and the clinical spectrum of cryoglobulinemia (Cryo) among 101 maintenance hemodialysis (HD) patients and 148 kidney transplant (KT) recipients, with or without chronic hepatitis C virus (HCV) infection. Cryo was present in 32% (16 of 50) of the HCV-positive HD patients, 5.9% (3 of 51) of the HCV-negative HD patients, 37.8% (28 of 74) of the HCV-positive KT recipients, and 27% (20 of 74) of the HCV-negative KT recipients. Cryoprecipitate in 56.3% (9 of 16) of the HCV-positive Cryo HD patients and 53.8% (14 of 26) of the HCV-positive Cryo KT recipients contained HCV-RNA. Interestingly, the cryocrit values among HD and KT patients were much lower than these in other reports on nonrenal failure cases. Also, the cryoglobulinemic syndrome (with purpura, arthralgia, etc.) in HD and KT patients with Cryo were not common (Tables 1 and 2). There was not correlation between Cryo and age,sex, and liver function. Only longer duration of end-stage renal disease was noted in these patients. In addition, we suggested that KT patients are more susceptible to having Cryo. Further studies are necessary to better define whether any other subclinical viral or nonviral chronic infection may induce Cryo in HCV-negative KT recipients.

Long-term results with pediatric kidney transplants in adult recipients

The shortage of donor kidneys available for transplantation has resulted in an expansion of the criteria used for donor selection. The use of cadaveric pediatric kidneys has been suggested as a means to overcome this shortage, but is debated because of technical complications and an increased incidence of functional allograft impairment. We examined the records of all adult patients receiving renal allograft transplants from January, 1983 through December 1994, to determine whether kidneys from pediatric donors can be used safely for transplantation. During the study period, 204 adult patients received kidney transplants. The patients were divided into three groups by donor age: group 1, 26 months to 7 years old (n = 12); group 2, 7 to 14 years old (n = 19); and group 3, adult donors (n = 173). Cyclosporine- and/or azathioprine-based immunosuppression regimens were used. The three groups did not differ from one anther with respect to recipient age, recipient sex, primary renal disease, human leukocyte antigen (HLA) mismatching, or the proportion of recipients with previous transplants. The graft survival rates at 1 and 3 years, respectively, were 75% and 75% in group 1,84% and 79% in group 2, and 85% and 72% in group 3 (p > 0.05). The patient survival rates at 1 and 3 years, respectively, were 75% and 75% in group 1,95% and 90% in group 2, and 90% and 83% in group 3 (p > 0.05). The frequency of fixed proteinuria (> or = 0.8 gm/day) in the first 3 years was higher in the two pediatric groups (50%) than in the adult group (28%) (p < 0.05). The frequency of surgical complications was higher with pediatric grafts (group 1 vs group 3: 67% vs 24%, p < 0.005). In particular, group 1 patients had much higher rates of lymphocele (50% vs 8%), renal graft artery stenosis (33% vs 11%), and hydronephrosis (33% vs 9%) than group 3. We conclude that pediatric donor kidneys can be used with reasonable safety, although surgical complications remain a major problem.

Long-term outcome of adult patients with minimal urinary abnormalities and normal renal function

AIM

To define the long-term outcome of patients with minimal urinary abnormalities (defined by the presence of microscopic hematuria with no or less than 1 gm/day proteinuria), and normal renal function (defined by a serum creatinine < 1.3 mg/dl), we retrospectively studied patients who fulfilled the above criteria and had a kidney biopsy done before the year of 1992 (i.e. at least followed up for 5 years), with a definite pathological diagnosis.

METHODS

A total of 41 cases among 719 cases of primary glomerulonephritis (5.7%) were enrolled into the study. There were 19 males and 22 females with a mean age of 35.4+/-14.7 years at biopsy. The duration of renal disease was 116.0+/-60.5 months and the duration of follow-up post biopsy was 100.2+/-38.1 months. The pathological diagnosis was: IgA nephropathy (21 cases), focal glomerulosclerosis (9 cases), mesangial proliferative glomerulonephritis (8 cases), membranous glomerulonephritis (2 cases) and acute glomerulonephritis (1 case).

RESULTS

At the end of follow-up, 8 cases (19.5%) had a certain degree of renal insufficiency including 2 (4.9%) in end-stage renal disease. The other cases were either in complete remission (6 cases) or stable condition (27 cases) with persistent microscopic hematuria and normal renal function. The long-term outcome was not correlated with any of the following parameters: age, sex, disease duration, serum creatinine at presentation, daily protein loss at presentation, degree of glomerular change and degree of interstitial inflammatory cell infiltration. However, a poor long-term outcome was correlated with tubular atrophy (p < 0.05) and interstitial fibrosis (p < 0.05).

CONCLUSION

We conclude that a minimal urinary abnormality with normal renal function at presentation does not necessarily imply a favorable long-term outcome in certain patients. Tubular atrophy and interstitial fibrosis but not glomerular change correlates with a worse prognosis. This further emphasizes the importance of renal biopsy in such cases.

Malignancy following renal transplantation

BACKGROUND

A markedly increased incidence of malignancy in transplant recipients is well recognized. However, the incidence and pattern of post-transplantation malignancies shows some discrepancy among different reports. The renal transplant recipients monitored at Taichung Veterans' General Hospital comprise the largest group in Taiwan. An analysis of the characteristics of post-transplant malignancies emphasizes the differences from malignancies that occur in the Taiwanese general population and those reported in Western countries.

METHODS

The incidence and characteristics of de novo malignancy in 390 renal transplant recipients who underwent renal transplantation between May 1983 and June 1996 were analyzed. A total of 232 men and 158 women (mean age at transplantation: 38.5 +/- 10.7 years) were included. The relative risk for developing malignancies was calculated based on the sex- and age-matched cancer incidence of reference for the Taiwanese population; data from the Cancer Registry Annual Report in Taiwan (1989) was obtained for comparison.

RESULTS

A total of 25 cancers were diagnosed in 24 renal transplant recipients, for an incidence of 6.2%. The relative risk of renal malignancy was 13.8-fold higher among transplant recipients than in the general population. The impact of gender and age on the development of post-transplantation malignancy was not significant. The most common types of cancer were transitional cell carcinoma (TCC) of the urinary tract (8/25), and hepatoma (8/25), followed by two cases of Kaposi's sarcoma. Aside from immunosuppressive agents, the high incidence of hepatoma and TCC may be attributed to the high incidence of hepatitis infection and the possible carcinogenic effect of abnormal milieu induced by uremia per se. Survival was largely dependent on the extent of disease at presentation, and post-transplantation cancer did not show more aggressive behavior if detected early.

CONCLUSIONS

The high cumulative incidence of malignancies makes it imperative to define an effective safe immunosuppressive regimen to achieve a lower risk of malignancies. In the future, the prime approach to treatment of post-transplantation malignancies should begin with early detection and ensuing aggressive treatment to improve the outcome.

Soluble interleukin 2 receptor in dialyzed patients

Azotemic patients are usually characterized by a state of so-called preactivation resulting in excessive expression of interleukin 2 receptors (IL-2R) on T lymphocytes. The etiological mechanism of this preactivation is, however, still speculative. We studied the serum level of the soluble form of IL-2R (sIL-2R) in azotemic patients on either hemodialysis (HD) (n = 49) or continuous ambulatory peritoneal dialysis (CAPD) (n = 45). Both patient groups had significantly higher sIL-2R levels (1,750+/-664 U/ml in the HD group and 1,769+/-647 U/ml in the CAPD group, respectively) p < 0.00001 as compared to the normal control group (511+/-436 U/ml). However, there was no significant difference between the levels of the HD and CAPD group patients. When clinical parameters were studied for their influence on sIL-2R levels, none of the following caused any significant changes: blood transfusion, type of dialyzer used, type of dialysis fluid used, treatment with erythropoietin, hepatitis B infection, or liver function profile. We conclude that chronic renal failure per se is the major cause of the preactivation of T lymphocytes. The modes of treatment and various clinical variables in these patients have no significant influence on sIL-2R levels.

Neurotrophic factors decrease the release of creatine kinase and prostaglandin E2 from metabolically stressed muscle

We have used an in vitro model of oxidative stress by exposing rat muscle to 2:4 dinitrophenol. This causes an efflux of creatine kinase (CK) and prostaglandin E2 (PGE2) commonly used as indicators of muscle cell damage. We then investigated compounds with a putative cell protective effect in the system. Ciliary neurotrophic factor, brain derived neurotrophic factor and insulin like growth factor 1 all prevent the release of PGE2 and CK. To the extent that these indicators may reflect cell damage, the results might support the investigation of the therapeutic potential of these compounds in muscle disease.

Another simpler bypassing dialysate technique for measuring post-haemodialysis BUN

BACKGROUND

The most popular method for estimating post-haemodialysis BUN is the low blood flow technique. The low blood flow technique with a blood flow of 50 ml/min for 3 min may encompass the first two phases of post-haemodialysis urea rebound by access and cardiopulmonary recirculations. Some patients may have risk of clotting in extracorporeal circuit while slowing blood flow. Therefore we proposed another simpler sampling technique for measuring post-haemodialysis BUN(C2).

METHODS

In the present study, 28 long-term haemodialysis patients were divided into two groups. In group 1 (n = 15), C2 sample (C2-50) was collected immediately after blood flow was slowed down to 50 ml/min for another 3 min. Then blood flow was reset to 300 ml/min. Finally, C2 sample (C2B) was obtained from arterial port at the end of bypassing dialysate for another 3 min. In group 2 (n = 13), C2 sample (C2B) was obtained from arterial port at the end of bypassing dialysate for 3 min with a blood flow of 250 ml/min. Then dialysate was reset to original flow rate and C2 sample (C2-50) was collected soon after blood flow was slowed down to 50 ml/min for another 3 min. In the meantime, recirculation rate was also checked.

RESULTS

The above two groups have similar results and there are no significant differences of post-haemodialysis BUN and calculated Kt/V between low blood flow technique and bypassing dialysate technique.

CONCLUSION

The bypassing dialysate technique is another simpler and practical technique for the routine estimation of post-haemodialysis BUN.

Complications of membrane-filtration plasma exchange

BACKGROUND

Plasma exchange (PE) has been extensively used to treat a variety of disease states in the past three decades. Although PE is commonly thought to be a relatively safe procedure, a number of unpleasant side effects may occur. To highlight the need for continuing quality assurance in providing PE service, a retrospective review of PE records over a 13-year period was undertaken.

METHODS

From April 1983 to March 1996, 694 therapeutic PE procedures, membrane-filtration type, were performed on a total of 157 patients in this hospital. Plasmaflo op-05(L) (Asahi Japan) was used as the plasma separator and fresh frozen plasma of one plasma volume as replacement fluid. The PE sheets for all procedures were reviewed as were medical charts in order to evaluate clinical efficacy.

RESULTS

Totally 694 PEs in 157 patients, 84 male and 73 females, ranging in age from 1 to 75 years (median, 35 years), were treated. Patients received a median of 4 treatments (range, 1 to 34). The most frequent indications were severe jaundice (41.4%), systemic lupus erythematosus (23.6%), and myasthenia gravis (15.3%). The overall effective rate was 40.8%, and was best in neurological diseases (91.4% effective). Complications of PE were noted during 36% of the procedures involving 59.2% of the patients treated. The most common adverse reactions were paresthesia (12.7%), chills (10.2%), urticaria (8.5%), chest pain (5.9%), nausea (2.9%) and dyspnea (2.0%). Less common complications included: catheter infection (0.3%), catheter oozing (1.2%), dizziness (1.3%), headache (0.4%), muscle cramps (1.3%), vomiting (0.4%), abdominal pain (0.9%), fever (0.3%), hypotension (1.3%), bleeding (0.4%), consciousness change (0.7%) and respiratory arrest (0.4%). These complications were classified as "mild" (23%), "moderate" (11.4%) and "severe" (1.6%). No deaths occurred within 24 hours after PE.

CONCLUSIONS

Although the use of membrane-filtration PE represents a valuable and relatively safe therapy, some life-threatening reactions do occur.

Infantile hypertrophic pyloric stenosis after surgery for esophageal atresia with tracheoesophageal fistula

Infants with esophageal atresia and tracheoesophageal fistula may have other associated anomalies. The development of infantile hypertrophic pyloric stenosis in the postoperative course of esophageal atresia with tracheoesophageal fistula is rarely reported. Because its symptoms may mimick postoperative complications such as gastroesophageal reflux or anastomotic stricture, the diagnosis may be delayed. We report an infant who had surgery for esophageal atresia with tracheoesophageal fistula at birth. The infant presented with nonbilious projectile vomiting at 4 weeks of age. Plain abdominal x-ray, barium upper gastrointestinal series and abdominal ultrasonography all supported the diagnosis of hypertrophic pyloric stenosis. The diagnosis was confirmed during surgery. After pyloromyotomy, the patient's condition improved.

Long-term clinical and morphological evaluation of primary membranoproliferative glomerulonephritis

BACKGROUND

Membranoproliferative glomerulonephritis (MPGN) is a relatively rare primary glomerulonephritis (GN). Its incidence has decreased progressively in the past two decades. To improve knowledge of this rare GN, a retrospective review of 22 patients during a 12-year period was undertaken.

METHODS

From November 1982 to December 1994, from a total 814 cases of primary GN, 22 patients with primary MPGN were diagnosed. Clinical data, medical records, renal pathology and outcome were reviewed.

RESULTS

Patients included 15 male and 7 females, aged from 11 to 67 years. The average follow-up period was 46.3 months, with a range of 1 to 140 months. Tissue was available for electromicroscopic study in 11 cases; of which 9 cases fulfilled morphologic criteria of Type I MPGN; the other 2 cases were Type II MPGN. The clinical presentations at diagnosis included nephrotic syndrome (86.4%), impaired renal function (63.6%), microhematuria (50%), gross hematuria (31.8%) and hypertension (50%). Low serum C3 was found in 40.9% cases, 44.4% in Type I and 50% in Type III MPGN. The positive rate of hepatitis B virus infection was 22.7% with 33.3% in Type I and none in Type III MPGN. All 22 patients received various combined antihypertensive agents, immunosuppressant, anticoagulant and antiplatelet agents at diagnosis, but 17 had progressive disease, 4 maintained normal renal function with proteinuria and only 1 had complete remission. Fifteen patients, including six Type I and no Type III MPGN, progressed to end-stage renal failure. Both patients with Type III MPGN maintained normal renal function and responded to treatment. The 5 and 10 year actuarial renal survival rates were 33.3% and 16.7% respectively. The median kidney survival time was 51.2 months.

CONCLUSIONS

A majority of cases with MPGN presenting with impaired renal function (86.7%) and hypertension (85%) at diagnosis progressed to end-stage renal failure. Delayed diagnosis and poor compliance were possible reasons for compared with for worse prognosis previous reports. But two patients with Type III MPGN had favorable prognosis previously described. Treatments generally failed to halt disease progression. Since at least five cases (22.7%) maintained normal renal function after treatments, a course of immunosuppressant is probably indicated if there is no contraindication. Further study with a larger population is warranted to clarify this issue.

Serum immunoglobulin E in primary IgA nephropathy

The biosynthesis of human immunoglobulin E (IgE) is regulated by a complex network involving T and B lymphocytes. Diseases associated with high serum IgE (sIgE) levels are usually characterized by T cell disorders. Total sIgE level has been found to be of clinical relevance in minimal change nephrotic syndrome. However, the clinical significance has rarely been studied in primary IgA nephropathy (IgA N). We retrospectively studied 99 cases of primary IgA N. There were 59 males and 40 females with a mean age of 30.0 +/- 12.1 years. The mean follow-up duration was 45.9 +/- 31.1 months. Pathological grading was done according to the criteria of Meadow et al. Median sIgE for the entire group was 122.0 IU/ml (range: 2.8-5805 IU/ml) which was significantly higher than the healthy control group (median: 43,7 IU/ml, range: 5.0-1003 IU/ml, p < 0.001). However, when the IgA N cases were stratified into grades, only grade I (median: 514 IU/ml, range: 72.1-5805.0 IU/ml) and grade II (median: 229 IU/ml, range: 5.0-5464 IU/ml) patients had significantly higher sIgE than the control group (p < 0.0005 and p < 0.001 respectively). Patients with nephrotic ranged proteinuria (32 cases) were further classified into "stable" and "progressive" groups. The "stable" group had a significantly higher sIgE level (median: 922.0 IU/ml, range: 2.8-5805 IU/ml), compared to that of the "progressive" group (median: 55.3 IU/ml, range: 5.0-1600 IU/ml, p < 0.02). The effect of aggressive treatment (including corticosteroid and/or cyclophosphamide, cyclosporine) was also assessed.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison and correlation of measurements of glomerular filtration rates by Tc-99m DTPA and 24-hour creatinine clearance

BACKGROUND

The measurement of 24-hour creatinine clearance (CCr) is most commonly used to estimate glomerular filtration rate (GFR). A new rapid method for determining GFR by radionuclide compound Tc-99m diethylenetriamine-pentaacetic acid (DTPA) has been developed and widely used in the last decade. The purpose of this study is to compare and correlate the measurements of GFR by the two method.

METHODS

The present series included 6 normal volunteer outpatients and 49 hospitalized patients with various degrees of renal dysfunction who were studied at Taichung Veterans General Hospital from June 1985 to June 1986. All patients underwent both Tc-99m DTPA GFR and 24-hour CCr. Tc-99m DTPA computed GFR was calculated using the formula of Gates.

RESULTS

The radionuclide computed GFR for each subject was compared with his or her 24-hour CCr. The correlation coefficient (r) was 0.89 with p < 0.001. The subjects were divided into two groups. Group A consisted of 6 normal volunteers and 14 patients with serum creatinine less than 1.4 mg/dl (creatinine: normal range 0.7 to 1.4 mg/dl). Group B consisted of 35 patients with serum creatinine greater than 1.4 mg/dl. Group B was further divided into Subgroup 1 with serum creatainine from 1.4 to 10 mg/dl, and Subgroup 2 with serum creatinine above 10 mg/dl. There was good correlation and less absolute error between DTPA-GFR and CCr in Group A and Subgroup 1. The results suggest that, when serum creatinine is less than 10 mg/dl, either DTPA or CCr is a good method for detection of GFR.

CONCLUSIONS

DTPA-GFR measurement using this radionuclide technique has shown good correlation with CCr when serum creatinine is under 10 mg/dl. In patients with renal impairment and with serum creatinine above 10 mg/dl, neither examination is reliable. A more sensitive test to evaluate GFR in severe renal impairment is required for further investigation.

Fabry's disease: clinical, pathologic and biochemical manifestations in two Chinese males

Fabry's disease is a rare hereditary disease transmitted as an X-linked recessive trait with the primary metabolic defect of an enzyme alpha-galactosidase A, resulting in deposition of glycolipids (ceramide trihexoside) in various tissues, including the kidneys. Two sibling cases of Chinese adult male patients in a family with Fabry's disease were completely evaluated including the clinical, pathologic and biochemical studies. Both of the patients had the similar clinical manifestations such as telangiectases, proteinuria, acral pains, corneal opacities, tortuous renal vessels and recurrent fever. Chronic renal insufficiency was noted in Case 1, whereas Case 2 had normal renal function. Microscopic hematuria was noted in Case 1. In renal biopsy, LM showed foamy vacuolation of the glomerular visceral epithelial cells and EM showed widespread myelin bodies (Zebra bodies) in kidney tissues, most numerous in visceral epithelia in both cases. Those findings are diagnostic for Fabry's disease. The plasma activity of alpha-galactosidase of Case 1 was 0.8 and that of Case 2 was 1.0 (normal reference range: 8.5-18.5 nmol/hr/min). The plasma activity of alpha-galactosidase A of Case 1 was 0.4 and that of Case 2 was 0.8 (normal reference range: 7.9-16.9 nmol/hr/min). All the enzyme activities in both cases were much lower than those of normal subjects. In addition to clinical presentations, pathologic study and biochemical study with assays of plasma or serum activities of alpha-galactosidase and alpha-galactosidase A are important steps in the diagnosis of Fabry's disease.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinicopathological spectrum of renal amyloidosis

BACKGROUND

Renal amyloidosis is an uncommon cause of nephrotic syndrome. The clinical conditions in Chinese people remain obscure. This is a retrospective review of the clinicopathological spectrum of 12 cases diagnosed in Taichung Veterans General Hospital from October 1982 to November 1993.

METHODS

Charts and renal pathological slides were reviewed retrospectively. A scoring system was set to evaluate the degree of amyloid deposition in the renal tissue. The clinical profile, immunological data, pathological picture and final outcomes are presented and discussed, with literature review.

RESULTS

There were 12 cases of primary amyloidosis including 1 case of multiple myeloma. All were confirmed by renal biopsy. The cases were all male with mean age of onset as 53.3 +/- 11.3 (range: 32 to 65 years). The mean follow-up duration was 22.9 +/- 32.8 months. The initial average creatinine clearance was 66.7 +/- 42.7 ml/min; mean daily urine protein was 7.0 +/- 4.1 grams. Nephrotic syndrome was the main clinical manifestation, present in all 12 cases. Other presenting symptoms and signs included: malaise in 7 cases; hypertension and anorexia in 4 cases; limb numbness in 3 cases; low back pain, dizziness and microhematuria in 2 cases each; anemia, headache, stroke, restrictive cardiomyopathy, hepatomegaly, syncope, body weight loss, dysphagia and skin itching in one case individually. Amyloid cardiomyopathy was present in 4 of the 8 patients who received echocardiography. The mean serum albumin level was 1.9 +/- 0.7 mg/dl, globulin level 3.1 +/- 1.1 mg/dl. Urinary Bence-Jones protein examination was performed in 8 cases; none revealed positive response. The mean immunoglobulin (Ig) level for the patients included: IgG 1018 +/- 901 mg/dl, IgA 262.0 +/- 313.8 mg/dl, IgM 104.8 +/- 84.2 mg/dl. There were at least 4 cases with high levels of one Ig but depressed levels in the others. M-component was shown by immunoelectrophoresis (IEP) in 90% of the cases. IEP impression in 10 cases revealed 2 cases of IgA lambda, 2 cases IgA kappa, 3 cases IgG lambda and 1 case IgG kappa monogammopathy, 1 case free lambda myeloma and 1 case negative. The ratio of kappa to lambda chain was 3:6. Bone marrow biopsy performed in 8 cases found only 1 case with multiple myeloma, one with amyloidosis; the other 6 cases were unremarkable. Mesangium was the site of heaviest amyloid deposition, followed by tubular basement membrane, artery and interstitium. The median survival time for those whose total score was lower than 3 points was 97.5 months; 3 to 5 points, 14 months; 6 points or more, 18.5 months. The median survival time was 21.6 months and 3-year-survival rate was 32.7%. The 2 cases with long-term survival were of 111 months and 84 months. The possible reason included: 1) Organ-limited renal amyloidosis; 2) Light amyloid deposition; 3) Younger age; 4) Other undetected favorable factors.

CONCLUSIONS

1) Renal amyloidosis is not a frequent diagnosis of nephrotic syndrome in Taiwan, but it should be suspected in every patient over 50 years old with a recent onset of proteinuria. 2) Renal amyloidosis can be diagnosed only by renal biopsy. 3) Primary renal amyloidosis is a disease of poor prognosis.

Statistical and parametric analysis of beta-2-microglobulin removal from uremic patients in high flux hemodialysis

Beta-2-microglobulin (beta 2M) associated amyloidosis has been seen in patients with chronic renal failure after long-term hemodialysis. However, the exact mechanism of beta 2M formation and accumulation is not clinically understood. In this investigation, the formation and removal kinetics of beta 2M were studied by compartmental modeling of a patient dialyzer system. Statistical and parametric analyses of model equations, coupled with clinical data from selected patients, enabled us to predict the behavior and influence of membrane materials upon the clearance characteristics of beta 2M during and between hemodialysis treatments.

Lymphocyte proliferation in uremic patients: correlation with zinc status

The pivotal role of zinc in the immune response has been well demonstrated in animals with normal renal function; however, there are fewer studies in uremic patients. Twenty uremic patients on regular hemodialysis (HD), and 20 patients on continuous ambulatory peritoneal dialysis (CAPD) were studied for their lymphoproliferative response to concanavalin A, phytohemagglutinin and pokeweed mitogen. CAPD patients had significantly lower levels of plasma zinc (65.8 micrograms/dL vs 75.1 micrograms/dL, p < 0.05) and serum albumin (3.5 g/dL vs 4.4 g/dL, p < 0.05) than HD patients. However, the stimulation indices were similar between these two groups no matter what mitogens were used, although they were significantly lower than those for the normal control group. Regression analysis revealed that there was no correlation between zinc status and the stimulation indices. However, there was a significant correlation between serum zinc and the absolute counts in HD patients. These findings suggest that zinc does not play a consistent role in the impaired lymphoproliferative response among uremic patients receiving different modes of dialysis therapy.

Clinical experience and model analysis on beta-2-microglobulin kinetics in high-flux hemodialysis

Beta-2-microglobulin (beta 2M) is associated with amyloidosis. The study of beta 2M kinetics can provide information on the elimination of this uremic toxin. A beta 2M kinetic model modified from Gotch, considering the volume changes between intracellular, interstitial, and intravascular compartments and the generation stimulation and inhibition during hemodialysis is proposed. The clinical experiments on 8 stable hemodialysis patients treated with polysulfone (F80) and polymethyl methacrylate (PMMA, BK2.1p) 3 times a week were conducted. There was an 18% decrease of beta 2M clearance in the period from 30 to 180 min with a time-averaged beta 2M clearance of 48 ml/min using polysulfone dialyzers (F80). In PMMA dialyzers, there was a 64% decrease of beta 2M clearance from 30 to 180 min with a time-averaged clearance of 56.3 ml/min. During hemodialysis, the generation rate was 0.379 mg/min in polysulfone and 0.828 mg/min in PMMA dialyzers. There was a stimulation generation of 0.309 mg/min in polysulfone and 0.749 mg/min in PMMA during hemodialysis. In conclusion, we provide a beta 2M kinetic model including volume changes, polymerization, generation stimulation, and inhibition that is similar to the human physiological condition. This model can be used for further clinical study.

Primary IgA nephropathy: a nine-year clinicopathologic study in the Veterans General Hospital-Taichung

IgA nephropathy (IgA N) is the most common type of primary glomerulonephritis (GN) diagnosed in Taiwan. From February 1983 to May 1992, 194 patients with primary IgA N, representing 25.3% of the primary GN, were diagnosed by renal biopsy at this hospital. Clinicopathologic correlation was made in 175 cases of IgA N with adequate clinical and pathologic data including light-(LM), immunofluorescent (IF) and/or electron-(EM) microscopy. Modified classification of Meadow et al. was adopted for the histologic grading of glomerular lesions. Forty-nine biopsies (28.0%) showed Grade IV and V lesions (Grade IV, 10.9%; Grade V, 17.1%, respectively) in association with a high level of serum creatinine and a lower frequency of gross hematuria when compared with lesions of histologic Grades I to III. Patients with Grade V lesions revealed a high frequency of hypertension as compared with those with Grades I to IV. The frequencies of nephrotic range proteinuria in those with various grades of IgA N was not statistically significant in this study. One hundred and thirty patients were followed up for one to eight and half years or until end-stage renal disease (ESRD) developed (mean 3.9 years), excluding the biopsies done at ESRD or from the graft kidney. Forty-two patients (32.3%) had chronic renal insufficiency, of those 25 (19.2%) eventually developed ESRD. Seventy-five percent of the patients with histologic Grades IV and V showed progressive renal disease, while only 16% of patients with Grades I to III lesions revealed progressive disease, the latter indicating a more benign course (P < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Effective renal plasma flow in renal transplant rejection]

It is important to differentiate between cell-mediated (acute) and humoral (chronic) rejection in renal transplantation in order to initiate appropriate therapy. Since effective renal plasma flow (ERPF) provides a sensitive method of analyzing renal function, this test was undertaken to evaluate the possibility of differentiating acute and chronic rejections by ERPF. A total of 90 patients (no rejection: 33, acute rejection: 45, chronic rejection: 12) were retrospectively included in this study. ERPF was determined by performing comprehensive renal function test (Tauxe et al., 1980) and Student's unpaired t-test was used to evaluate the statistical difference (no rejection vs chronic rejection, no rejection vs acute rejection, acute rejection vs chronic rejection). The ERPF value of the no rejection group (228.9 +/- 119.2 ml/min) was significantly higher than the ERPF value of the acute rejection group (167.5 +/- 86.9 ml/min) and the chronic rejection group (137.2 +/- 60.2 ml/min) (P < 0.05). By in contrast, there was no significant difference between the acute rejection group and the chronic rejection group (P > 0.05). We concluded that ERPF value alone could not differentiate between acute rejection and chronic rejection in renal transplantation.

[Bone mineral density in patient with renal transplant]

Progressive renal failure may cause disturbance of mineral metabolism. Successful renal transplantation may correct many features of disturbance of calcium and phosphorus metabolism. Dual photon absortiometry (DPA) provides a noninvasive method for the serial measurements of bone mass of the vertebral bodies. Using this method, bone mineral density (BMD) was detected and evaluated in patients with renal transplants. In this study, BMDs of lumbar vertebrae 2 to 4 were measured and the mean value was presented as gm/cm2. Forty seven patients (over 40 years of age) with renal transplants and 103 normal controls of a similar age group were included in this study. Surprisingly, no significant difference in bone mineral density was found between the patients with renal transplant and the normal controls in our preliminary study.

Pentazocine addict nephropathy: a case report

Medical complications associated with narcotic addiction include bacterial endocarditis, pneumonia, pulmonary embolism and renal disease. Renal disorders associated with pentazocine abuse are rarely reported. They vary with method of administration, dosage, and duration of abuse. We describe a 33-year-old male addict, using intravenous pentazocine for 6 years. He has nephrotic syndrome with a rapid deterioration of renal function to a uremic stage within 3 weeks. The laboratory data includes: IgG 1270 mg/dl, IgA 369mg/dl, IgM 326mg/dl, C'3 65.2 mg/dl, C'4 16.3 mg/dl, and serum soluble interleukin-2 receptor level (sIL-2R) greater than 6000U/ml. A renal biopsy revealed membranoproliferative glomerulonephritis (MPGN) type I with tubulointerstitial nephritis. Immunofluorescent (IF) study revealed granular deposition of C'3 and IgM in mesangium and the glomerular capillary wall. The pathogenesis of glomerular disease in drug addicts is discussed, and the literature reviewed.

Immunoglobulin-E-specific suppressor factors in primary glomerulonephritis with nephrotic syndrome

Human immunoglobulin (Ig) E synthesis is regulated by T-cell-derived binding factors which include potentiating factors and suppressor factors (IgE-SFs) and B-cell-derived factors. Seventeen cases of primary glomerulonephritis (GN) with nephrotic syndrome and high serum IgE were studied for their serum IgE-SFs. These include 8 cases of minimal-change disease (MCD), 3 cases of IgM nephropathy, 4 cases of focal segmental glomerulosclerosis, and 2 cases of IgA nephropathy, aged between 20 and 60 years (mean: 37.2). A significantly lower activity of these factors was noted in the patient group as shown by a lower overall inhibition rate on in vitro IgE synthesis (median: 22.9 vs. 53.2%, p less than 0.05). Some of them even exhibited an enhancing activity in their serum as shown by a negative inhibition rate. These findings suggest that there is a T cell disorder in some of the primary GNs with high serum IgE, especially in MCD, which causes an abnormal regulation of IgE synthesis.

Glomerular diseases in human renal allograft

A total of 64 renal graft biopsies performed on 44 transplant patients from among 116 transplants (12 from living donors, 104 from cadavers) were analyzed during the period from July 1983 to December 1990. The frequency of allograft glomerular disease was 22.7% (10/44). Membranous glomerulonephritis (MGN) was detected in five patients; focal segmental glomerulosclerosis (FSGS), in two; transplant glomerulopathy, in two; and IgA nephropathy, in one. Nephrotic syndrome occurred in nine of the ten patients. Progressive deterioration of graft function developed in four patients associated with chronic rejection, and two of them later lost the graft. The remaining six patients had no chronic rejection and retained a stable renal condition with one exception, a patient who suffered from acute total occlusion of the right internal iliac artery and who eventually lost the graft. It is concluded that MGN is the most common allograft glomerular disease, but the outcome of the graft is probably related to the coexistent chronic rejection.

[Cyclosporin A for treatment in nephrotic syndrome of childhood--a preliminary report]

We treated five, three steroid resistant and 2 steroid dependent nephrotic syndrome with oral cyclosporin A and prednisolone. All children received more than eight weeks course of prednisolone, and were in a critically ill status from their nephrotic syndrome and by steroid-toxic side effects. Cyclosporin A was started at 7 mg/kg/day and titrated to maintain serum level of 150-250 ng/ml. Prednisolone was given initially at a dose of 1 mg/kg/day x 1 month, subsequently at a dose of 0.4 mg/kg/day x 1 month, then 0.2 mg/kg/day x 4 months. After a total course of six months, cyclosporin A was tapered to 3.5 mg/kg/day. Prednisolone was maintained at a dose of 0.2 mg/kg/day. Renal biopsies of the 3 steroid resistant children showed membranous glomerulonephritis with focal segmental glomerulosclerosis, focal segmental glomerulosclerosis and IgM nephropathy respectively. These three cases all went into complete remission within four weeks. Among them, one case relapsed twice within one year. Renal biopsies of the two steroid dependent children showed minimal change and focal segmental glomerulosclerosis respectively. These two cases went into complete remission within three weeks sustained up to a year. Side effects of cyclosporin A were observed in one patient with gum hypertrophy and two patients with hirsutism. Other side effects were not found. After cyclosporin A treatment for one year, the renal biopsy of the relapsing patient showed no interstitial fibrosis or tubular atrophy. In conclusion, cyclosporin A was found to be effective in steroid resistant and dependent patients. The duration of cyclosporin A treatment is so far unknown. It needs further evaluation in the future.

Persistant abnormal serum parathyroid hormone after renal transplantation: correlation between renal graft function

Secondary hyperparathyroidism in uremia renal transplantation. We studied the i-PTH (immunoactive parathyroid hormone) of nineteen immunoactive parathyroid hormone) of nineteen patients before and after renal transplantation with average of 20 months post transplantation. In group I patients with normal i-PTH serum level had an significant lower serum level of creatinine than Group II with elevated abnormal i-PTH. While the calcium and phosphorus showed no significant difference between group I and Group II patients. We suggested that abnormal serum i-PTH level after renal transplantation after one year was closely related to renal graft function. This group of abnormal serum i-PTH should be closely monitored for their renal graft function.

Serum IgE in primary glomerular diseases and its clinical significance

Total serum IgE was measured in 119 cases of primary glomerular diseases and 33 normal healthy persons. Statistically significant higher levels were noted in minimal change disease (MCD; median: 630 U/ml), IgM nephropathy (IgMN; 618 U/ml), focal glomerulosclerosis (FGS; 373 U/ml) and membranous glomerulonephritis (MGN; 144 U/ml). A higher level of serum IgE was noted in association with more frequent relapse or steroid resistance in MCD and IgMN and in FGS with nephrotic syndrome. A small group of IgA nephropathy with nephrotic range proteinuria was also noted to have extraordinarily high serum IgE. These findings suggest that IgE may play an important role in the pathogenesis of MCD, IgMN, and FGS and may serve as a prognostic indicator in terms of steroid responsiveness in MCD and IgMN.

Glomerulonephritis in ankylosing spondylitis

There have been a few reports suggesting the association between glomerulonephritis (GN) and ankylosing spondylitis (AS). The reported glomerulonephritides include IgA nephropathy, mesangial proliferative GN and membranous nephropathy. From January 1983, through December 1984, we observed 5 cases of GN among 116 cases of definite AS. Three of them were IgA nephropathy. The other two were mesangial proliferative GN, with IgM deposit in one case and isolated C3 deposit in another. Microscopic hematuria was observed in all of them. The renal function and 24-hour urine protein excretion were all within normal limits. Serum IgA level increased in all but the case of mesangial proliferative GN with IgM deposit. All except one had the antigen of HLA-B27. Serum IgA level was determined in 78 cases (86 estimations) of AS. The mean value was 399.6 +/- 15.0 mg/dl (mean +/- SE) (normal range: 100-350 mg/dl). Fifty-four of them (63%) had a value higher than 350 mg/dl. The interrelationship of AS and IgA nephropathy was discussed.

Why do patients with lupus nephritis die?

Over 20 years 42 of 138 patients with systemic lupus erythematosus "died"--that is, suffered actual death or went into terminal renal failure, or both; data from 41 were available for analysis. In most patients the causes of death were multiple. Twenty seven patients went into terminal renal failure, of whom 25 were offered dialysis treatment. Three regained renal function later, 12 survived on dialysis or with functioning kidney allografts--almost all with inactive lupus--but 13 died after starting dialysis, most within a few weeks or months. The principal causes were active lupus or infection. In those patients with renal failure after rapid deterioration in renal function (n = 14) there were nine deaths, while of 10 patients with a slow evolution into renal failure, only four died. Four patients with impaired and 10 with normal renal function died, again most often from complications of lupus or from infection. Vascular disease was a major cause of death in seven patients, all but two of whom were young; of 15 postmortem examinations, eight showed severe coronary artery atheroma, and three surviving patients required coronary bypass operations. Analysis of the timing of death or entry into renal failure showed that in 12 out of 13 patients who died within two years of onset the lupus was judged to be active, while this was true in only eight out of 19 patients who died later. Six of the seven vascular deaths occurred later than two years from onset, while only nine of 26 renal "deaths" occurred before two years; deaths from infections (n = 13) were distributed equally. Despite this and aggressive treatment of active disease, the principal cause of actual death was uncontrolled lupus.

Placental proteins (human chorionic gonadotropin, human placental lactogen, pregnancy-specific beta 1-glycoprotein, and placental protein 5) in seminal plasma of normal men and patients with infertility

Placental proteins, including human chorionic gonadotropin (hCG), human placental lactogen (hPL), pregnancy-specific beta 1-glycoprotein (SP1), and placental protein 5 (PP5) have been detected in human seminal plasma of 20 normal men and 42 patients with infertility. Levels of hPL, SP1, and PP5 were similar in these groups. There were significantly higher levels of hCG in subjects with normal sperm counts than in those with oligospermia or azoospermia. The levels of PP5 in seminal plasma showed an association with sperm motility, suggesting that PP5 may have a significant biologic function in the maintenance of sperm motility.

Home treatment of uremia with gastrointestinal dialysis

Twenty patients with end-stage renal disease and a creatinine clearance of less than 5 ml/min were tre ated with oral gastrointestinal (GI) dialysis. The dialyzate contained an electrolyte solution with 180-220mmoles/l of mannitol. In fasting state in the morning the self-prepared 7 liters of dialyzate was drunk at a rate of one glass every 5 minutes for about 3 hours. Intermittent diarrhea with passage of watery fluid occurred during the whole period. After each treatment the average drop in BUN in individual patients was 11--22%, but no significant decrease in serum creatinine. With twice to thrice weekly GI dialysis uremic symptoms such as anorexia, nauseal and vomiting were usually improved with slight prolongation of life. However, treatment is usually difficult when the patient becomes oliguric or anuric, so its value in long-term management of chronic uremia is limited. Most of our patients either died or shifted to hemodialysis within a few months of institution of the therapy.