Clinical Effect of Recombinant Human Erythropoietin on Anemia Associated with Chronic Renal Failure. A Multiinstitutional Study in Japan

Clinical effect and safety of recombinant human erythropoietin (r-HuEPO) were evaluated in 66 hemodialysis patients with intractable anemia. Initially, 50U/kg dry weight (DW) of r-HuEPO was administered intravenously at the end of every hemodialysis procedure for 4 weeks, then the dosage was increased to 100 and 200U/kg DW for poor responders. The patients’ hematocrits rose from 19.8 ± 2.3% (pretreatment) to 30.2 ± 4.9% after 12 weeks. From 206 U of blood transfusion requirement in the 3-month period before the study, only 34 U were needed after treatment. Serum iron and ferritin levels fell significantly during the study, and iron storage was considered to be one of the decisive factors in the response to r-HuEPO. Blood pressure rose in the course of r-HuEPO administration, but uncontrollable hypertension was rarely observed. There was no significant adverse effect of r-HuEPO except for this mild hypertension. These results indicate that r-HuEPO is an excellent therapeutic aid for the anemia associated with chronic renal failure.

Development of low-turnover bone diseases after parathyroidectomy and autotransplantation

Parathyroidectomy and immediate autotransplantation (PTX-AT) has been shown to decrease bone pain and increase bone mineral density. However, adynamic bone disease (ABD) has been predicted to develop if the serum intact parathyroid hormone (i-PTH) level remains lower than normal for a long period of time. Therefore, we investigated the bone histology of patients whose serum i-PTH levels did not increase over 70 pg/mL for 1 year after PTX-AT. Four chronic hemodialysis patients were investigated. The serum intact osteocalcin (i-OC) level was measured and histomorphometry for cancellous bone was performed 1 year after the operation. Tetracycline hydrochloride was administered in the 12 weeks after PTX-AT. The serum i-PTH levels were 20.5 +/- 15.0 pg/mL and i-OC levels were 19.5 +/- 0.9 ng/mL. Histomorphometric analyses showed the osteoclast surface to be 0.1% in two cases and 0% in the other two cases, the eroded surface was 7.7 +/- 6.1%, and the fibrosis volume and osteoblast surface were 0% in all four cases. Osteoid volume, osteoid surface and osteoid thickness were lower in cases 1-3, but higher in case 4. All tetracycline labelings were in contact with the mineralization front in cases 1 and 3, but some were not in cases 2 and 4. Serum i-PTH and i-OC levels indicated that ABD developed in these four cases. Histomorphometric analyses revealed that ABD developed in case 1, while either ABD or low-turnover osteomalacia developed in cases 2 and 4, and low-turnover osteomalacia was observed in case 3 after PTX-AT. In conclusion, i-PTH should not be maintained at lower levels to avoid low-turnover bone diseases.

Early changes of bone histology and circulating markers of bone turnover after parathyroidectomy in hemodialysis patients with severe hyperparathyroidism

AIMS

There have so far been no reports on the changes in bone histology in the early period after parathyroidectomy and autografting (PTX-AG). We investigated the effects of PTX-AG on bone histology during the initial 12 weeks after undergoing these surgical procedures.

MATERIALS AND METHODS

We performed bone histomorphometry 3 times (before as well as 4 and 12 weeks after PTX-AG) in 6 patients and 2 times (before and 4 weeks after PTX-AG) in 3 hemodialysis patients. In addition, the circulating parameters of bone metabolism were also assessed before and after PTX-AG in all 9 patients. The changes in the histomorphometric (static) parameters between pre-surgery and 4 weeks after surgery and those between 4 weeks and 12 weeks after surgery were assessed by the t-test while changes in the circulating parameters of bone metabolism were analyzed by Friedman's test.

RESULTS

Bone formation parameters including carboxy terminal propeptide of human type I procollagen (PICP), alkaline phosphatase (ALP) and intact osteocalcin (i-OC) were all extremely high before surgery. These parameters initially increased after PTX-AG and thereafter gradually declined. In contrast, the circulating bone resorption parameters including tartrate-resistant acid phosphatase (TRAP) and deoxypyridinoline (Dpyr) were also extremely high at baseline but markedly declined after operation. Osteoid-related parameters including osteoid volume (OV/BV), osteoid surface (OS/BS), and osteoid thickness (O.Th) all initially increased at 4 weeks after PTX-AG. In contrast, osteoblast surface (Ob.S/BS), osteoclast surface (Oc.S/BS), eroded surface (ES/BS), and fibrosis volume (Fb.V/TV) all decreased at 4 weeks after surgery, while Ob.S/BS decreased further at 12 weeks in cases 1-6. Although bone mineralization was ongoing at 4 weeks after surgery, both the mineral apposition rate (MAR) and bone formation rate (BFR) remained below the mean for normal individuals.

CONCLUSIONS

The circulating bone formation parameters and osteoid-related parameters showed an initial increase after PTX-AG. The concomitant decline in the circulating bone resorption parameters reflected the reduction in bone resorption. BFR decreased, but bone mineralization did not stop after PTX-AG.

[A case report of use of horseshoe kidney as renal transplant from live donor]

This is a report on a surgery performed in February, 1995 describing the donation of a living donor's horseshoe kidney used for renal transplantation. The recipient was a 31 years-old male on hemodialysis since 1994. The donor was the healthy 55 years-old father of the recipient who had an uncomplicated horseshoe kidney. The isthmus was perfused by an accessory artery. Via transperitoneal approach, the horseshoe kidney was mobilized for in situ perfusion. A microwave coagulator was used to divide the isthmus, and the cut surfaces were closed by mattress sutures and fibrin glue. The left kidney was transplanted into the recipient's right iliacfossa. While his post-transplant course was complicated by urinary leakage, the graft remained free of rejection until and beyond the 6 months post transplant period when he was discharged at s-Cr 1.7 mg/dl. The donor's convalescence was uneventful. During the 20 months post-transplant period both the donor and recipient are doing well.

Evaluation of laser Doppler flowmetry in renal transplantation

Renal grafts are presently evaluated based on the surgeon's observation of the organ microcirculation. Effectiveness of organ microcirculation has traditionally been accomplished through evaluation of the appearance of the graft. Laser doppler flowmetry (LDF) has been suggested as a possible means to determine graft effectiveness. Renal grafts in 46 transplants were studied using LDF and the technique was evaluated. It was found to be a useful technique for monitoring effectiveness of grafts.

[The clinical significance of albuminuria in renal transplantation]

Urinary excretion of albumin was measured after renal transplantation in 37 patients who received cyclosporine quadrotherapy (cyclosporine A, azathioprine, prednisolone and antilymphocytoglobulin). In 26 patients with a favorable clinical course, daily urinary albumin level increased significantly on the first operative day. Subsequently, it decreased gradually, and remained at about 40mg/day after 3 weeks. In these patients, the urinary albumin level did not correlate with blood pressure, whole blood cyclosporine level, serum creatinine level nor urinary enzyme level, i.e. beta 2-microglobulin, NAG, gamma-GTP. As for correlation between the urinary albumin level and biopsy findings in 21 patients who underwent renal graft biopsy, the urinary albumin level was significantly increased in 5 patients with high degree of lymphocyte infiltration in the renal graft as compared with 16 patients with low degree of infiltration. However, there was no significant correlation between the urinary albumin level and the degree of tubular damage. In 4 patients of allograft rejection, a clinical course was reflected better in the albumin level than in the urinary enzyme level, these results show that the measurement of urinary albumin is a useful clinical examination to evaluate the allograft rejection of renal transplantation in cyclosporine era.

Changes of enzyme activity levels in red blood cells in hemodialysis patients by recombinant human erythropoietin

In a phase II clinical trial to test the ability of recombinant human erythropoietin (r-HuEPO) to reverse the anemia of patients undergoing hemodialysis, the changes of enzyme activity in red blood cells were evaluated in 5 hemodialysis anemic patients who were treated with r-HuEPO. Concerning the activity levels measured, the following conclusions are drawn. 1) HK, ALD, TPI, G6PD and 6PGD were statistically significantly increased at the time when the hematocrit has risen by 8% with the use of r-HuEPO. 2) The enzyme activity levels of PFK, GA3PD, MPGM, ENOL, PK, GR and ADA were higher than normal already before the r-HuEPO treatment. 3) The increases of HK and G6PD by r-HuEPO, as age dependent enzymes, may reflect the generation of young red blood cells. 4) In view of the fact that they are related to ATP production in the glycolysis cycle, we infer that increases of red blood cell enzymes by r-HuEPO may play at least some part in bringing a sensation of "well-being" to severely anemic patients undergoing hemodialysis.

Selective deficiency of C1s associated with a systemic lupus erythematosus-like syndrome. Report of a case

We describe a patient who developed a systemic lupus erythematosus-like syndrome characterized by bilateral malar erythema, antinuclear antibody, and anti-double-stranded DNA antibody. He was started on hemodialysis (3 times/week) because of renal failure. He completely lacked total hemolytic complement (CH50) activity, which was subsequently determined to be due to the absence of the first component of complement (C1). The specificity was further defined, by Ouchterlony analysis using anti-C1s antiserum, and was found to be the C1 subcomponent C1s. There was no absence of C1r. We conclude that this is a case of selective deficiency of C1s.

Endoscopic management of shoulder pain in long-term haemodialysis patients

In 48 shoulders of 29 patients receiving long-term haemodialysis and complaining of intolerable shoulder pain, endoscopic resection of the coracoacromial ligament was performed under local anaesthesia on an outpatient basis, using the Universal Subcutaneous Endoscope system. Predominant endoscopic findings were proliferation of the subacromial bursae and popping between the coracoacromial ligament and the rotator cuff. Amyloid originating from beta 2 microglobulin (beta 2-M) was demonstrated in 87% of the resected coracoacromial ligaments and 86% of the subacromial bursae. Resection of the coracoacromial ligament relieved the shoulder pain in all patients.

Clinical application of Fragmin (FR-860) in hemodialysis: multicenter cooperative study in Japan

A multicenter cooperative study was designed to evaluate the efficacy and safety of Fragmin (FR-860) as an anticoagulant in hemodialysis. Sixty-one stable maintenance hemodialysis patients were enrolled from 14 institutions in Japan. The study period was fixed at 2 weeks. Dosage requirements were 15.0 to 20.0 anti-Xa U/kg as bolus and 7.5 to 10.0 anti-Xa U/kg/hr as continuous infusion. The total dosage of Fragmin was 2505 +/- 127 anti-Xa U compared with 6124 +/- 190 U of conventional heparin. No differences were observed in residual blood in extracorporeal circuits between the groups. The hemostasis times at puncture sites after completion of dialysis were significantly shortened in the Fragmin group (7.9 +/- 0.7 minutes) when compared with the conventional heparin group (11.4 +/- 1.1 minutes; p less than 0.01). Plasma anti-Xa levels were 0.24 +/- 0.03 and 0.36 +/- 0.04 U/ml 1 hour after the initiation and at the completion of dialysis, respectively. ACTs, measured by the Hemochron method, were not prolonged during dialysis. APTTs varied from 34.3 +/- 1.2 before dialysis to 41.0 +/- 1.9 (p less than 0.01) 1 hour after the start of dialysis and 39.9 +/- 1.6 seconds (p less than 0.01) at the end of dialysis. Plasma AT III activity increased from 96.8 +/- 2.5% before dialysis to 113.0 +/- 3.2% (p less than 0.01) at the end of dialysis. No significant changes were observed in both ADP- and collagen-induced platelet aggregation during dialysis. Dialysis efficiency was the same for both groups. Slight itching developed in one of 61 cases. No abnormal laboratory data were observed during the study. The efficacy, safety, and utility rates were 98.4, 98.5, and 98.4%, respectively. Fragmin proved to have a higher utility rate and was a good and convenient alternative to conventional heparin as an anticoagulant in hemodialysis treatment.

Clinical effect of recombinant human erythropoietin on anemia associated with chronic renal failure. A multi-institutional study in Japan

Clinical effect and safety of recombinant human erythropoietin (r-HuEPO) were evaluated in 66 hemodialysis patients with intractable anemia. Initially, 50U/kg dry weight (DW) of r-HuEPO was administered intravenously at the end of every hemodialysis procedure for 4 weeks, then the dosage was increased to 100 and 200U/kg DW for poor responders. The patients' hematocrits rose from 19.8 +/- 2.3% (pretreatment) to 30.2 +/- 4.9% after 12 weeks. From 206 U of blood transfusion requirement in the 3-month period before the study, only 34 U were needed after treatment. Serum iron and ferritin levels fell significantly during the study, and iron storage was considered to be one of the decisive factors in the response to r-HuEPO. Blood pressure rose in the course of r-HuEPO administration, but uncontrollable hypertension was rarely observed. There was no significant adverse effect of r-HuEPO except for this mild hypertension. These results indicate that r-HuEPO is an excellent therapeutic aid for the anemia associated with chronic renal failure.

Acute changes in C3a and C5a in an anaphylactoid reaction in hemodialysis patients

Blood sample were collected from both the arterial and venous lines of the patients undergoing hemodialysis using cuprophan membrane at several time intervals. Radioimmunoassay was then applied to measure the C3a and C5a levels. C3a levels from the arterial lines of patients undergoing uneventful hemodialysis were 463.2 +/- 51.3 ng/ml (mean +/- S.D.), 1112.9 +/- 109.9, 956.0 +/- 72.1, and 721.2 +/- 49.6 at 0, 15, 120 and 360 min, respectively. C5a levels did not change significantly during uneventful hemodialysis. C3a and C5a levels were significantly higher in the blood from the venous lines than those from the arterial lines, a finding indicating that complement activation via alternative pathway takes place in the dialyzer. C3a and C5a levels were markedly elevated in patients with anaphylactoid reaction. Reuses of dialyzers on the patients having a history of an anaphylactoid reaction during hemodialysis suppressed not only the rise of C3a levels, but also the recurrence of the reaction. From these findings, it is concluded that rises of C3a and C5a in the arterial lines of patients are causally related to the induction of anaphylactoid reaction during hemodialysis.

Multi-component analysis of urine of dogs with liver diseases by high-performance liquid chromatography

Components of the urine of normal dogs and dogs with liver diseases were analysed by high-performance liquid chromatography (HPLC) using a macroreticular anion-exchange resin with UV detection. The dogs with liver diseases were experimentally prepared by either Eck fistula by portal-caval anastomosis, dimethylnitrosamine-induced liver failure or total hepatectomy by operation. Eighteen chromatographic peaks were numbered and the cross-correlation coefficient of the intensities of every pair of peaks was computed. There were high correlations between several pairs of peaks according to the types and degrees of the hepatic failures, whereas no significant correlation was observed for the peak pairs of normal urine samples. The results showed that HPLC analysis of urine is useful in the diagnosis of the physiological state in liver dysfunction.

A new method for early detection of renal allograft rejection. Gel high-performance chromatography of urinary IgM

We developed a new device utilizing high-performance chromatography to measure urinary IgM protein in renal transplant recipients. With this device we were able to obtain a reliable result in less than 2 h, requiring much less time than using the conventional method. Urinary IgM was found in 22 of 23 posttransplantation patients (96%) during acute rejection. An increase in urinary IgM excretion was noted 2-3 days before the appearance of clinical signs of acute rejection.

Successful pregnancy in a patient undergoing chronic hemodialysis

A 29-year-old woman who had been undergoing regular hemodialysis for 4 years became pregnant, and a male infant weighing 1320 g was delivered by cesarean section. The infant has grown uneventfully and shows no abnormalities at present. This is the first case in Japan and the eighth reported case to date (1979) in which a patient undergoing chronic hemodialysis became pregnant and was delivered of a live infant.

Chorio-meningo-encephalitis due to Listeria monocytogenes after renal transplantation

A 35-year-old man, who underwent renal transplantation, died of meningo-encephalitis with symptoms of meningitis for only 8 days. The autopsy revealed marked chorio-meningo-encephalitis caused by Listeria monocytogenes. This report on listeriosis in renal transplant patients is the second in our country, where adult cases of listeriosis are rare. Recent knowledge about listeriosis in renal transplants is reviewed and discussed.