A randomized study comparing methylprednisolone plus chlorambucil versus methylprednisolone plus cyclophosphamide in idiopathic membranous nephropathy

To assess whether chlorambucil or cyclophosphamide may have a better therapeutic index in patients with idiopathic membranous nephropathy, we compared two regimens based on a 6-mo treatment, alternating every other month methylprednisolone with chlorambucil or methylprednisolone with cyclophosphamide. Patients with biopsy-proven membranous nephropathy and with a nephrotic syndrome were randomized to be given methylprednisolone (1 g intravenously for 3 consecutive days followed by oral methylprednisolone, 0.4 mg/kg per d for 27 d) alternated every other month either with chlorambucil (0.2 mg/kg per d for 30 d) or cyclophosphamide (2.5 mg/kg per d for 30 d). The whole treatment lasted 6 mo; 3 mo with corticosteroids and 3 mo with one cytotoxic drug. Among 87 patients followed for at least 1 yr, 36 of 44 (82%; 95% confidence interval [CI], 67.3 to 91.8%) assigned to methylprednisolone and chlorambucil entered complete or partial remission of the nephrotic syndrome, versus 40 of 43 (93%; 95% CI, 80.9 to 98.5%) assigned to methylprednisolone and cyclophosphamide (P = 0.116). Of patients who attained remission of the nephrotic syndrome, 11 of 36 in the chlorambucil group (30.5%) and 10 of 40 in the cyclophosphamide group (25%) had a relapse of the nephrotic syndrome between 6 and 30 mo. The reciprocal of plasma creatinine improved in the cohort groups followed for 1 yr for both treatment groups (P < 0.01) and remained unchanged when compared with basal values in the cohort groups followed for 2 and 3 yr. Six patients in the chlorambucil group and two in the cyclophosphamide group did not complete the treatment because of side effects. Four patients in the chlorambucil group but none in the cyclophosphamide group suffered from herpes zoster. One patient per group developed cancer. It is concluded that in nephrotic patients with idiopathic membranous nephropathy both treatments may be effective in favoring remission and in preserving renal function for at least 3 yr.

Similarities of essential and spontaneous hypertension. Volume and number of blood cells

Spontaneously hypertensive rats have long been used as an animal counterpart of human essential hypertension. The validation of this strain as a model rests mainly on the "clinical" similarity of the two syndromes, but it has scarcely been founded on numerical comparison of measurable parameters. We investigated three hematological indexes previously recognized to be altered in spontaneously hypertensive rats: the single-cell volume of erythrocytes, the single-cell volume of platelets, and the erythrocyte number. Erythrocyte volume was lower by 7%, platelet volume was higher by 12%, and erythrocyte count was higher by 22% in spontaneously hypertensive rats in comparison with Wistar-Kyoto controls. More unexpectedly, it was found that erythrocyte volume is lower by 2%, platelet volume is higher by 3%, and erythrocyte number is higher by 6% in essential hypertensive subjects when compared with normotensive healthy subjects. These results, combined with previously reported blood cell alterations in subjects and rats, reinforce the evidence of a biological similarity between essential and spontaneous hypertension.

Renal tubular acidosis associated with vitamin D-resistant rickets. Role of phosphate depletion

3 children with vitamin D-resistant rickets (VDRR), and severe phosphate depletion had moderate metabolitic acidosis and evidence of impaired distal tubular acidifying mechanisms. Therapy with 1-alpha-OH-vitamin D3 and phosphate supplementation improved the clinical and radiological rachitic manifestations, and resulted in the normalization of systemic acid-base parameters as well as of tubular acidification. Profound phosphate depletion is another cause of acquired, reversible distal renal tubular acidosis (RTA).

[Physiopathological and clinical features of hypernatremia]

The observation of hypernatriaemia in a large series under a variety of clinical conditions (gastrointestinal loss, increased "forced loss", and insufficiency parenteral feeding) is made the occasional for an overview of its main physiopathological and clinical features. From the physiopathological standpoint, the syndrome is rarely coupled with an absolute water deficiency. More commonly, sodium and water losses go together to bring about a fall in both intracellular and extracellular volume. The clinical significance of hypernatriaemia is essentially linked to increased osmolar content, not only of the extracellular liquid, but more particularly (due to water depletion) of the intracellular compartment, which underlies the establishment and progress of the anatomopathological lesions and the clinical symptoms.