Mycophenolate as maintenance therapy for lupus nephritis with impaired renal function

BACKGROUND

Mycophenolate (MF) is effective as a maintenance therapy after induction therapy in patients with lupus nephritis (LN). However, little is known about its role in patients with impaired renal function. The purpose of this study was to evaluate the efficacy and safety of MF as a maintenance therapy for LN and its association with renal function.

METHODS

Data were obtained for 56 Spanish patients who were receiving MF as a maintenance therapy for LN. Patients were classified into two groups according to renal function at the initiation of MF treatment: group 1 [estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m(2)] and group 2 (eGFR <60 ml/min/1.73 m(2)). The primary endpoints of the study were the rates of renal relapse and responses, and their relationship with baseline renal function. Secondary outcomes were the appearance of side effects during treatment.

RESULTS

At initiation of MF treatment, the only differences between the groups were for age, hemoglobin levels, anti-DNA antibody titer, proteinuria, and renal function. In group 1 (n = 38), the eGFR was 98 ± 34 ml/min/1.73 m(2) and in group 2 (n = 18) the eGFR was 43 ± 14 ml/min/1.73 m(2). Only 3 cases had an eGFR <30 ml/min/1.73 m(2). No significant differences were observed in the rate of relapse at 6 months (group 1: 20%; group 2: 23%) or at 12 months (group 1: 25%; group 2: 17%). Response rates were also similar in both groups. Side effects were unremarkable.

CONCLUSIONS

MF is effective and safe as a maintenance therapy for LN both in patients with normal renal function and in those with renal impairment.

Optimization of expanded donors using dual kidney transplantation: case-control study

BACKGROUND

Cadaveric donation is now experiencing a trend toward the use of expanded criteria donors (ECD) who may not yield a suitable kidney for single organ transplantation which has occasionally led to their use as dual renal transplantations.

MATERIAL AND METHODS

We undertook a case-control study to analyze our experiences between May 2007 and March 2011 with 80 kidneys from ECD who were older than 65 years. Of these, 40 were used as single transplants (STX) and the other 40 as dual cases (DTX). Criteria to determine STX versus DTX were established by biopsy results and other donor factors.

RESULTS

The mean age of the ECD for STX was 68.7 ± 3.0 years and for DTX, 74.2 ± 4.3 years (P < .001), with more women among DTX (75%) versus STX (40%; P < .001). The DTX kidneys showed higher biopsy scores than the STX organs. DTX were older than STX recipients, but there were no differences in cold ischemia time, delayed graft function, hemorrhagic complications or reinterventions. DTX recipients achieved better CrCl at 1, 3, 6, and 12 months, although only significantly so at 6 months (53.4 ± 19.5 Ml/min versus 44.5 ± 15.6 mL/min; P < .05). Death-censored graft survival was 90% at 3 years for both groups.

CONCLUSIONS

DTX offered good results for graft survival and renal function, despite the more complicated surgery and worse quality of the allografts. DTX allowed the use of ECD kidneys that showed less satisfactory histologic and donor characteristics.

Continuously evaluating performance in deceased donation: the Spanish quality assurance program

The Spanish Quality Assurance Program applied to the process of donation after brain death entails an internal stage consisting of a continuous clinical chart review of deaths in critical care units (CCUs) performed by transplant coordinators and periodical external audits to selected centers. This paper describes the methodology and provides the most relevant results of this program, with information analyzed from 206,345 CCU deaths. According to the internal audit, 2.3% of hospital deaths and 12.4% of CCU deaths in Spain yield potential donors (clinical criteria consistent with brain death). Out of the potential donors, 54.6% become actual donors, 26% are lost due to medical unsuitability, 13.3% due to refusals to donation, 3.1% due to maintenance problems and 3% due to other reasons. Although the national pool of potential donors after brain death has progressively decreased from 65.2 per million population (pmp) in 2001 to 49 pmp in 2010, the number of actual donors after brain death has remained at about 30 pmp. External audits reveal that the number of actual donors could be 21.6% higher if all potential donors were identified and preventable losses avoided. We encourage other countries to develop similar comprehensive approaches to deceased donation performance.

Mycophenolate as induction therapy in lupus nephritis with renal function impairment

BACKGROUND

Mycophenolate (MF) is effective as induction therapy for lupus nephritis (LN) in patients with normal renal function; however, little is known about its role in patients with impaired renal failure. The purpose of this study was to evaluate the response to MF in LN and its association with baseline renal function.

METHODS

Data were obtained for 90 patients from 12 Spanish renal units who were receiving MF as induction therapy for LN. Patients were classified into 2 groups: group 1 (estimated glomerular filtration rate [eGFR] ≥60 ml/min/1.73 m(2)) and group 2 (eGFR <60 ml/min/ 1.73 m(2)). The primary outcome measure was the percentage of patients who achieved any response and its relationship with initial eGFR. The secondary outcome measures were the percentage of patients who achieved a complete response (CR) or partial response (PR) and the appearance of relapses during treatment and side effects.

RESULTS

At initiation of MF treatment, there were no differences in the main parameters between group 1 (n = 63; eGFR 87 ± 23 ml/min/ 1.73 m(2)) and group 2 (n = 27; eGFR 44 ± 12 ml/min/1.73 m(2)). Exposure to prednisone and MF was similar. The percentages of patients who achieved a response in groups 1 and 2 were, respectively, 69.2 and 43.8% at 6 months and 81.3 and 73.7% at 12 months. CR was more frequent in group 1, whereas PR was similar in both groups. Four patients relapsed and side effects were unremarkable.

CONCLUSIONS

MF is effective and safe as induction therapy for LN, and response is even achieved in patients with baseline renal impairment.

Differential analysis of donor characteristics for pancreas and islet transplantation

Suitable selection of donors is key to the success of human islet isolation and transplantation. Although several important donor-related factors have been identified previously, they needed to be confirmed in our setting. The aims of this study were: (1) to compare the characteristics of islet donors with those of pancreas donors (national transplant registry). (2) to compare the characteristics of islet donors resulting in a successful isolation in our facility with the characteristics of pancreas donors, and (3) to compare the characteristics of islet donors at this facility, whether or not isolation was successful, with donors elsewhere whose islets were transplanted and included in the Collaborative Islet Transplant Registry. The 35 islet isolations completed at our facility were analyzed for various characteristics. Significant differences were seen in donor age body mass index (BMI), and body weight between our islet donors and our pancreas donors (P < .001). These differences were maintained in the subgroup analysis corresponding to donors of successful isolations compared to pancreas donors (P < .01). Most successful isolations in our islet isolation facility were associated with donors of BMI >25. The percentage of successful isolation (>300,000 IEq) was higher among donors with a body weight >90 kg. We concluded that there was little overlap between the donor profiles for pancreas transplantation and for islet transplantation. More specific selection criteria relative to both BMI and body weight for islet donors may result in greater success of pancreas islet isolation and transplantation.

[Glutamin concentrations in patients treated with cisplatin have a predicting value of renal failure development]

Glutamine is an amino acid (AA) whose mission is carrying nitrogen. Abnormalities in protein and AA metabolism has been observed in patients with acute renal failure. Several clinical trials had showed abnormalities in plasma AA and its elimination in uremic environment. Moreover, renal failure disturbs hepato-splachnic circulation of glutamin, tyrosine and proline. Cisplatin is a key drug in the chemotherapy pharmacology, and the nephrotoxicity due to tubular injury, is one of its most important side effects, which sometimes is irreversible and leads to substitutive renal treatment. The goal of this work is to find predictive factors of renal failure secondary to cisplatin. Fifty four patients treated with cisplatin were studied. The plasma AA concentration and another plasmatic and urine parameters were measured in three different days after each pulse of chemotherapy. Plasma AA modifications through the pulses and reabsortion percentages of everyone were analysed too. Significant differences were observed in 13 AA reabsortion percentages and 16 plasmatic concentration. Glutamin concentration through the pulses was higher in 13 patients, (24%) who presented renal failure (Plasmatic glutamin concentration higher than 1000 mM/L at the third day after cisplatin administration was highly predictive value about getting renal failure, with significant difference from patients with o normal renal function. Others parameters analysed did not rise significant predictive values, so as it was not found relation between hyperaminoaciduria and renal function. It is concluded that cisplatin leads to renal failure in a 24% of this patients. Glutamin, concentrations higher than 1000 mM/L at the third day after cisplatin administration have a high predictive value about getting renal failure; so, it is suggested this could be a early marker of cisplatin nephrotoxicity before the serum creatinine is elevated, in order to get an early and suitable treatment of it.

[Intravenous cyclophosphamide in lupus nephritis: twenty years reducing dose]

The prognosis for patients with proliferative glomerulonephritis associated with systemic lupus erythematosus has dramatically improved over recent decades. We review our experience with intermittent pulse therapy with intravenous cyclophosphamide (IC) in 97 patients (75 female) aged over 20 years. The series was divided into three groups. Group A (n=39) received monthly IC pulses (begin 1 g) for up to 24 months between 1985-1991. Group B (n=47) received monthly IC pulses (1 g) for six months with additional quarterly doses for a maximum of 18 months, depending on the therapeutic response (from 1991). From 1999, Group C (n=11) patients were treated with low-dose IC (3 g in three months) followed by azathioprine (2 mg/kg) or mycophenolate mofetil (1.5-2.0 g/day) for 12-18 months. The total IC doses (g) administered were: Group A, 15.1+/-9.0; Group B, 8.5+/-3.5; and Group C, 3.0+/-0.0. These figures show the trend progressive reduction in exposure to IC. Overall, treatment with the different IC regimens achieved satisfactory control of lupus nephritis in 76% of the patients. Comparison of the values at baseline and after 24 months showed that the serum creatinine (mg/dl) fell in Group A from 1.77+/-1.06 to 1.09+/-0.63, in Group B from 1.22+/- 0.85 to 0.95+/- 0.45, and in Group C from 0.90+/-0.23 to 1.17+/-0.54 (p<0.05). In the same period, proteinuria (g/day) fell in Group A from 6.19+/-4.31 to 0.79+/-1.76, in Group B from 4.43+/- 3.17 to 2.08+/-3.65, and in Group C from 5.43+/- 3.37 to 3.22+/-4.00 (p=0.05). There was not differences between the three groups in both variables. The adverse effects were mainly viral and bacterial infections, with no intergroup differences. Avascular osteonecrosis requiring hip replacement and early menopause were more frequent in Group A. Nine patients died, seven due to cardiovascular causes and two with infection. No differences were detected between the three groups when analyzing the overall patient survival at 5, 10 and 15 years (95%, 92%, and 84%, respectively). The likelihood of maintaining serum creatinine within normal ranges or less than twice the baseline range was similar in the three groups at 5, 10 and 15 years (92%, 72% and 66%, respectively). There were 47 episodes of relapse, with no differences between the three groups. In Summary, treatment with different regimens of intermittent IC is relatively safe and efficient to control the disease and lupus nephritis in SLE patients even with progressively smaller doses. The price paid concerned infectious complications, and bone and ovarian toxicity. New alternatives should at least maintain the same efficacy, but with fewer adverse effects and relapses.

[Giant renal arteriovenous malformation: a suspicious bruit]

Arteriovenous (AV) malformations remain relatively rare clinical lesions consisting in abnormal shunts between the arterial and venous vascular systems. Both,congenital or acquired fistulas, are unusual causes of renal or heart failure. Congenital AV fistulas usually present with hematuria, while acquired ones are more likely to present with hemodynamic changes, such as hypertension, cardiomegaly and congestive heart failure. Here we present a 61 year-old woman studied before by probable pulmonary arteriovenous fistula and referred to nephrologist with a six-month history of dyspnea and peripheral edema. Physical examination was remarkable for an apical systolic ejective murmur as well as another bruit over the right pulmonary base. Blood tests showed a sCr of 1.7 mg/dl with normal urinalysis. On imaging, renal duplex ultrasound showed a pulsatile hiliar mass on the right kidney with an arterial flow of 300 cm/sec that was identified as a giant AV fistula on MRA. An echocardiogram revealed severe pulmonary hypertension with a cardiopulmonary output of 12,9 l/min that doubled the systemic one (6,49 l/min). In view of the large size of the AV fistula occupying the majority of the parenchyma, endovascular approach was turned down and a laparoscopic nephrectomy was performed successfully. There was an immediate clinical improvement and 45 days after the procedure, a control-echocardiogram showed normalization of the cardiopulmonary parameters with minimal changes in glomerular filtration rate.

Expanded Criteria Donors for Kidney Transplantation: Quality Control and Results

Although the number of kidneys from expanded criteria deceased donors (ECDs) is growing in most transplant centers, the limits for acceptance of these kidneys and the safety standards have still not been fully established. We evaluated 342 kidney transplants performed between January 1999 and December 2004. In 77 (22.5%) of these, the kidneys were from ECDs, that is, donors age >60 years and with one of the following characteristics: hypertension, death due to cerebrovascular accident (CVA) or glomerular filtration rate (GFR) <70 mL/min. The results of the ECD transplants were compared with 265 transplants during the same period from standard donors (SDs), that is, donors age <60 years and GFR > 70 mL/min. All the ECD kidneys underwent biopsy and were accepted for transplantation only if the score was <7. The ECDs (66.5 +/- 4.3 years) in comparison with the SDs (48.0 +/- 16.0 years) had a greater frequency of death due to CVA (94.8% vs 49.8%) and a lower GFR (80.4 +/- 25.0 vs 111 +/- 41.6 mL/min; P < .05). Of the ECDs, 97.4% had a history of hypertension versus 24.3% of the SDs. Kidney biopsies were performed in 116 SD kidneys because the donor age was >55 years or there was a history of hypertension. The median score for the kidney biopsies of the ECD kidneys was 3 versus 2 for the SD kidneys. Graft survival was not significantly different until the fifth year. The GFR at 12 months was significantly different (SDs, 58.0 +/- 22.7 vs ECDs, 48.9 +/- 16.5 mL/min; P < .05). Although the GFR in the ECD kidneys was lower than that of the SD kidneys, it could still be adequate for recipients older than 50 years of age. Accordingly, the acceptance criteria for ECD kidneys based mainly on the kidney biopsy score and donor GFR benefit the recipients.

Expanded Donor Criteria Due to Age: An Effort Rewarded

The life expectancy of the current Spanish population is 78 years, with some 20% of the population aged over 65 years. The continuing increase in the demand for transplants has led to widening of the criteria for acceptance of donors without worsening the results, but without reducing transplant waiting lists or mortality. This has resulted in the need to include the concept of the expanded criteria donor (ECD). We undertook a retrospective study of 77 donors from a hospital with no neurosurgery service from January 2000 to December 2005. Four of the donors younger than 60 years of age (n = 38) were not appropriate (10.5%), whereas five of the donors older than 60 years of age (n = 39) were not appropriate (12.8%; P = NS). The older donors provided 47 used kidneys (60.2%) and 22 livers (56.4%), slightly fewer than those obtained from the younger donors, though the difference was not significant. Thus, ECDs, those older than 60 years of age, did not result in a significant loss of kidneys or livers available for transplantation. Other factors associated with systemic vascular disease and accompanying disorders could be determinant when predicting the usefulness of organs for transplantation.

Multifactorial snowball effect in the reduction of refusals for organ procurement

Interviewing the family of a possible organ donor is a legal requirement in Spain, but it is the stage at which most potential donors are lost. Multiple factors influence the family's acceptance or rejection of this option, including awareness of the wishes of the deceased, personal preconceived attitudes of family members, as well as issues related to the hospital and its health care personnel, whose attitudes are a key factor in obtaining permission. We examined all 651 donation situations in a single hospital that included a family interview over the last 15 years. Among these 651 cases, 191 families refused donation (29.3%). The rate of donation refusal has fallen from 46.3% to 12.5% over these 15 years. To better understand the evolution of donor characteristics, interviewees, and the setting, we divided the sample into three 5-year periods to analyze key variables collected from the family interviews. The results showed that at the same time as the donor profile has changed, namely, fewer brain trauma cases and more victims of stroke as well as older mean age and more coexistent diseases, these has been an improvement in the factors related to the information and opinion of both the families and the donor about this process. The main reasons for refusal of donation have changed from negation of brain death, religious factors, and the desire to maintain the body intact during the 1990s, to sociocultural reasons in minority ethnic groups, to presumed refusal during life, and to family disagreements during the more recent years.

Pancreas donation for islet transplantation

Islet transplantation, though still in the experimental phase, is a therapeutic option that has opened new expectations for the control of diabetes mellitus. Initial results are encouraging for the significant advantages compared with whole pancreas transplantation for selected patients with type 1 diabetes mellitus, with or without kidney failure. However, the success of transplantation, both at centers with more experience and others with less, is limited by the difficulty in obtaining a suitable number of donors and by laboratory isolation techniques. Significant advances require changes in donor selection, perfusion, oxygenation, and transfer of the pancreas, and in the process of isolation, purification, and culture in the laboratory. Of the 32 pancreases sent to the islet isolation laboratory from different hospitals in Andalusia, a viable percentage of islets was finally available in 19. However, in only 4 (18%) procedures were the preparations considered optimal for implantation in 2 recipients.

Systemic lupus erythematosus in Europe at the change of the millennium: lessons from the "Euro-Lupus Project"

The "Euro-Lupus Cohort" is composed by 1000 patients with systemic lupus erythematosus (SLE) that have been followed prospectively since 1991. These patients have been gathered by a European consortium--the "Euro-Lupus Project Group". This consortium was originated as part of the network promoted by the "European Working Party on SLE", a working group created in 1990 in order to promote research in Europe on the different problems related to this disease. The "Euro-Lupus Cohort" provides an updated information on the SLE morbidity and mortality characteristics in the present decade as well as defines several clinical and immunological prognostic factors.

Organ Donation: A Comparison of Donating and Nondonating Families

The family interview to determine the wishes of the deceased during life about organ donation is not only a legal requirement, it is also the stage at which most potential donors are lost. Minimizing these losses necessitates awareness of all the variables involved in the family interview so that, before starting the interview, one understands the important key points affecting the outcome. We showed that some variables among 268 interviews are susceptible to intervention: the information and treatment perceived by the family members during the hospital stay and the preparation of the interview, such that a suitable number of the closest members of the family with a decision capacity is always present. Other noncontrollable factors that are important in the final decision included the social and demographic level, the prosocial attitude of the deceased, and prior knowledge and opinions about organ donation. Informative events within the hospital to improve the predisposition and collaboration of health care professionals were key to improving the public's perception of organ donation and achieving greater confidence in health care centers and their staff. Furthermore, the family interview must be planned by the transplant coordinators to limit improvisation.

[Mycophenolate mofetil in high risk IgA glomerulonephritis]

Mesangial IgA glomerulonephritis (MIgAGn) is the most common biopsied primary glomerulonephritis worldwide, with a poor long-term prognosis for renal function in over a third of all patients. No proven therapy currently exists for MIgAGn. Recent studies have suggested some benefit with mycophenolate mofetil (MMF), especially in hypertensive patients with kidney failure and proteinuria, though other studies have failed to corroborate these findings. We report eight adult patients with biopsy proven MIgAGn followed in a single hospital. They all received angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Compassionate use of MMF was based on the presence of clinical and analytical data suggesting a high risk of short- to medium-term progression to chronic renal failure. MMF treatment was stopped after two and three months in two patients who had advanced renal failure at the start of therapy because of disease progression and greater fluid retention. Several months later they both required dialysis and kidney transplantation. The mean duration of MMF therapy in the other six patients was 15 (range: 10-18) months. The mean serum creatinine concentration fell from 1.82 +/- 0.47 to 1.55 +/- 0.41 mg/dl (p = 0.04). Protein loss in 24-hour urine collection fell from 1.95 +/- 1.35 to 0.77 +/- 0.58 g/day (p = 0.02). These results in this low number of patients showed that treatment with MMF in high-riks patients with MIgAGn and early stage kidney failure generally stabilized the disease and reduced proteinuria. MMF was well tolerated and may be of some benefit in a subgroup of patients with MIgAGn and a poor prognosis.

Prostate-specific antigen in the assessment of organ donors

Transplantation is limited worldwide by the shortage of organs, thus, donors of older ages are necessary to be used to meet the increasing demand for transplants. To minimize the transmission of cancer from this population, it is mandatory to rule out the presence of neoplasms. We present our experience with analysis of the prostate-specific antigen (PSA) for male donors older than 50 years of age. Eleven (5.9%) had PSA levels >6 ng/mL, 2 had prostate cancer. In 7 donors with high PSA levels postextraction study of the whole prostate gland showed carcinoma in 1 and prostate infarction in 1; the other 5 were reported as normal or having benign prostatic hypertrophy (BPH). Donors with high PSA levels are suitable for transplantation if urgent pathological studies do not find prostate cancer. Nevertheless, in most donors, increased PSA levels are secondary to causes other than malignant tumors, thus, the risk of transmission of prostate cancer with transplants is minimal. In conclusion, measurements of PSA levels alone prior to extraction are not sufficient to diagnose cancer in organ donors. We conclude that this analysis must be restricted to donors with a past history of prostate disease. Meanwhile, better tests to avoid false-positive results are required.

[Survival of myeloma patients treated with dialysis]

BACKGROUND

Renal failure is a common complication of myeloma. Renal replacement therapy in these patients is controversial due to poor survival outcomes and low tolerance to treatment. We reviewed our experience on patients with myeloma undergoing dialysis therapy at one centre.

PATIENTS AND METHODS

Between 1980 and 2000, 28 patients (21 men and 7 women) with myeloma were admitted to chronic dialysis programme and the following variables were analysed: sex, age when starting dialysis, lapse of time between diagnosis of myeloma and admission to dialysis (TD), disease stage, comorbity, mode of presentation, calcium, creatinine at diagnostic, albumin and Hb at the beginning of dialysis, and cause of death. We studied survival among these patients (Kaplan-Meier), identified predictors of survival outcome (Cox's regression) and compared survival between the two decades studied.

RESULTS

Mean age was 65 years, median TD was 0.4 months, and modes of presentation were: end-stage renal failure (18 patients), acute renal failure (8), amyloldosis (2). Eleven patients (39%) had myeloma IgG, four (14%) IgA and thirteen (46%) had light chains. Kappa light chain was the most frequent one. In 75% of patients myeloma was at IIIb stage. Cause of death were: Cardiovascular disease (5 patients), infections (4), suspension of treatment (4), tumours (4), and others causes (2). Median survival for all patients was 16.8 months (range 0.4-78) and 25% survived over 39 months. Hb level was the only significant predictor in the multivariant analysis (p = 0.02). In the 80's median survival was 6.17 months versus 17 months in the 90's but this difference was not significant with long-rank test.

CONCLUSION

Although survival of patients with myeloma treated with dialysis is still short, 25 percent survive over 3 years, being Hb level the only predictive factor. Moreover, we observed an improvement of survival in recent years.

Lessons from the "Euro-Lupus Cohort"

The "Euro-Lupus Cohort" is composed by 1,000 patients with systemic lupus erythematosus (SLE) that have been followed prospectively since 1991. These patients have been gathered by a European consortium - the "Euro-Lupus Project Group". This consortium was originated as part of the network promoted by the "European Working Party on SLE", a working group created in 1990 in order to promote research in Europe on the different problems related to this disease. The "Euro-Lupus Cohort" provides an updated information on the SLE morbidity and mortality characteristics in the present decade as well as defines several clinical and immunological prognostic factors.

Short- and long-term success of organs transplanted from acute methanol poisoned donors

BACKGROUND

The shortage of organs for transplantation has made it necessary to extend the criteria for the selection of donors, among others including those patients who die because of toxic substances such as methanol. Methanol is a toxic which is distributed through all the systems and viscera of the organism and tends to cause a severe metabolic acidosis. It can specifically cause serious or irreversible lesions of the central nervous system (CNS) and retina, and ultimately brain death. We present our experience with 16 organ donors who died as a result of acute methanol intoxication in 10 Spanish hospitals over the last 14 yr.

PATIENTS AND METHODS

Between October 1985 and July 1999, 16 organ donors with brain death caused by acute methanol intoxication, 13 females and three males with a mean age of 38.4 +/- 7.6 yr (interval: 26-55 yr), allowed 37 elective transplants to be performed: 29 kidneys, four hearts and four livers for 37 recipients, and one urgent liver transplantation to a recipient with fulminant hepatitis.

RESULTS

The immediate postoperative period was favourable for the 38 graft recipients. None of the graft recipients presented gap anion metabolic acidosis in the immediate postoperative period, nor symptomatology or lesions of the CNS characteristic of methanol intoxication. Two patients died during the first month post-transplantation, a liver recipient and a heart recipient, at 16 and 24 days, respectively, because of acute rejection of the graft. At 1 month after transplantation 35 of the 36 recipients had been discharged from hospital with normal-functioning grafts. The last of the recipients, a kidney recipient, was discharged at 6 wk with normal-functioning graft. Actuarial survival of the graft and patient of kidney recipients at 1, 3 and 5 yr was 92.6, 77.8, and 75%, and 100, 88.9 and 83.3%, respectively; with average serum creatinines of 139.9 +/- 42.9, 150.4 +/- 42.8, and 164.4 +/- 82.5 micromol/L, respectively. At 1 yr after transplantation the three heart recipients and two of the three liver recipients had normal-functioning graft.

CONCLUSIONS

Methanol intoxication is not transferred from the donor to the recipient. The survival of the graft and kidney, heart and liver recipients using organs from donors who die because of methanol does not differ in the short- and long-term from the transplants performed with organs from donors who die from other causes.

[Intracytoplasmic crystals and Fanconi syndrome in a patient with IgA kappa myeloma]

A 45 year old man with IgA-Kappa myeloma had adult Fanconi Syndrome. Examination of renal biopsy revealed lesions in proximal tubules without glomerular lesions and without intratubular casts. By electron microscopy cytoplasmic crystalline inclusions were observed in renal proximal tubular epithelium. Increased plasma cells (28%) in bone marrow aspiration also contained crystalline inclusions. The treatment of myeloma produced partial remission of proliferative disease and Fanconi syndrome. We discuss the pathogenesis of Fanconi syndrome induced by light chains as well as the composition of crystalline deposits and the effects of treatment on Fanconi Syndrome.

Discriminant variables between organ donors and nondonors: a post hoc investigation

CONTEXT

Few studies in organ donation have focused on the attitudes and opinions of families who were asked to donate the organs of a deceased relative.

OBJECTIVE

To determine what variables influenced a family's decision to donate.

DESIGN

Post hoc investigation using a survey.

SETTING

Málaga, Spain.

PARTICIPANTS

Seventy-one people who had been approached for the donation of their deceased relatives' organs at a single hospital.

MAIN OUTCOME MEASURE

Consent to donate.

RESULTS

Based on a stepwise discriminant function analysis, the following variables played a determining role in a family member's decision to donate: (1) the expressed wish of the deceased, (2) having a clear understanding of the definition of "brain death." (3) the manners and approach of the doctors, (4) the hospital facilities, (5) concerns regarding the donation process, and (6) educational level.

CONCLUSION

Prodonation campaigns geared toward the public and hospital staff should focus on specific objectives to increase the likelihood of consent for organ donation.

[Long-term effects of captopril versus nifedipine retard on the lipid profile of mild to moderate normolipidemic essential hypertension patients. In representation of the Eastern Andalouz Cooperative Study]

The aim of the study was to evaluate the long-term (12 months) effects of captopril and nifedipine retard on the lipid profile of the non obese, non diabetic and normolipemic essential hypertensives. In a multicenter, randomised, open study we included 185 mild-moderate essential hypertensives responders to captopril (n = 96) or nifedipine retard (n = 89) in monotherapy, and with a total cholesterol between 200-239 mg/dl. No dietetic recommendations were given to the patients, except for moderate salt restriction. After 1 year follow-up, our results show that both drugs improved the lipid profile of the hypertensives. Patients with nifedipine retard showed a statistical significant decrease in the level of the total and LDL cholesterol and apoprotein B; while total and LDL cholesterol, triglycerides and apoproteins significantly decreased in the group treated with captopril. The possible pharmacological mechanisms involved in these beneficial effects are discussed; concluding that these properties made much more attractive these drugs to be used as first step therapy in the essential hypertensives.

Effect of dipyridamole with or without aspirin on urine protein excretion in patients with membranous glomerulonephritis

The antiproteinuric effect of the antiplatelet agent dipyridamole has been assessed after inhibition of thromboxane B2 (TxB2) synthesis in 8 patients with confirmed membranous glomerulonephritis. There were three study periods, each of 30 days, and 45 days apart, namely a washout period, treatment with dipyridamole 300 mg/d, and dipyridamole 225 mg/d plus aspirin 150 mg/d. On Days 1 and 30 of each study period serum and urine creatinine, 24-h excretion of protein, creatinine clearance, platelet aggregometry on whole blood and serum TxB2 were measured. Treatment with dipyridamole alone or with aspirin produced significant inhibition of platelet aggregation and a fall in 24-h protein excretion; the latter amounted to 54% with dipyridamole alone and 56% with dipyridamole plus aspirin (NS). Dipyridamole plus aspirin caused an 82% reduction in serum TxB2.

Effects of dipyridamole on the short-term evolution of glomerulonephritis

The aim of the present study is to evaluate the effect of dipyridamole (300 mg/day) versus placebo in a double-blind randomized trial on membranous glomerulonephritis (M-GMN), mesangial IgA glomerulonephritis (IgA-GMN), and segmentary and focal hyalinosis glomerulonephritis (SFH-GMN) during the first 3 months of treatment. In the case of M-GMN, proteinuria dropped by 60% of the basal value in patients treated with dipyridamole; in the case of IgA-GMN it dropped by 65-70%; and in the case of SFH-GMN it dropped by 40% of the basal value. Inhibition of proteinuria in M-GMN was correlated to platelet response, and above all, to the ADP-induced platelet aggregation in whole blood.

Hyperprolactinemia in chronic renal failure: impaired responsiveness to stimulation and suppression. Normalization after transplantation

(PRL) secretion was investigated in 12 undialyzed patients with chronic renal failure (CRF), 30 hemodialyzed patients (HD), 19 renal transplant (RT) recipients and 17 controls. Basal PRL levels in CRF and HD patients were higher than in controls and RT subjects. Plasma PRL values were higher in CRF than in HD patients. In the HD group, plasma PRL concentrations were significantly higher in men with reduced sexual potency than in those in which it was normal. After TRH stimulation in CRF and HD the PRL response was considerably less and the time of peak delayed with respect to the controls. In RT subjects PRL did not return towards baseline after 120 min. After bromocriptine, plasma PRL suppression in CFR and HD patients ws lower than in controls and RT subjects. These findings suggest that some factor which accumulates in uremia, is only partially removed by hemodialysis, and might be responsible for the hyperprolactinemia and might also interfere with the binding of TRH and bromocriptine to their respective pituitary receptors. Although a pituitary defect seems to be prevalent, a concomitant hypothalamic disorder cannot be excluded. Hyperprolactinemia seems to play a role in the sexual disturbances showed by some HD men. Whatever the alterations responsible for the impaired PRL regulation in uremia are, they are reversed by successful renal transplant.