Additive antiproteinuric effect of enalapril and losartan in children with hemolytic uremic syndrome

Background

Angiotensin-converting enzyme inhibitors or angiotensin II type 1 receptor blockers decrease postdiarrheal hemolytic uremic syndrome (D + HUS) sequelar proteinuria. However, proteinuria may persist in some patients. In nephropathies other than D + HUS, an additive antiproteinuric effect with coadministration of both drugs has been observed.

Methods

To assess such an effect in D + HUS, 17 proteinuric children were retrospectively studied. After a median period of 1 year post-acute stage (range 0.5–1.9) patients received enalapril alone for a median of 2.6 years (range 0.33–12.0) at a median dose of 0.4 mg/kg/day (range 0.2–0.56). As proteinuria persisted, losartan was added at a median dose of 1.0 mg/kg/day (range 0.5–1.5) during 2.1 years (range 0.5–5.0).

Results

The decrease in proteinuria with enalapril was 58.0 %, which was further reduced to 83.8 % from the initial value after losartan introduction. The percentage of reduction was significantly greater with the association of both drugs (p?=?0.0006) compared with the effect of enalapril exclusively (p?=?0.023). Serum potassium, glomerular filtration rate, and blood pressure remained unchanged.

Conclusions

Our results suggest that adding losartan to persisting proteinuric D + HUS children already on enalapril is safe and reduces proteinuria more effectively. Whereas this effect is associated with long-term kidney protection, it should be determined by prospective controlled studies.     

Does graft mass impact on pediatric kidney transplant outcomes?

Background

The aim of this study is to assess the evolution of renal size and function in pediatric transplant patients according to the graft mass/recipient size ratio.

Methods

Fifty pediatric renal transplant recipients were followed over 2 years. Grafts were weighed, and three different graft mass/m² ratios were determined: (1) low graft mass (58 g/m², range?31–57 g/m²), (2) median (142 g/m², range?59–141 g/m²) and high (267 g/m², range?143–353 g/m²). Patients underwent repeated ultrasound Doppler scans and repeated measurements of estimated glomerular filtration rate (eGFR; 1 week and 1, 6, 12 and 24 months), urinary retinol-binding protein (RBP) and proteinuria (1 week and 6, 12 and 24 months).

Results

The volume of renal tissue increased by 12?±?5.6 cm³ at 24 months (p?=?0.035) in the low graft mass and decreased by ?14?±?7 cm³ (p?=?0.046) in the high graft mass. The eGFR increased when either low (30?±?5 ml/min/1.73 m², p?<?0.001) or median (19?±?4 ml/min/1.73 m², p?<?0.001) graft mass was transplanted but remained stable when high graft mass was transplanted. The resistive index (RI) presented a significant decrease throughout early follow-up in the transplants involving low and median graft mass, whereas a slight rise was observed in those involving high graft mass. A significant difference was apparent 6 months post-transplant. Transplants of low and median graft mass were associated with an initial higher urinary RBP. No significant differences in proteinuria were detected.

Conclusions

Small kidneys undergo increases in volume and function without escalation of either proteinuria or urinary RBP, characterizing an adequate adaptation to the recipient. Children receiving larger kidneys present a reduction in volume, stable GFR and higher RI at 6 months.     

Prevalence of renal disease within an urban HIV-infected cohort in northern Italy

Background

Renal disease is an increasingly recognized noninfectious comorbidity associated with human immunodeficiency virus (HIV) infection.

Methods

Our retrospective, cross-sectional study evaluated prevalence of nephropathy among HIV-infected patients followed up in our outpatient clinic during the year 2011. Renal dysfunction and chronic kidney disease (CKD) were defined as estimated glomerular filtration rate (eGFR) <90 ml/min per 1.73 m² and as renal damage or eGFR <60 ml/min per 1.73 m² over a 3-month or greater period, respectively.

Results

We enrolled 894 HIV-infected patients with a mean age of 44.2 years and a mean current CD4 lymphocyte count of 508 cells/mm³. The prevalence of renal dysfunction and CKD was 27.4 and 21.3 %, respectively. Older age, male gender, hypertension, diabetes, proteinuria, hypertriglyceridemia, lower nadir CD4 cell count, current use of tenofovir or tenofovir plus a ritonavir-boosted protease inhibitor were independently associated with renal dysfunction.

Conclusion

Renal dysfunction is a frequent comorbidity among HIV-infected persons and requires a careful clinical and laboratory monitoring of renal function.     

Skeletal findings in the first 12 months following initiation of glucocorticoid therapy for pediatric nephrotic syndrome

Summary

Incident vertebral fractures and lumbar spine bone mineral density (BMD) were assessed in the 12 months following glucocorticoid initiation in 65 children with nephrotic syndrome. The incidence of vertebral fractures was low at 12 months (6 %) and most patients demonstrated recovery in BMD Z-scores by this time point.

Introduction

Vertebral fracture (VF) incidence following glucocorticoid (GC) initiation has not been previously reported in pediatric nephrotic syndrome.

Methods

VF was assessed on radiographs (Genant method); lumbar spine bone mineral density (LS BMD) was evaluated by dual-energy X-ray absorptiometry.

Results

Sixty-five children were followed to 12 months post-GC initiation (median age, 5.4 years; range, 2.3–17.9). Three of 54 children with radiographs (6 %; 95 % confidence interval (CI), 2–15 %) had incident VF at 1 year. The mean LS BMD Z-score was below the healthy average at baseline (mean ± standard deviation (SD), ?0.5?±?1.1; p?=?0.001) and at 3 months (?0.6?±?1.1; p?<?0.001), but not at 6 months (?0.3?±?1.3; p?=?0.066) or 12 months (?0.3?±?1.2; p?=?0.066). Mixed effect modeling showed a significant increase in LS BMD Z-scores between 3 and 12 months (0.22 SD; 95 % CI, 0.08 to 0.36; p?=?0.003). A subgroup (N?=?16; 25 %) had LS BMD Z-scores that were ≤?1.0 at 12 months. In these children, each additional 1,000 mg/m² of GC received in the first 3 months was associated with a decrease in LS BMD Z-score by 0.39 at 12 months (95 % CI, ?0.71 to ?0.07; p?=?0.017).

Conclusions

The incidence of VF at 1 year was low and LS BMD Z-scores improved by 12 months in the majority. Twenty-five percent of children had LS BMD Z-scores ≤?1.0 at 12 months. In these children, LS BMD Z-scores were inversely associated with early GC exposure, despite similar GC exposure compared to the rest of the cohort.     

Urinary protein patterns in patients with Balkan endemic nephropathy

Purpose

Urinary excretion of beta2-microglobulin (beta2-MG), albumin, immunoglobulin G (IgG) and protein was examined in patients with Balkan endemic nephropathy (BEN), glomerulonephritis (GN) and healthy controls.

Methods

The proteins were measured in morning urine samples from 74 patients with BEN, 50 healthy persons and 22 patients with GN.

Results

In BEN patients, median values for albumin, beta2-MG and protein were above upper normal limits, but median IgG was inside normal range. All patients with GN had microalbuminuria (MAU) and half of them had increased urinary beta2-MG, which was also found in eleven patients with increased urinary IgG. In BEN patients, there were significant negative correlations between eGFR and all measured urinary proteins, the composition of which changed during the course of BEN. In patients with eGFR > 60 ml/min/1.73 m² isolated beta2-MG was the most frequent finding (10/12 patients), but MAU was present in 4/12 patients. In BEN patients with eGFR between 30 and 59 ml/min/1.73 m², beta2-MG appeared as often as the combination of beta2-MG and albumin and isolated MAU. Out of 49 BEN patients with eGFR > 30 ml/min/1.73 m² 15 had increased urinary IgG either alone (1) or together with beta2-MG (3) or albumin (3) or beta2-MG and albumin (8). In BEN patients with GFR < 30 ml/min/1.73 m² only 1/25 had isolated beta2-MG but increased urinary IgG with increased beta2-MG, and albumin was the most frequent.

Conclusion

Although low-molecular weight proteinuria was the most frequent urinary finding in BEN patients, MAU was frequently detected in advanced stages of BEN but also in some patients with eGFR > 60 ml/min/1.73 m². IgG was increasingly found as eGFR decreased.     

Impact of kidney function and urinary protein excretion on pulmonary function in Japanese patients with chronic kidney disease

Background

Although the cardiorenal relationship in chronic kidney disease has been investigated, information about the lung?kidney relationship is limited. Here, we investigated the impact of kidney function and urinary protein excretion on pulmonary dysfunction.

Methods

The data from pulmonary function tests and kidney function (estimated glomerular filtration rate [eGFR] and urinary protein) between 1 April 2005 and 30 June 2010 were selected from our laboratory database. Data were classified into 4 categories according to eGFR and proteinuria. Category 1, eGFR ≥60 ml/min/1.73 m² and urinary protein <0.3 g/gCr; category 2, eGFR <60 ml/min/1.73 m² and urinary protein <0.3 g/gCr; category 3, eGFR ≥60 ml/min/1.73 m² and urinary protein ≥0.3 g/gCr; and category 4, eGFR <60 ml/min/1.73 m² and urinary protein ≥0.3 g/gCr. Pulmonary function data were evaluated according to these 4 categories.

Results

A total of 133 participants without major respiratory disease, abnormal computed tomography and smoking history were enrolled. Hemoglobin (Hb)-adjusted percentage carbon monoxide diffusing capacity (%DL_CO) in category 4 (46.2 ± 7.5) and category 2 (63.6 ± 17.8) were significantly lower than in category 1 (75.8 ± 18.9) (P < 0.05). In addition, Hb-adjusted %DL_CO was weakly correlated with eGFR in participants with urinary protein <0.3 g/gCr (R = 0.30, P = 0.001). Hb-adjusted %DL_CO was strongly correlated with eGFR in participants with urinary protein ≥0.3 g/gCr (R = 0.81, P < 0.001). Other pulmonary function test markers (percentage (%) vital capacity, % forced expiratory volume in one second (FEV1), FEV1/forced vital capacity, % total lung capacity, and % residual volume) were not significantly different between categories.

Conclusion

This study suggests that decreased eGFR is associated with decreased %DL_CO in proteinuric patients.     

Blood lead and cadmium levels and renal function in Korean adults

Background

The objective of this study was to evaluate the associations of blood lead and cadmium levels with estimated glomerular filtration rate (eGFR) and proteinuria in Korean adults.

Methods

This was a cross-sectional study based on the Korea Nation Health and Nutrition Examination Survey (KNHANES) to analyze the association of blood lead and cadmium levels with renal dysfunction and urine protein excretion. We defined renal dysfunction as eGFR < 60 ml/min/1.73 m², as measured by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and proteinuria as positive urine dip-stick result.

Results

Blood lead and cadmium levels were significantly increased in the renal dysfunction group compared with the normal renal function group. Lead levels were significantly higher in the proteinuria group than in the group with no proteinuria. There were no differences in cadmium levels according to the amount of proteinuria. Multivariate logistic regression analysis adjusted for age and sex demonstrated higher lead and cadmium levels in the renal dysfunction group than in the group with normal renal function [odds ratio (OR) 1.344, 95 % confidence interval (CI) 1.157–1.162, P < 0.05; OR 1.467, 95 % CI 1.077–1.999, P < 0.05, respectively]. For proteinuria, the fully adjusted ORs comparing the highest versus the lowest lead and cadmium quartiles were 1.22 (95 % CI 1.00–1.50) and 0.51 (95 % CI 0.24–1.08), respectively, showing no significance. For reduced eGFR, the fully adjusted ORs comparing the highest versus the lowest lead and cadmium quartiles were 1.23 (95 % CI 0.98–1.53) and 1.93 (95 % CI 1.39–2.67), respectively, showing the significant association between lead and cadmium levels and renal function. The risk of having reduced eGFR for individuals in the highest quartiles of both lead and cadmium levels in blood was greater than for those in the highest quartile of blood level of lead or cadmium only.

Conclusion

The CKD-EPI equation showed that blood lead and cadmium levels were associated with renal dysfunction in the Korean adult population. This finding has significant implications for environmental institutional strategies regarding heavy metal exposure.     

Should screening of renal markers be recommended in a working population?

Introduction

It is debated whether the general population should be screened for kidney disease. This study evaluated whether screening of albuminuria and estimated glomerular filtration rate (eGFR) in a working population should be recommended to detect subjects with chronic kidney disease.

Methods

The unreferred renal insufficiency study is a cross-sectional study in 1,398 workers aged 17–65. Markers of cardiovascular and renal disease were measured. Cardiovascular risk (CVR) was defined by hypertension (n = 416), diabetes (n = 45), dyslipidemia (n = 159) and/or history of a cardiovascular event (n = 10).

Results

In our population, 5 % of the workers had microalbuminuria, 0.5 % had macroalbuminuria and <0.1 % had eGFR <60 ml/min/1.73 m². All workers with an eGFR <60 ml/min/1.73 m² and/or macroalbuminuria (8/8) had at least one CVR factor, whereas this was the case in only half of workers with microalbuminuria (36/73, p = 0.007). In workers without CVR factors, the presence of microalbuminuria was associated with low body mass index (BMI, p < 0.001) or physiochemical exposure risk (p < 0.001).

Conclusions

Screening of renal markers in a working population, identified only a few subjects with an eGFR <60 ml/min/1.73 m² or macroalbuminuria. Although microalbuminuria was more prevalent, it might not necessarily indicate kidney disease, as it may have a completely different meanings depending of the phenotype of the screened subjects. Besides underlying CVR factors, microalbuminuria was also associated with low BMI in absence of any risk factor, suggesting presence of benign postural proteinuria. In addition, microalbuminuria also seemed to be related to physicochemical exposure. In view of the impossibility to further analyze this finding in the present study, the meaning of this observation needs to be further investigated.     

Does Chronic Kidney Disease Affect Outcomes after Major Abdominal Surgery? Results from the National Surgical Quality Improvement Program

Introduction

The impact of chronic kidney disease (CKD) and end-stage renal disease on outcomes following major abdominal surgery is not well defined.

Materials and Methods

The 2008 NSQIP database was queried to identify adult patients undergoing complex abdominal surgery (major colorectal, hepatobiliary, pancreatic, gastric, and esophageal operations). Thirty-day morbidity and mortality in patients on hemodialysis (HD) versus patients not on HD were compared. The impact of preoperative renal insufficiency, measured by glomerular filtration rate (GFR), on morbidity and mortality was then assessed in non-dialysis patients.

Results

Of 24,572 patients who underwent major abdominal operations, excluding emergency cases, only 149 (0.6 %) were on HD preoperatively. Thirty-day mortality in the HD group was 12.8 % compared to 1.8 % for those not on HD (p?<?0.0001). Overall complication rate was 23.5 versus 12.3 % (p?<?0.0001). In particular, rates of pneumonia (6.7 vs 3.0 %, p?<?0.05) and sepsis (12.8 vs 5.3 %, p?<?0.001) were higher in patients on HD. In patients not on HD, GFR was significantly predictive of postoperative mortality after controlling for age, gender, race, emergency status, and comorbidities. Compared to patients with normal preoperative kidney function (GFR, 75–90 ml/min/1.73 m²), even modest CKD (GFR, 45–60 ml/min/1.73 m²) was associated with increased postoperative mortality (odds ratio (OR), 1.62). With greater impairment in kidney function, postoperative mortality was even more marked (GFR, 30–45 ml/min/1.73 m² and OR, 2.84; GFR, 15–30 ml/min/1.73 m² and OR, 5.56). In addition, CKD was independently associated with increased postoperative complications.

Conclusion

Any degree of preoperative kidney impairment, even mild asymptomatic disease, is associated with clinically significant increases in 30-day postoperative morbidity and mortality following major abdominal surgery.     

A Higher Glomerular Filtration Rate Predicts Low Risk of Developing Chronic Kidney Disease in Living Kidney Donors

Background

The risk of developing chronic kidney disease (CKD) among living kidney donors (LKDs) is seldom included in evaluations of patients’ outcomes. Potential risk factors and new criteria for estimating the glomerular filtration rate (eGFR) indexed for body surface area (BSA) were investigated with a view to prevent the development of CKD in LKDs.

Methods

We conducted a retrospective study of LKDs from May 1983 to March 2011. The Mann–Whitney U test and χ² test were used to analyze the male versus female groups. Survival analysis was plotted as CKD-free survival and analyzed separately by different eGFR index classifications. The Cox regression model was used to identify potential risk factors for development of CKD.

Results

A total of 105 LKDs with a mean age of 46.3 ± 12.5 years had a mean eGFR indexed for BSA of 88.9 ± 21.5 ml/min per 1.73 m². After a mean duration of 5.4 ± 4.9 years’ follow-up, eGFR dropped to 61.4 ± 16.4 ml/min per 1.73 m² (p = 0.002). Median CKD-free survival was only 5.7 years. The difference between eGFR ≥ 80 ml/min per 1.73 m² and <80 ml/min per 1.73 m² was not statistically significant (p = 0.980). Multivariate Cox regression analysis showed that higher eGFR at donation (HR = 0.952, p = 0.0199) could be a protective factor. The receiver operating characteristic (ROC) curve for initial eGFR with best sensitivity of 52.78 % and specificity of 81.40 % was obtained with a cutoff value of 90.2 ml/min per 1.73 m² for preoperative eGFR. An eGFR of 90 ml/min per 1.73 m² yielded a significant survival curve (p = 0.0199) after 21 years of follow-up. Further classifications of eGFR >90 ml/min per 1.73 m² into 90–99 ml/min per 1.73 m², 100–109 ml/min per 1.73 m², and ≥110 ml/min per 1.73 m² were examined, but this survival curve was not statistically significant (p = 0.1247).

Conclusions

Living kidney donors will develop CKD after a long duration of follow-up if there is insufficiently high eGFR at donation. An eGFR above 90 ml/min per 1.73 m² before donation is the only factor that predicts prevention of CKD. Larger studies with longer duration of follow-up are necessary to clarify the clinical outcome of this postoperative CKD group, especially for patients with eGFR between 80 and 90 ml/min per 1.73 m².     

Alport syndrome: the effects of spironolactone on proteinuria and urinary TGF-β1

Background

Alport syndrome (AS) is a progressive hereditary glomerular disease. Recent data indicate that aldosterone promotes fibrosis mediated by the transforming growth factor-β1 (TGF-β1) pathway, which may worsen proteinuria. Spironolactone (SP) antagonizes aldosterone and this study aimed to evaluate the efficacy of SP in reducing proteinuria and urinary TGF-β1 excretion in proteinuric AS patients.

Methods

The study involved ten children with AS, normal renal function, and persistent proteinuria (>6 months; uPr/uCr ratio >1). SP 25 mg once a day for 6 months was added to existing ACE inhibitor treatment with or without angiotensin-II receptor blockade. Urine and blood samples were examined monthly. Urinary TGF-β1 levels were measured twice before and three times during SP treatment. Plasma renin activity (PRA) and serum aldosterone levels were also measured. In eight patients, uProt/uCreat was also assessed after 9 months and 12 months of SP treatment.

Results

After beginning SP therapy, all patients showed significant decrease in mean uProt/uCreat ratio (1.77?±?0.8 to 0.86?±?0.6; p?<?0.001) and mean urinary TGF-β1 levels (104?±?54 to 41?±?20 pg/mgCreatinine; p?<?0.01), beginning after 30 days of treatment and remaining stable throughout SP administration. PRA remain unchanged, and mean serum aldosterone increased from 105?±?72 pg/ml to 303?±?156 pg/ml (p?<?0.001). The only side effect was gynecomastia in an obese boy. After 1 year of therapy, mean uProt/uCreat remains low (0.82?±?0.48).

Conclusions

Addition of SP to ACE-I treatment with or without angiotensin II receptor blokers (ARB) significantly reduced proteinuria. This was mediated by decreased urinary TGF-β1 levels and not associated with major side effects.     

Electronic microarray screening of podocin mutations: a single-center study

Background

Because of resistance to immunosuppressants in nephrotic syndrome and reduction of proteinuria relapses following renal transplantation, it seems that new horizons have arisen from mutational screening of the podocin gene. The aim of this study was to assess electronic microarray screening of the podocin mutation.

Methods

Twelve previously identified podocin mutations were screened by the electronic microarray method in known DNA samples and in patients (aged 5 months–18 years, n = 38) with steroid-resistant primary nephrotic syndrome, isolated proteinuria, end-stage renal disease secondary to idiopathic nephrotic syndrome, and proteinuria relapses following renal transplantation.

Results

DNA samples previously supplied to define the mutation profile for analysis and which were used as controls were completely and correctly detected by this method. None of the 12 mutations was detected in our patients. The duration of analysis for one mutation, including hybridization, was only 30 min for 38 cases.

Conclusion

Electronic microarray screening for NPHS2 mutations is not only rapid but also accurate. Previous identification of the mutation profile most often encountered in the investigated population is needed, however.     

An algorithm using the early changes in PINP to predict the future BMD response for patients treated with daily teriparatide

Summary

About two thirds of patients with a procollagen type I N-terminal propeptide (PINP) increase of >80 μg/l at 1 month after starting teriparatide therapy showed a ≥10 % increase in lumbar spine (LS) bone mineral density (BMD) from baseline at 12 months. We recommend this algorithm as an aid in the clinical management of patients treated with daily teriparatide.

Introduction

An algorithm using PINP is provided in osteoporotic patients with teriparatide treatment. The correlations between the early changes in PINP and the subsequent BMD changes after daily teriparatide therapy were studied to develop an algorithm to monitor patients.

Methods

We evaluated whether early changes in PINP correlated with the changes in BMD at 12 months and developed an algorithm using the early changes in PINP to predict the upcoming BMD increases.

Results

The highest correlation coefficient for the relationship between PINP and LS BMD response was determined for the absolute change in PINP at 1 month and the percent change in LS BMD at 12 months (r?=?0.36, p <0.01). Using a receiver operator curve analysis, we determined that an 80 μg/l increase in PINP was the most convenient predictor of a 10 % increase in LS BMD from baseline (area under curve?=?0.72). Using a cut-off value of 80 μg/l, the positive predictive value for predicting a 10 % increase in LS BMD from baseline to 12 months was 65 %.

Conclusion

Greater short-term changes in PINP with teriparatide therapy are associated with greater 12-month increases in LS BMD. About two thirds of patients with a PINP increase of >80 μg/l at 1 month after starting treatment showed a ≥10 % increase in LS BMD from baseline at 12 months. We recommend this algorithm as an aid in the clinical management of patients treated with teriparatide.     

Late Conversion to Belatacept After Kidney Transplantation: Outcome and Prognostic Factors

Background

Conversion to belatacept at a later point after kidney transplantation (KT) as a rescue therapy has been shown to be beneficiary in an increasing number of patients, but prognostic factors for a favorable outcome have never been investigated.

Effect of tonsillectomy and its timing on renal outcomes in Caucasian IgA nephropathy patients

Purpose

The role of tonsillectomy in the treatment of IgA nephropathy in Caucasian patients is controversial.

Methods

A retrospective cohort study was conducted in 264 patients with biopsy-proven primary IgA nephropathy to examine the association between tonsillectomy and long-term renal survival, defined as the incidence of estimated glomerular filtration rates (eGFRs) of ≤30 ml/min/1.73 m² or end-stage renal disease (the composite of initiation of dialysis treatment or renal transplantation). The association of tonsillectomy with renal end-points was examined using the Kaplan–Meier method and Cox models.

Results

One-hundred and sixty-six patients did not undergo tonsillectomy (Group I, follow-up 130 ± 101 months) and 98 patients underwent tonsillectomy (Group II, follow-up 170 ± 124 months). The mean renal survival time was significantly longer for both end-points between those patients who underwent tonsillectomy (Group II) versus patients without tonsillectomy (Group I) (p < 0.001 and p = 0.005). The mean renal survival time was significantly longer for both end-points between those patients who had macrohaematuric episodes versus patients who had no macrohaematuric episodes (p = 0.035 and p = 0.019). Tonsillectomy, baseline eGFR and 24-h proteinuria were independent risk factors for both renal end-points.

Conclusion

Tonsillectomy may delay the progression of IgA nephropathy mainly in IgA nephropathy patients with macrohaematuria. Prospective investigation of the protective role of tonsillectomy in Caucasian patients is needed.     

Positive C1q staining associated with poor renal outcome in membranoproliferative glomerulonephritis

Background

Pathogenesis and clinical prognosis of membranoproliferative glomerulonephritis (MPGN) has not yet been established.

Methods

We conducted a retrospective study of 41 patients with MPGN (type I and III) and examined the renal survival. In addition, factors contributing to survival time were analyzed.

Results

Fourteen patients (34 %) were classified into the renal death group. Patients with nephrotic syndrome and positive C1q staining of glomerular deposits showed a particularly poor prognosis. Significantly higher frequency of nephrotic syndrome and higher urinary protein excretion were observed in the renal death group (p = 0.0002, p = 0.0002) than in the renal survival group. The intensity of C1q staining was positively correlated with the severity of the proteinuria (p = 0.004). Factors that influenced the survival time were positive C1q staining of glomerular deposits (p = 0.003), presence of nephrotic syndrome (p = 0.004), serum albumin (p = 0.02), and proteinuria (p = 0.04).

Conclusions

C1q staining in glomerular deposits and nephrotic syndrome were important factors influencing the prognosis and outcome in MPGN patients. C1q deposition may play a key role in the pathogenesis of MPGN, as evidenced by numerous observations, such as induction of proteinuria.     

Comparative effects of teriparatide and ibandronate on spine bone mineral density (BMD) and microarchitecture (TBS) in postmenopausal women with osteoporosis: a 2-year open-label study

Summary

Treatment effects over 2 years of teriparatide vs. ibandronate in postmenopausal women with osteoporosis were compared using lumbar spine bone mineral density (BMD) and trabecular bone score (TBS). Teriparatide induced larger increases in BMD and TBS compared to ibandronate, suggesting a more pronounced effect on bone microarchitecture of the bone anabolic drug.

Introduction

The trabecular bone score (TBS) is an index of bone microarchitecture, independent of bone mineral density (BMD), calculated from anteroposterior spine dual X-ray absorptiometry (DXA) scans. The potential role of TBS for monitoring treatment response with bone-active substances is not established. The aim of this study was to compare the effects of recombinant human 1–34 parathyroid hormone (teriparatide) and the bisphosphonate ibandronate (IBN), on lumbar spine (LS) BMD and TBS in postmenopausal women with osteoporosis.

Methods

Two patient groups with matched age, body mass index (BMI), and baseline LS BMD, treated with either daily subcutaneous teriparatide (N?=?65) or quarterly intravenous IBN (N?=?122) during 2 years and with available LS BMD measurements at baseline and 2 years after treatment initiation were compared.

Results

Baseline characteristics (overall mean ± SD) were similar between groups in terms of age 67.9?±?7.4 years, body mass index 23.8?±?3.8 kg/m², BMD L1–L4 0.741?±?0.100 g/cm², and TBS 1.208?±?0.100. Over 24 months, teriparatide induced a significantly larger increase in LS BMD and TBS than IBN (+7.6 %?±?6.3 vs. +2.9 %?±?3.3 and +4.3 %?±?6.6 vs. +0.3 %?±?4.1, respectively; P?<?0.0001 for both). LS BMD and TBS were only weakly correlated at baseline (r ²?=?0.04) with no correlation between the changes in BMD and TBS over 24 months.

Conclusions

In postmenopausal women with osteoporosis, a 2-year treatment with teriparatide led to a significantly larger increase in LS BMD and TBS than IBN, suggesting that teriparatide had more pronounced effects on bone microarchitecture than IBN.     

Changes in Bone Mineral Density After Sleeve Gastrectomy or Gastric Bypass: Relationships with Variations in Vitamin D,Ghrelin, and Adiponectin Levels

Background

A major long-term concern after gastric bypass (GBP) is the risk of osteoporosis; however, little is known about this complication in patients undergoing sleeve gastrectomy (SG).

Objective

To evaluate changes in bone mineral density (BMD) after GBP and SG, and its relationship with changes in vitamin D, parathyroid hormone (PTH), ghrelin, and adiponectin.

Methods

Twenty-three women undergoing GBP (BMI 42.0?±?4.2 kg/m²; 37.3?±?8.1 years) and 20 undergoing SG (BMI 37.3?±?3.2 kg/m²; 34.2?±?10.2 years) were studied before and 6 and 12 months after surgery. BMD was measured by dual-energy X-ray absorptiometry. Plasma PTH, 25-hydroxyvitamin D (25-OHD), ghrelin, and adiponectin concentrations were determined. Food as well as calcium and vitamin D supplement intake was recorded.

Results

Excess weight loss (mean?±?SE), adjusted by baseline excess weight, was 79.1±3.8 % and 74.9?±?4.1 % 1 year after GBP and SG, respectively (p?=?0.481). Significant reduction in BMD for total body (TB), lumbar spine (LS), and femoral neck (FN) was observed after GBP. In the SG group, reduction in BMD was significant only for TB. Adjusted by baseline BMD, the difference between change in BMD for GBP vs. SG was not significant for TB, LS, or FN. Percent reduction in ghrelin concentration was a main factor related to total BMD loss (GBP group) and LS BMD loss (GBP and SG groups).

Conclusions

One year after gastric bypass, bone mineral density was significantly affected, mainly at the femoral neck. Decreases in bone mineral density were more dramatic among patients who had greater baseline BMD and greater reduction in ghrelin concentrations.     

Remifentanil temporarily improves renal function in adult patients with chronic kidney disease undergoing orthopedic surgery

Purpose

The objective of this study was to confirm the renal protective effect of remifentanil-based anesthesia in perioperative adult patients with chronic kidney disease (CKD).

Methods

A total of 90 non-dialysis perioperative adult patients with CKD, with preoperative estimated glomerular filtration rate from creatinine (eGFRcreat) values of lower than 50 ml/min/1.73 m², who had undergone orthopedic surgery under general anesthesia were retrospectively selected. The subjects were divided into two groups according to whether or not remifentanil was used for anesthesia management: group R, in which remifentanil was used for anesthesia management (n = 45), and group NR, in which remifentanil was not used for anesthesia (n = 45). eGFRcreat was measured pre-surgery (pre), 7 days after surgery (day-7), and 14 days after surgery (day-14).

Results

In group R, both day-7 eGFRcreat (52.2 ± 17.0 ml/min/1.73 m²) and day-14 eGFRcreat (49.7 ± 15.5 ml/min/1.73 m²) were significantly higher than the pre eGFRcreat (40.7 ± 7.5 ml/min/1.73 m²) (day-7: p < 0.01; day-14: p < 0.01). In group NR, on the other hand, pre eGFRcreat (37.8 ± 7.6 ml/min/1.73 m²), day-7 eGFRcreat (41.2 ± 10.9 ml/min/1.73 m²), and day-14 eGFRcreat (40.2 ± 10.5 ml/min/1.73 m²) values were similar. Furthermore, both day-7 eGFRcreat and day-14 eGFRcreat were significantly higher in group R than in group NR (day-7: p < 0.01; day-14: p < 0.01).

Conclusions

Our findings suggest that anesthesia management using remifentanil may have a renal protective effect in perioperative adult CKD patients undergoing orthopedic surgery.     

Clinical and genetic features in autosomal recessive and X-linked Alport syndrome

Background

This study determined the family history and clinical features that suggested autosomal recessive rather than X-linked Alport syndrome.

Methods

All patients had the diagnosis of Alport syndrome and the mode of inheritance confirmed by genetic testing, and underwent examination at a single centre.

Results

Patients comprised 9 males and 6 females with autosomal recessive Alport syndrome, and 18 males and 22 females with X-linked disease. Fourteen (93 %) individuals with autosomal recessive Alport syndrome developed early end-stage renal failure, all 15 had hearing loss, and most had lenticonus (12, 80 %), and a central (13, 87 %) or peripheral (13, 87 %) retinopathy. These features occurred as often as in males with X-linked disease. Females with autosomal recessive inheritance were less likely to have an affected family member in another generation (p?=?0.01) than females with X-linked disease. They were more likely to have renal failure (p?=?0.003), hearing loss (p?=?0.02) and lenticonus (p?<?0.001). Fifty percent had a central retinopathy compared with 18 % with X-linked disease (p?=?0.14), but peripheral retinopathy prevalence was not different (p?=?0.64). Nonsense mutations accounted for 67 % (8/12) of these disease-causing mutations.

Conclusions

Autosomal recessive inheritance is increased in females with Alport syndrome and early onset renal failure, hearing loss, lenticonus, and, possibly, central retinopathy.