Risk Factors for Recurrence of Immunoglobulin A Nephropathy After Renal Transplantation: Single Center Study

We investigated the risk factors for recurrence of IgA nephropathy after kidney transplantation. Of the 184 recipients of allografts for end‐stage renal disease caused by primary IgA nephropathy at our institution and affiliated hospitals between 1990 and 2005, 70 developed recurrent IgA nephropathy (group 1), while the remaining 114 did not develop recurrent IgA nephropathy (group 2). The diagnosis of recurrent IgA nephropathy was based on case and/or protocol renal biopsies. We examined the risk factors for recurrence of IgA nephropathy by comparing the two groups. In addition, we also investigated the risk factors for graft loss in the patients with recurrent IgA nephropathy. The recipient's age at transplantation was significantly younger in group 1 than in group 2 (33.4 ± 10.4 vs. 36.7 ± 10.7, P = 0.037). No significant influence of the immunosuppressive regimens used was observed on the likelihood of recurrence of IgA nephropathy. In the analysis of the risk factors for graft loss, the mean age of the donor was significantly higher in the patient group with graft loss (59.1 ± 9.5 vs. 53.9 ± 9.0, P = 0.033), and the serum creatinine level at one year after surgery was also significantly higher in the patient group with graft loss (1.62 ± 0.52 vs. 1.34 ± 0.34, P = 0.022). Recipients with recurrent IgA nephropathy after transplantation, especially younger patients, need to be followed up carefully.     

Levosimendan improves renal function in patients with advanced chronic heart failure awaiting cardiac transplantation

BackgroundLong-term impact of levosimendan on renal function remains undefined. Prospectively, we evaluated effects of levosimendan on renal function in patients with advanced chronic heart failure awaiting cardiac transplantation.Methods and ResultsOf 40 patients, 20 were randomized to receive levosimendan (10-minute bolus 12 μg/kg, followed by 0.1 μg/kg/min for 24 hours; LS Group), and 20 received no levosimendan (Controls). The groups did not differ in age, heart failure etiology, left ventricular ejection fraction, and plasma brain natriuretic peptide. Patients were followed for 3 months. At baseline, the groups did not differ in serum creatinine (1.92 ± 0.13 mg/dL in LS Group versus 1.91 ± 0.12 mg/dL in Controls, P = .81) and creatinine clearance (43.7 ± 2.9 mL/min versus 43.9 ± 2.8 mL/min, P = .84). At 3 months, we found a decrease in serum creatinine and an increase in creatinine clearance in LS Group, but not in Controls, leading to a significant intergroup difference in serum creatinine (1.60 ± 0.26 mg/dL in LS Group versus 1.90 ± 0.14 mg/dL in Controls, P = .005) and creatinine clearance (53.6 ± 8.6 mL/min versus 44.0 ± 3.3 mL/min, P = .005). An improvement in creatinine ≥0.5 mg/dL occurred in 50% patients from LS Group compared with 10% of Controls (P = .005).ConclusionsLevosimendan improves long-term renal function in advanced chronic heart failure patients awaiting cardiac transplantation.     

Immunoglobulin G levels can predict non-diabetic renal disease in patients with type 2 diabetes mellitus

Background: Proteinuria in patients with diabetes mellitus (DM) is sometimes caused by glomerular diseases other than diabetic nephropathy. In patients with type 2 DM (T2DM), specific predictors for non‐diabetic renal disease (NDRD) are needed in addition to the traditional indicators for renal biopsy. Methods: From 1 January 2000 to 31 March 2011, we retrospectively enrolled 54 T2DM patients with proteinuria who had undergone renal biopsies into the present study. Associations between NDRD and 20 potential biomarkers, including serum levels of Igs and proteins associated with kidney function, and urinary protein and red blood cell levels, and hepatitis virus carrier status, were analyzed by multivariate logistic regression. Results: Multivariate logistic regression showed that reduced serum IgG (odds ratio [OR] 0.997; P = 0.006; 95% confidence interval [CI] 0.94–0.998) and creatinine (Cr; OR 0.587; P = 0.014; 95% CI 0.348–0.897) were predictors of NDRD. The area under the receiver operating characteristic curve (AUC_ROC) confirmed the good discriminatory power of IgG (AUC_ROC 0.857 ± 0.058; 95% CI 0.744–0.970; P < 0.001) and Cr (AUC_ROC 0.838 ± 0.054; 95% CI 0.732–0.943; P < 0.001). The IgG level below which the risk for NDRD increased, as calculated by obtaining the best Youden index, was 919.5 mg/dL (sensitivity 91.7%; specificity 83.3%), and the corresponding Cr level was 4.1 mg/dL (sensitivity 58.3%; specificity 96.7%). Conclusion: Serum IgG levels <919.5 mg/dL and serum Cr levels <4.1 mg/dL are associated with NDRD in T2DM patients.     

Does acute ingestion of large amounts of alcohol cause pancreatic injury? A prospective study

Summary The contribution of ethanol to the pathogenesis of acute pancreatitis has been questioned for a long time. The authors asked whether acute ingestion of large amounts of alcohol may lead to pancreatic injury, as assessed by serum amylase levels, clinical picture, and abdominal ultrasound. Therefore, all patients (N=112) admitted to our medical emergency ward with the diagnosis of alcohol intoxication were evaluated prospectively during a 12-mo period. Of these, 78 (56 M, 22 F; mean age 36±15) could be evaluated. The other 44 were excluded because of incomplete data (n=18), mixed intoxications (n=8), repeated admission (n=9), incorrect diagnosis on admission (n=7), and chronic pancreatitis (n=2). Serum ethanol, amylase, and GOT were measured. Serum ethanol was 246±122 mg/dL (3–500 mg/dL), amylase 83±44 U/L (27–361 U/L), and GOT 25±37 U/L (5–271 U/L) without significant differences among the genders. No correlation between serum ethanol and serum amylase levels could be detected.     

Long‐Term Antiproteinuric Effect of Dual Renin–Angiotensin System Blockade

We evaluated the long‐term changes on overt proteinuria induced by dual blockade of the renin–angiotensin system (RAS). Dual blockade was produced by adding an angiotensin II receptor blocker (ARB) to treatment with maximal recommended doses of an angiotensin converting enzyme (ACE) inhibitor in proteinuric patients. A total of 28 patients (19 men and 9 women) with proteinuria higher than 1 g/24 h were enrolled in this trial of treatment with the ARB candesartan (from 4 up to 32 mg daily) added to existing treatment with an ACE inhibitor. At 6, 12, 24, and 36 months, we evaluated proteinuria in 24‐h urinary collections, office blood pressure (BP), plasmatic creatinine (Cr), serum potassium (K), and 24 h urine collection creatinine clearance (CrC). During monoblockade of the RAS by ACE inhibitor treatment, albuminuria was 2.94 ± 1.92 mg/24 h; BP was 137/76 mmHg; K+ was 4.8 ± 0.5 mmol/l, Cr was 1.76 ± 0.67 mg/dL, and CrC was 62 ± 31.9 mL/min. After 6 months, dual blockade of the RAS albuminuria was 2.18 ± 2.29 mg/24 h (P < 0.01 vs. baseline) and BP was 133/75 mmHg (not significant). At 36 months, albuminuria was 2.21 ± 2.20 mg/24 h (P < 0.05 vs. baseline); BP was 133/73 mmHg (not significant). CrC was not changed along the follow up. A small increment of Cr was detected at 24 months (2.11 ± 1.06 mg/mL, P < 0.05). The antiproteinuric effect of dual renin–angiotensin system blockade combining candesartan and ACE inhibitors remain after 36 months without losing its initial effect. Blood pressure changes seem not to explain this long‐term antiproteinuric effect.     

Outcome survey in unselected hypertensive patients with type 2 diabetes mellitus: effects of ace inhibition

Although the benefit of angiotensin converting enzyme (ACE) inhibitors in diabetic nephropathy is well documented in double-blind randomized, controlled clinical trials, it is uncertain whether the benefit extends to unselected patients with diabetes mellitus and arterial hypertension in general practice. In 2504 unselected patients with type 2 diabetes mellitus (mean age 63 ± 10 years) blood pressure, cardiovascular, renal, and metabolic parameters were assessed at baseline and during a treatment period of 1 year with the ACE inhibitor cilazapril by primary care physicians. The average dose of cilazapril was 2.5 mg/day. Outcome measures were blood pressure, serum creatinine, proteinuria (dip stick), HbA_1c levels, evaluation of edema, and exertional dyspnea. In the study cohort, systolic blood pressure decreased by 24 ± 17 mm Hg and diastolic blood pressure by 12 ± 11 mm Hg. An increase in serum creatinine (> 0.2 mg/dL) occurred more frequently in patients with than in those without renal involvement (19% v 7%; P < .05). Serum creatinine decreased more frequently in patients with renal involvement than in those without (26% ± 4% v 12% ± 3.8%; P < .05). Overall renal function in patients with diabetic nephropathy (n = 318) improved (2.1 ± 1.6 mg/dL v 1.7 ± 1.4 mg/dL; P < .05). The frequency of proteinuria was lower after 1 year than at baseline (62% ± 9% v 82% ± 8%; P < .05). Metabolic control of diabetes mellitus improved in parallel (median HbA_1c 8.0% v 7.0%; P < .01). Scores for edema formation and exertional dyspnea improved as well (P < .01). In this outcome survey of unselected patients with type 2 diabetes mellitus and arterial hypertension, the ACE inhibitor cilazapril effectively lowered blood pressure, which was associated with an improvement in glucose metabolism, cardiac function, and renal function.     

高血压病患者冠状动脉粥样硬化与主动脉脉压的相关性

目的研究冠状动脉粥样硬化与高血压病患者主动脉脉压的关系。方法入选300例初发未经治疗的高血压病患者,根据冠状动脉造影结果将患者分为冠心病组和非冠心病组。在冠状动脉造影前测量主动脉根部的收缩压和舒张压并计算主动脉脉压,收集患者的临床指标和实验室检查资料。结果冠心病组的主动脉收缩压(150.3±26.5 mmHg)和脉压(77.1±22.7 mmHg)明显高于非冠心病组(145.6±23.3 mmHg和70.4±19.3 mmHg,P<0.05),冠心病组每搏输出量与主动脉脉压的比值(1.15±0.44 mL/mmHg)明显低于非冠心病组(1.31±0.50 mL/mmHg,P<0.05)。另外,冠心病组患者的空腹血糖(122.3±24.0 mg/dL比95.6±24.4 mg/dL,P<0.01)和血清肌酐(1.06±0.19 mg/dL比0.99±0.14 mg/dL,P<0.01)比非冠心病组高,而高密度脂蛋白胆固醇(47.7±11.7 mg/dL比54.9±15.6 mg/dL,P<0.01)比非冠心病组低。结论动脉粥样硬化可进一步加重高血压病患者大动脉僵硬度,使主动脉脉压增宽。此外,动脉粥样硬化还导致高血压病患者的肾功能受损,并影响脂质代谢。     

BLOOD PRESSURE REDUCTION IN THE MORNING YIELDS BENEFICIAL EFFECTS ON PROGRESSION OF CHRONIC RENAL INSUFFICIENCY WITH REGRESSION OF LEFT VENTRICULAR HYPERTROPHY

Self-monitoring values of blood pressure may better reflect the average long-term blood pressure value than sporadic measurements in the physician's office and be more useful for blood pressure control. In the present study, we compared the results of self-monitoring of blood pressure values, especially in the morning, with office blood pressure, and related these to progression of chronic renal insufficiency and left ventricular hypertrophy (LVH). Thirty-four patients were selected from 316 subjects with chronic renal insufficiency (average serum creatinine 1.72 ± 0.15 mg/dl, mean age 52.6 ± 3.5 yrs) in accordance with the following criteria office blood pressure was less than 140/90 mmHg, blood pressure was controlled with amlodipine (5–20 mg/day) combined with benazepril (2.5 mg/day), morning blood pressure was greater than 150/90 mmHg at 6–9 AM and LVH had been determined by echocardiography (posterior wall thickness; PWT ≥ 12 mm). The patients were assigned to 2 groups at random and were given: guanabenz (GB; 2–8 mg at 11 PM, n = 17) or placebo (n = 17). Two years later, the average blood pressure of both groups as measured in the office was not significantly different: however, BP in the morning was significantly reduced from 158 ± 6 to 134 ± 4 mmHg in GB treated group (P < 0.001). In 14 of 17 patients in GB treated group, LVH resolved and there was only mild progression of nephropathy (serum creatinine: 1.69 ± 0.18 to 1.81 ± 0.19 mg/dl). In 12 of 14 patients in placebo group, whose morning blood pressure remained at greater than 150/90 mmHg, LVH was retained and there was moderate progression of nephropathy (serum creatinine: 1.73 ± 0.14 to 2.62 ± 0.50 mg/dl). From these results, it is suggested that antihypertensive treatment with combination therapy based on self-monitoring BP is cardio-renoprotective in patients with chronic renal insufficiency and LVH.     

Saxagliptin add‐on therapy in Chinese patients with type 2 diabetes inadequately controlled by insulin with or without metformin: Results from the SUPER study,a randomized,double‐blind,placebo‐controlled trial

This prospective, multicentre, phase III study (NCT02104804) evaluated the efficacy and safety of saxagliptin add‐on therapy in Chinese patients with type 2 diabetes inadequately controlled by insulin ± metformin. Patients with glycated haemoglobin (HbA1c) 7.5% to 10.5% and fasting plasma glucose (FPG) <15 mmol/L (270 mg/dL) on stable insulin therapy (20‐150 U/d) were randomized (1:1) to saxagliptin 5 mg once daily (N = 232) or placebo (N = 230) for 24 weeks, stratified by metformin use. The primary efficacy measure was change in HbA1c. Saxagliptin treatment resulted in a greater adjusted mean change in HbA1c from baseline to week 24 than placebo (?0.58%; P < .001), irrespective of metformin use, and a greater mean change in FPG (0.9 mmol/L [?15.9 mg/dL]; P < .001). More patients achieved HbA1c <7% with saxagliptin (11.4%) than with placebo (3.5%, P = .002). Adverse events and incidence of hypoglycaemia were similar in both groups. Overall, add‐on saxagliptin 5 mg once daily significantly improved glycaemic control without increasing hypoglycaemia risk and was well tolerated in Chinese patients with type 2 diabetes inadequately controlled by insulin (± metformin).     

Effectiveness of theophylline in preventing contrast-induced nephropathy after coronary angiographic procedures

Background: Contrast‐induced nephropathy (CIN) is the third most common cause of hospital acquired acute renal failure and is associated with increased morbidity and mortality. The use of theophylline for prevention of CIN has yielded conflicting results. This study aimed at examining the effectiveness of theophylline in prevention of CIN when added to IV hydration and N‐acetylcysteine (NAC). Methods: Patients with stable serum creatinine and at least moderate risk for CIN according to Mehran's risk score were included in this parallel group, 1:1, single‐blind, randomized controlled trial. All patients received IV hydration (1 mL/kg per hour for 24 hours) and NAC (600 mg bid for 2 days). Patients were randomized to placebo (group P) or theophylline (200 mg in 100 mL 0.9% saline, as IV infusion 30 minutes before contrast medium (CM) administration; group T). Patients underwent standard coronary angiography ± angioplasty. Serum creatinine (SCr) was assessed just before and 72 hours after contrast administration and estimated glomerular filtration rate (eGFR) was calculated. Results: This study included 60 patients with mean SCr 1.44 ± 0.7 mg/dL and eGFR 60.2 ± 29.2 mL/min. Mean SCr among group T was 1.54 ± 0.7 mg/dL with eGFR 58.6 ± 28.6 mL/min, while group P showed mean SCr of 1.34 ± 0.7 mg/dL and eGFR of 61.8 ± 30.1 mL/min. Among group P, 6 (20%) patients developed CIN while none of the patients in group T developed CIN. In comparison to placebo, theophylline significantly decreased SCr (P = 0.0001) and increased eGFR (P = 0.001) at 72 hours. Multivariate regression analysis showed that receiving placebo instead of theophylline, anemia, congestive heart failure, chronic renal impairment, and high‐contrast load are all independent predictors for deteriorating renal function after CM administration. Conclusion: Theophylline seems to be an effective prophylaxis against CIN for moderate‐ and high‐risk patients undergoing coronary angiography or angioplasty. It offers additive protection when added to IV hydration and NAC. (J Interven Cardiol 2012;25:404–410)     

Does Nebivolol Prevent Contrast‐Induced Nephropathy in Humans?

Background:

An experimental study showed that nebivolol is an effective agent in contrast‐induced nephropathy (CIN) prophylaxis.

Hypothesis:

We hypothesized that prophylactic nebivolol use had protective effects on renal function in human beings subjected to iodinated contrast agent since it has vasodilatory effect and antioxidant properties.

Methods:

The present study enrolled 120 patients scheduled for coronary angiography and ventriculography. All patients were hydrated with intravenous isotonic saline. The patients in group I received 600 mg N‐acetylcysteine every 12 hours for 4 days. The patients in group II received 5 mg nebivolol every 24 hours for 4 days. The patients in group III were only hydrated. The primary endpoint was the occurrence of CIN. The secondary endpoint was the change in serum creatinine (Cr) levels at 2 days and 5 days after the contrast exposure.

Results:

Nine (22.5%) patients in group I developed CIN, as did 8 patients (20.0%) in group II and 11 patients (27.5%) in group III (P = 0.72). Changes in mean Cr level from baseline to day 2 were not statistically significant in all groups. However, we detected a statistically significant increase in mean Cr levels at day 5 compared with baseline levels in group I and group III (from 1.42 ± 0.13 to 1.52 ± 0.26, p2 = 0.02; and from 1.43 ± 0.14 to 1.55 ± 0.30, p2 = 0.01, respectively). Although an increase was detected in mean Cr level from baseline to the 5‐day Cr level in group II, this did not reach statistical significance (from 1.40 ± 0.12 to 1.48 ± 0.23, P = 0.06).

Conclusions:

Pretreatment with nebivolol is protective against nephrotoxic effects of contrast media. © 2012 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Kidney dysfunction and deterioration of ejection fraction pose independent risk factors for mortality in implantable cardioverter-defibrillator recipients for primary prevention

Background:

A growing number of patients with advanced heart failure fulfill a primary‐prevention indication for an implantable cardioverter‐defibrillator (ICD). This study seeks to identify new predictors of overall mortality in a Sudden Cardiac Death in Heart Failure Trial (SCD‐HeFT)‐like collective to enhance risk stratification.

Hypothesis:

An impaired renal function and severely depressed left ventricular ejection fraction pose relevant risk factors for mortality in primary prevention ICD recipients.

Methods:

Ninety‐four consecutive ICD patients with New York Heart Association class II–III heart failure and depressed left ventricular function (left ventricular ejection fraction [LVEF] ≤35%) with no history of malignant ventricular arrhythmias were followed for 34 ± 20 months.

Results:

During this period, 30 patients died (32%). Deceased patients revealed a significantly worse renal function before ICD implantation (1.55 ± 0.7 mg/dL vs 1.1 ± 0.4 mg/dL; P = 0.007), suffered more often from coronary artery disease (53 vs 29; P = 0.006), and were older (69.5 ± 8 y vs 67 ± 12 y; P = 0.0002) than surviving patients. Furthermore, increased serum creatinine at baseline (2 mg/dL vs 1 mg/dL; odds ratio [OR]: 3.96, 95% confidence interval [CI]: 1.2–13.04, P = 0.02), presence of coronary artery disease (OR: 8.6, 95% CI: 1.1–65, P = 0.036), and low LVEF (OR per 5% baseline LVEF deterioration: 1.4, 95% CI: 1–1.8, P = 0.034) represented strong and independent predictors for overall mortality.

Conclusions:

Impaired renal function, the presence of coronary artery disease, and reduced LVEF before implantation represent independent predictors for mortality in a cohort of patients with advanced systolic heart failure. These conditions still bear a high mortality risk, even if ICD implantation effectively prevents sudden arrhythmic death. Indeed, in patients suffering from several of the identified “high‐risk” comorbidities, primary‐prevention ICD implantation might have a limited survival benefit. The possible adverse effects of these comorbidities should be openly discussed with the potential ICD recipient and his or her close relatives. Clin. Cardiol. 2012 doi: 10.1002/clc.22018 The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Prevalence of left ventricular hypertrophy in Type I diabetic patients with diabetic nephropathy

Summary The increased mortality of patients with diabetic nephropathy is mainly due to cardiovascular disease and end stage renal failure. Left ventricular hypertrophy is an independent risk factor for myocardial ischaemia and sudden death. The aim of our cross-sectional study was to evaluate left ventricular structure and function in Type I (insulin-dependent) diabetic patients with diabetic nephropathy. M-mode and Doppler echocardiography were done on 105 Type I diabetic patients with diabetic nephropathy [61 men, age (means ± SD) 44 ± 9 years, and albuminuria [median(range)] 567(10–8188) mg/24 h, serum creatinine 109 (53–558) μmol/l], and 140 Type I diabetic patients with persistent normoalbuminuria [79 men, 47 ± 10 years, urinary albumin excretion rate 8 (0–30) mg/24 h, and serum creatinine 81 (55–121) μmol/l]. Patients with and without nephropathy were comparable with respect to sex, body mass index, and duration of diabetes. Arterial blood pressure was slightly higher in patients with nephropathy: 140/79 ± 17/9 mm Hg vs 134/78 ± 15/8 mm Hg, p < 0.01, and the majority of proteinuric patients received antihypertensive drugs, 84 vs 17 %, respectively, p < 0.001. Left ventricular mass index was increased in the nephropathic group (means ± SD) 100.6 ± 23.9 g/m² compared with the normoalbuminuric group 91.4 ± 21.9 g/m², p = 0.002. Left ventricular hypertrophy was found more often in patients with nephropathy 23 (14–31)% compared with patients with normoalbuminuria 9 (5–14)%, p < 0.005. Diastolic function, assessed by the ratio between the peak diastolic velocity and the peak atrial systolic velocity (E/A ratio) and isovolumic relaxation time, was reduced in patients with vs without nephropathy: 1.17 ± 0.29 vs 1.34 ± 0.32, and 81.7 ± 16.5 vs 74.6 ± 14.5, p < 0.001 and p = 0.002, respectively. Systolic function was about the same and normal in both groups. Our study suggests that an increase in left ventricular mass index and a decrease in diastolic function occurs early in the course of diabetic nephropathy. [Diabetologia (1999) 42: 76–80] Received: 16 April 1998 and in final revised form: 5 August 1998     

Glomerular tip adhesions predict the progression of IgA nephropathy

Background

Focal segmental glomerulosclerosis-like lesions have been proposed to be predictive factors for IgA nephropathy. This single center, retrospective cohort study was designed to clarify which clinical and pathological factors are predictive of decreased estimated glomerular filtration rate (eGFR) at 5 and 10 years in IgA nephropathy patients.

Methods

Of the 229 patients with IgA nephropathy who were admitted to Aichi Medical University Hospital between 1986 and 2010, 57 were included in this study during the 5 to 10 years after renal biopsy. Clinical, laboratory, and pathological parameters were analyzed by multiple linear regression analysis with backward elimination to determine independent risk factors. After identifying such factors, we compared patients with and without each factor using the Student’s t test, Wilcoxon test, or Mann–Whitney U test.

Results

Four variables were identified as predictive factors for progression of IgA nephropathy: initial eGFR (p?=?0.0002), glomerular tip adhesion (p?=?0.004), global sclerosis (p?=?0.019), and diastolic blood pressure (p?=?0.024). The annual decrease in eGFR of patients with (n?=?9) or without glomerular tip adhesions (n?=?48) was 4.13?±?3.58 and 1.49?±?2.89 ml/min/1.73 m2, respectively (p?=?0.015). Serum total cholesterol levels were 231?±?45 mg/dl and 196?±?42 mg/dl, respectively (two-sided p?=?0.064; one-sided p?=?0.032).

Conclusions

The presence of glomerular tip adhesions predicts the progression of IgA nephropathy. High levels of serum total cholesterol may affect glomerular tip adhesions.

     

Effect of nutritional counseling on low-density lipoprotein cholesterol among Thai HIV-infected adults receiving antiretroviral therapy

HIV-infected patients receiving antiretroviral therapy have increased risk of metabolic syndrome, including dyslipidemia. In this study, we determined whether individual nutritional counseling reduced dyslipidemia, particularly low-density lipoprotein (LDL) cholesterol, among HIV-infected patients with dyslipidemia not currently taking lipid-lowering medication. We conducted a randomized 24-week trial among HIV-infected patients with dyslipidemia who were on antiretroviral therapy and were eligible to initiate therapeutic lifestyle changes according to the Thai National Cholesterol Education Program. Participants were randomly assigned to an intervention group that received individual counseling with a nutritionist for seven sessions (baseline, weeks 2, 4, 8, 12, 18, and 24) and a control group that received standard verbal diet information at baseline and nutritional counseling only at week 24. A 24-h recall technique was used to assess dietary intake for both groups at baseline and week 24. Lipid profile (total cholesterol, LDL, high-density lipoprotein (HDL), and triglyceride) was measured at baseline and after 12 and 24 weeks of therapy. An intention-to-treat and linear mixed model were used. Seventy-two patients were randomly assigned, and 62 (86%) participants completed their lipid profile test. After 12 weeks of follow-up, there were significant reductions in the intervention group for total cholesterol (?14.4?±?4.6?mg/dL, P?=?.002), LDL cholesterol (?13.7?±?4.1?mg/dL, P?=?.001), and triglyceride (?30.4?±?13.8?mg/dL, P?=?.03). A significant reduction in LDL cholesterol was also observed in the control group (?7.7?±?3.8?mg/dL, P?=?.04), but there were no significant differences in change of mean lipid levels between the groups at 12 weeks of follow-up. After 24 weeks, participants assigned to the intervention group demonstrated significantly greater decreases in serum total cholesterol (?19.0?±?4.6?vs. 0.2?±?4.3?mg/dL, P?=?.003) and LDL cholesterol (?21.5?±?4.1?vs. ?6.8?±?3.8?mg/dL, P?=?.009). There were no significant changes in HDL cholesterol or triglyceride levels in either group.     

Serum sialic acid concentration is elevated in IDDM especially in early diabetic nephropathy

Abstract. Objectives. Elevated serum sialic acid concentration is a strong predictor of cardiovascular mortality in non-diabetic subjects. Because patients with insulin-dependent diabetes mellitus (IDDM) and albuminuria have a highly increased cardiovascular morbidity and mortality, we hypothesized that IDDM patients with albuminuria would have an increased concentration of serum sialic acid. Design. Cross-sectional study. Setting. Outpatient clinic at Steno Diabetes Centre, Gentofte, Denmark. Subjects. Twenty-six non-diabetic controls and 74 IDDM patients with normoalbuminuria (urinary albumin excretion [UAE] < 30 mg 24 h^?1; n = 37), incipient nephropathy (UAE 30–300 mg 24 h^?1; n = 20) and clinical nephropathy (UAE > 300 mg 24 h^?1; n = 17), matched for sex, age and body mass index (BMI). Main outcome measures. Serum sialic acid concentration, concurrent fasting blood glucose, glycated haemoglobin (HbA1c), serum creatinine, plasma fibrinogen and erythrocyte sedimentation rate. Results. Normoalbuminuric patients had a higher serum sialic acid concentration (mmol L^?1) than non-diabetic controls (1.83 ± 0.24 vs. 1.67 ± 0.26; P < 0.02). Serum sialic acid concentration was further increased in patients with incipient nephropathy (2.02 ± 0.37; P < 0.03) and in patients with clinical nephropathy (2.13 ± 0.33; P < 0.002) compared with normoalbuminuric IDDM patients. Serum sialic acid correlated strongly with plasma fibrinogen (r = 0.78; P < 0.0001) and erythrocyte sedimentation rate (r = 0.62; P < 0.0001). In a multiple regression analysis including UAE, retinopathy status, fasting blood glucose, HbA1c, mean blood pressure, serum creatinine, age, BMI, duration and smoking, UAE and fasting blood glucose were the independent variables which correlated significantly with serum sialic acid concentration (P < 0.0001 and P < 0.05, respectively). Conclusion. Serum sialic acid is elevated in IDDM especially in albuminuric patients. Whether elevated serum sialic acid is predictive for early diabetic nephropathy and cardiovascular disease in IDDM has to be shown in the future.     

Related factors for worsening renal function following percutaneous transluminal renal angioplasty (PTRA) in patients with atherosclerotic renal artery stenosis

Abstract

Purpose: To identify candidates for PTRA in terms of the preservation of renal function, we herein evaluated factors that caused worsening renal function (WRF) after PTRA. Methods: We evaluated 92 patients with atherosclerotic renal artery stenosis (mean age 70.7?±?8.4 years). WRF was defined as a ≥0.3?mg/dL increase in creatinine levels after PTRA compared to before PTRA. Results: A total of 92 patients exhibited non-WRF 83 (90.2%), WRF 9 (9.8%). Significant differences were observed in serum creatinine levels between two groups both before (non-WRF 1.34?±?0.49 versus WRF 1.70?±?0.68?mg/dL, p?=?0.0462) and after PTRA (non-WRF 1.31?±?0.43 versus WRF 2.42?±?1.12?mg/dL, p?<?0.0001). Patients with WRF had higher comorbidity rate of diabetes mellitus (DM) (non-WRF 31.3% versus WRF 66.7%, p?=?0.0345) and proteinuria (non-WRF 27.7% versus WRF 66.7%, p?=?0.0169), and had higher systolic blood pressure (non-WRF 143.6?±?18.7 versus WRF 157.1?±?19.9?mmHg, p?=?0.0436), higher plasma B-type natriuretic peptide (BNP) levels, and larger left atrial and left ventricular end-diastolic dimensions before PTRA. Patients with WRF had a higher rate of taking diuretics (non-WRF 27.7% versus WRF 66.7%, p?=?0.0169) after PTRA. Multiple logistic regression analysis revealed that comorbidity of DM was an independent related factor for WRF (comorbidity of DM, yes: OR 31.0, 95% CI 2.44–1024.62, p?=?0.0055). Conclusions: Comorbidity of DM, coexisting of proteinuria, high creatinine level, high blood pressure, high BNP levels, and large left atrial and ventricular dimensions were related to WRF after PTRA in patients with atherosclerotic renal artery stenosis.     

Favorable Outcome After Aggressive Treatment of Infection in a Diabetic Patient With MRSA-Related IgA Nephropathy

IgA immune complex deposition is not commonly seen with acute postinfectious glomerulonephritis secondary to staphylococcal infections. Its deposition is usually indicative of IgA nephropathy or Henoch-Schonlein purpura nephritis. We describe a patient with a history of diabetes mellitus who was admitted with methicillin resistant Staphylococcus aureus bacteremia and subsequent demonstration on renal biopsy of crescentic glomerulonephritis associated with codominant IgA and C3 immune deposits and early changes of diabetic nephropathy. After aggressive treatment of infection, which included bilateral metatarsal amputation and subsequent left below-the-knee amputation as well as antibiotic administration for persistent osteomyelitis, the patient’s renal function progressively improved with a reduction in serum creatinine concentration from 6.1 mg/dL (539 μmol/L) to 2.7 mg/dL (239 μmol/L). On a 3-year follow-up evaluation, his serum creatinine concentration was 1.7 mg/dL (150 μmol/L) and urine was negative for protein and blood.     

Leptospirosis presenting as acute encephalitis syndrome (AES) in Assam,India

ObjectiveTo establish leptospirosis as a new aetiology of the patients presenting acute encephalitis syndrome (AES).MethodsJapanese encephalitis, West Nile, Dengue and Chikungunya negative samples were tested by IgM capture ELISA for leptospira specific IgM. For further confirmation, the IgM positive samples were subjected to Microscopic agglutination test (MAT). The clinical details and laboratory findings of the positive patients were recorded.ResultsWe report 8 cases of leptospirosis presenting as AES, proven on IgM capture ELISA and confirmed by MAT. Fever (100%) and altered sensorium (62.5%) were two most common symptoms. Low haemoglobin (7.5 ± 2.8) g/dL, elevated blood urea (79.16 ± 46.43) mg/dL, serum creatinine (1.5 ±1.2) mg/dL, SGOT (66.5 ± 14.84) U/L and SGPT (70.5 ± 4.9) U/L were observed in positive patients.ConclusionsThis is the maiden study reporting leptospirosis as a new aetiology of the patients presenting AES. Establishing aetiology is very important for a successful therapy at least in treatable conditions like leptospirosis.     

Renal kallikrein in diabetic patients with hypertension accompanied by nephropathy

Summary We measured the 24-h excretion of urinary kallikrein in 27 patients with Type 2 (non-insulin-dependent) diabetes and in 10 normal control subjects. Mean (± SD) kallikrein excretion in diabetic patients with nephropathy (6.2±2.4 naphthyl units (NU)/day,n=13) was significantly lower than in control subjects (12.8±3.4NU/day,p<0.01) and in diabetic patients without nephropathy (9.4±3.4NU/day,n=14,p<0.05). Kallikrein excretion in hypertensive diabetic patients with nephropathy (5.1±1.6 NU/day,n=8) was significantly lower (p<0.05) than in normotensive patients with nephropathy (8.3±2.1 NU/day,n=5). There were no significant differences in kallikrein excretion rate (24-h excretion of urinary kallikrein/24-h creatinine clearance) among control subjects (9.9±4.3 NU/ml), diabetic patients with (9.0±3.2 NU/ml) and without (9.3±3.5 NU/ml) nephropathy. However, kallikrein excretion rate in hypertensive diabetic patients with nephropathy (7.7±3.3 NU/ml) was significantly lower (p<0.05) than in normotensive diabetic patients with nephropathy (11.8 ±2.0 NU/ml,n=10). Respective basal and post-stimulated (with intravenous furosemide 40 mg plus 60 min ambulation) plasma aldosterone concentrations measured in control subjects and in hypertensive diabetic patients with nephropathy were similar and increased to the same extent in the 2 groups (5.5±3.2 versus 5.3±3.2 and 9.3±2.6 versus 10.5±3.4 ng/ml), although the respective plasma renin activity tended to be lower in diabetic patients than in control subjects (0.7±0.6 versus 1.3±0.9 and 1.8±1.8 versus 3.0±2.6 ng⁻¹ · ml⁻¹ · h⁻¹). The results indicate that urinary kallikrein excretion is decreased in hypertensive diabetic patients with nephropathy, and that the decrease might not be attributable to an altered renin-aldosterone system.