Clinical Spectrum of Chronic Renal Failure in the Elderly: a Hospital Based Study from Eastern India

The aim of this study was to describe the clinical spectrum of chronic renal failure (CRF) in the elderly. The diagnosis of CRF was made using standard clinical criteria. The elderly was defined as person with over 60 years of age. In total, 200 elderly patients with CRF were evaluated between July 2002 and February 2004. Their age (male: 146; female: 54) ranged between 60 and 90 (mean 64.31 ± 4.18) years. Diabetic nephropathy was the most common (46%) cause of CRF. Hypertensive nephrosclerosis, chronic interstitial nephritis and obstructive uropathy were responsible for CRF in 18%, 14% and 13% of patients, respectively. We observed chronic glomerulonephritis in 7% of elderly CRF. Urinary tract infection (55.5%), hypovolemia (22.2%), accelerated hypertension (11.1%) and sepsis (11.1%) were responsible for acute exacerbation of renal failure in 36 (18%) patients. Associated co-morbid conditions were noted in 93 (46.5%) patients. They included; coronary artery disease 46 (49.46%), cerebrovascular disease 20 (21.50%), osteoarthritis 13 (13.97%), chronic obstructive pulmonary disease 6 (6.45%), dilated cardiomyopathy 5 (5.37%), and malignancy in 3 (3.22%) patients. Acute dialytic support was required in 164 (82%) cases and remaining 36 (18%) patients received conservative management. Mortality was noted in 25 (12.5%) cases. The coronary artery disease (48%), acute pulmonary edema (20%) and hyperkalemia (12%) were the main causes of death. Subsequent evaluation revealed that 102 (51%) patients had ESRD of which only 3 (2.94%) patients could afford CAPD. A total of 11 (10.7%) patients underwent chronic maintenance hemodialysis for 3–4 months and then discontinue dialysis mainly because of financial constraints. Remaining 88 (86.27 %) patients with ESRD were discharged from hospital after symptomatic improvement with acute dialysis. Thus, diabetic nephropathy related to type-2 diabetes was the commonest cause of CRF in our elderly patients. Chronic renal failure in elderly was associated with a number of co-morbid conditions, which contributed significantly to morbidity and mortality. Acute on chronic renal failure with severe uremic complications were an important cause of hospitalization. The financial constraint was the major limiting factor for the management of elderly ESRD patients.     

Idiopathic tubulointerstitial nephritis and uveitis--'TINU syndrome'.

Sir, Acute interstitial nephritis (AIN) is an important cause ofacute renal failure (ARF). Kidney biopsies for evaluation ofcauses of ARF reveal AIN in 15% of the lesions [1]. Acute renalfailure due to idiopathic tubulointerstitial nephritis     

Spectrum of renal diseases in the elderly: Single center experience from a developing country

From November 1998 to March 2000, two hundredpatients over the age of 60 years (Elderly)with clinical renal disease were studied. 144patients were between ages of 60–69 years, 46between 70–79 years and 10 were above 80 years.The elderly patients (Male 165; Female 35) withrenal disease constituted 11% (200/1816) ofthe total nephrology consultation during thestudy period. The clinical presentationincluded chronic renal failure (42.5%); acuterenal failure (28%); nephrotic syndrome(14.5%); acute glomerulonephritis (7.5%);renal vascular disease (5%) and renal cysticdisease (2.5%). Diabetic nephropathy,obstructive uropathy and hypertensivenephrosclerosis were the major causes of CRF,accounting for 80% of total CRF in theelderly. Chronic glomerulonephritis and chronicpyelonephritis (CPN) were less common andetiology of CRF was uncertain in 5.9% ofcases. However, diabetic nephropathy was thecommonest (49.4%) cause of chronic renalfailure. We did not see a single case ofischemic nephropathy causing CRF in the presentstudy. Prerenal ARF, obstructive uropathy andsepsis were contributing factors for ARF in82% of the cases. Volume depletion due togastrointestinal fluid loss and urinary tractobstruction on account of enlarged prostatewere the leading causes of ARF in 20 (35.7%)and 8 (14.3%) cases respectively. Sepsis withor without multiorgan failure was the major(46.7%:) cause of mortality in patients withARF and overall mortality was 26.8%. Thecommonest (31%) cause of nephrotic syndromewas the idiopathic membranous nephropathy.Diabetic nephropathy related to type-2 diabetesmellitus was the second most common (24.1%)cause of nephrotic syndrome. Diffuseendocapillary proliferative GN of postinfectious etiology was the commonest (73.3%)type of acute GN in our elderly patients. Renalcystic diseases were noted in 5 (ADPKD 3;Simple cyst-2) patients. Thus, overall spectrumof renal disease in our elderly patients issimilar to that of developed nations except intwo ways: (i) Endocapillary proliferative GN ofpost infectious origin was the commonest typeof acute GN and (ii) Rarity or absence ofischemic nephropathy and atherosclerotic renalartery occlusive disease.     

Analgesic and non-steroidal anti-inflammatory drug-associated acute renal failure: a prospective collaborative study

During a one-year period analgesic and non-steroidal anti-inflammatory drug-(NSAID) associated acute renal failure (ARF) was recorded in 147 of 398 patients registered in 58 nephrology units. This figure represented 36.9% of drug-associated ARF, and 6.8% of total patients with ARF hospitalized during the same period. Drugs involved were primarily glafenin (79), NSAID (62), paracetamol (5) and phenacetin (1 case). Hypersensitivity reactions were documented in 32 patients. Acute tubular necrosis was found in 20, and interstitial nephritis (AIN) in 9 of 34 biopsied patients. All patients in the glafenin group and 71.4% in the NSAID group recovered fully or regained previous renal function (p less than 0.01). Permanent renal damage (9.5% of total cases) was more frequent in patients with AIN than in those with other types of ARF (p less than 0.001). Preventive measures should be especially directed to older patients receiving NSAID, by avoiding the combined use of drugs potentiating their action and by correcting any predisposing factor to ARF.     

Renal Biopsy in Elderly Patients: A Clinicopathological Analysis

As the numbers of aging patients with manifestations of renal disease increase, the elderly must frequently undergo renal biopsies. This study examined the characteristics of clinicopathological correlations in elderly patients. Medical and clinical records from renal biopsies registered in two hospitals between January 2000 and December 2004 were reviewed. Among 406 patients (female: male 224/182; age 43.9 ± 18.8 years, mean ± SD) who underwent renal biopsies, 61 (15.1%) who were aged 65 years and older (female: male, 29/32; age 72.8 ± 5.2 years) were selected. The elderly usually underwent percutaneous renal biopsies for renal diseases such as nephrotic syndrome (43%) and acute or rapidly progressive renal failure (A/RPRF, 39%). Focal/segmental glomerulosclerosis (23%), minimal change disease (19%), and membranous nephropathy (15%) are frequently diagnosed based on biopsy specimens from patients with nephrotic syndrome. Among patients presenting with A/RPRF, 17 (71%) and 4 (17%) had pauci-immune, MPO-ANCA positive, crescentic glomerulonephritis and interstitial nephritis, respectively, and benefited from therapeutic intervention. Histopathological and pre-biopsy clinical diagnoses differed in nine (15%) patients. The complication rate after biopsy was low (3%). Primary glomerular diseases presenting with nephrotic syndrome and primary crescentic glomerulonephritis associated with rapidly progressive renal failure were the most frequently diagnosed among the elderly who underwent renal biopsy. Percutaneous renal biopsy provides clinically useful information about the elderly because clinical presentation and the predicted diagnosis sometimes vary.     

Parathyroid hormone as a marker for the differential diagnosis of acute and chronic renal failure

It is often difficult to distinguish acute renal failure clinically from chronic renal failure, especially in patients who do not have records of their medical history. We investigated the magnitude of iPTH increase in ARF and the potential role of iPTH as a marker for differential diagnosis of ARF and CRF in new patients referred to our renal unit. We prospectively analyzed 122 (ARF n = 64, CRF n = 58) patients referred to our renal unit with serum creatinine higher than 2 mg/dL. ROC curve analysis was performed to investigate role of iPTH for differentiating ARF from CRF. The sensitivity, specificity, and positive predictive value of iPTH in discrimination of ARF and CRF were calculated. There was no statistically significant difference regarding the means of age, sex distribution, and serum chemistry between patients with ARF or CRF. But serum iPTH (p < 0.0001) levels were lower in patients with ARF than in those with CRF. A cutoff, set at 170 pg/mL for iPTH to discriminate patients with CRF, yielded a sensitivity of 88% and a specificity of 89%. This study confirms that the iPTH measurement is of clinical value in differentiating acute from chronic renal failure.     

Dyslipidaemia and the progression of renal disease in chronic renal failure patients.

BACKGROUND: Dyslipidaemia is common in patients with chronic renal failure (CRF), and there is increasing evidence to support the role of dyslipidaemia as a contributing factor in the progression of chronic renal disease. However, few prospective studies have been carried out which address the possible relationship between dyslipidaemia and the rate of progression of renal disease in patients with renal failure. METHODS: Between January 1985 and December 1997, we prospectively assessed the risk of CRF progression to dialysis in a cohort of 138 patients. Forty CRF patients reached end-stage renal disease (ESRD) and had to start supportive therapy during the follow-up period [group ESRD(+)]. The remaining 98 CRF patients served as controls [group ESRD(-)]. Potential clinical and laboratory risk factors for more rapid CRF decline to dialysis, including lipid abnormalities and baseline creatinine clearance were determined at the start of the follow-up period. RESULTS: Several significant differences were found in univariate analysis between the two groups of CRF, ESRD(+) and ESRD(-), namely a shorter follow-up period, a lower level of baseline creatinine clearance, a faster rate of creatinine clearance decline, a higher level of serum triglycerides, fibrinogen, total homocyst(e)ine and proteinuria, and a lower level of serum high-density lipoprotein in the ESRD(+) group than in the ESRD(-) group. However, by multivariate Cox analysis proteinuria [relative risk (95% confidence interval) 1.32 (1.16-1.50) for each g/day P = 0.001], baseline creatinine clearance [0.53 (0.40-0.70) for each 10 ml/min, P = 0.001] and chronic interstitial nephritis and hypertensive nephrosclerosis [0.38 (0.17-0.84) for presence, P = 0.005] were the only significant risk factors for CRF progression to dialysis. Hypertriglyceridaemia and male gender were selected in the final model, but were of borderline significance. CONCLUSIONS: These results suggest a limited role for dyslipidaemia in the progression of chronic renal disease to dialysis in CRF patients, in contrast with the powerful influence of proteinuria, baseline creatinine clearance and nephropathy type in predicting this progression.     

Renal biopsy in elderly patients: a clinicopathological analysis

As the numbers of aging patients with manifestations of renal disease increase, the elderly must frequently undergo renal biopsies. This study examined the characteristics of clinicopathological correlations in elderly patients. Medical and clinical records from renal biopsies registered in two hospitals between January 2000 and December 2004 were reviewed. Among 406 patients (female: male 224/182; age 43.9 +/- 18.8 years, mean +/- SD) who underwent renal biopsies, 61 (15.1%) who were aged 65 years and older (female: male, 29/32; age 72.8 +/- 5.2 years) were selected. The elderly usually underwent percutaneous renal biopsies for renal diseases such as nephrotic syndrome (43%) and acute or rapidly progressive renal failure (A/RPRF, 39%). Focal/segmental glomerulosclerosis (23%), minimal change disease (19%), and membranous nephropathy (15%) are frequently diagnosed based on biopsy specimens from patients with nephrotic syndrome. Among patients presenting with A/RPRF, 17 (71%) and 4 (17%) had pauci-immune, MPO-ANCA positive, crescentic glomerulonephritis and interstitial nephritis, respectively, and benefited from therapeutic intervention. Histopathological and pre-biopsy clinical diagnoses differed in nine (15%) patients. The complication rate after biopsy was low (3%). Primary glomerular diseases presenting with nephrotic syndrome and primary crescentic glomerulonephritis associated with rapidly progressive renal failure were the most frequently diagnosed among the elderly who underwent renal biopsy. Percutaneous renal biopsy provides clinically useful information about the elderly because clinical presentation and the predicted diagnosis sometimes vary.     

Treatment-related acute renal failure in the elderly: a hospital-based prospective study.

BACKGROUND: Elderly individuals need a host of diagnostic procedures and therapeutic interventions to take care of ailments. This prospective study was carried out to determine the magnitude of treatment-related acute renal failure (ARF) in the elderly in a hospital setting, to know about pathogenetic factors and to study the factors that could predict an adverse outcome. METHODS: All elderly patients (>60 years) admitted over a 12-month period were screened prospectively throughout their hospital stay for the development of ARF. RESULTS: Of 31860 patients admitted, 4176 (13%) were elderly. Of these 59 (1.4%) developed ARF in the hospital. Nephrotoxic drugs contributed towards development of ARF in 39 (66%), sepsis and hypoperfusion in 27 (45.7%) each, contrast medium in 10 (16.9%) and postoperative ARF occurred in 15 (25.4%) patients. These pathogenetic factors were responsible for ARF in different combinations. Amongst these combination of pathogenetic factors, radiocontrast administration (partial chi(2) 28.1, P<0.0001), surgery (partial chi(2) 14.89, P=0.001), and drugs (partial chi(2) 6. 22, P=0.0126) predicted ARF on their own. Nine patients (15.23%) needed dialytic support. Of 59 patients, 15 (25.4%) died, of those who survived, 38 (86.3%) recovered renal function completely and six (13.6%) partially. Mortality in the elderly with ARF was significantly higher than in those without ARF (25.4 vs 12.5%; chi(2) 8.3, P=0.03). Sepsis (odds ratio 43), oliguria (odds ratio 64), and hypotension (odds ratio 15) were independent predictors of poor patient outcome on logistic regression analysis. CONCLUSION: Incidence of treatment-related ARF in the elderly was 1.4%, with more than one pathogenetic factor playing a role in the development of ARF in the majority. Sepsis, hypotension, and oliguria were the independent predictors of poor patient outcome.     

Renal transplantation for end-stage renal disease following bone marrow transplantation: A report of six cases, with and without immunosuppression

BACKGROUND. Over 12000 bone marrow transplantations (BMT) are performed in the USA each year. This procedure is associated with significant morbidity including acute and chronic renal failure (CRF). CRF after BMT is usually secondary to radiation nephropathy and,or cyclosporine (CsA) toxicity. Survival on dialysis therapy for patients with radiation nephropathy is poor and renal transplantation may be a preferable form of renal-replacement therapy. METHODS: We report our experience with renal transplantation in 6 patients with end-stage renal disease (ESRD) following BMT: 4 as a result of radiation nephropathy; one secondary to hemolytic uremic syndrome; and 1 as a result of antitubular basement membrane nephritis. Ages at the time of BMT ranged from 26 to 40 yr. ESRD developed after a mean period of 94 months (range 42-140 months) after BMT. The kidney source was from a living donor in 5 patients, and a cadaveric donor (CAD) in 1 patient. In 3 recipients, the bone marrow and kidney were from the same donor. They are managed without any immunosuppressive therapy. The other 3 were initiated on triple therapy (prednisone, mycophenolate mofetil/azathioprine and cyclosporine/tacrolimus). RESULTS: These patients have been followed for up to 31 months (range 3-30 months) after kidney transplant, and 5 out of 6 are alive with functioning bone marrow and renal transplants. Their plasma creatinines range from 70 to 160 micromol/L (mean 97 micromol/L). One patient died following metastatic squamous cell cancer of the genital tract. CONCLUSIONS: 1) Renal transplant is a feasible alternative for patients with ESRD following BMT: 2) if bone marrow and kidney are from the same donor, the recipient requires little or no maintenance immunosuppression; 3) short-term results show good survival, but long-term follow-up is needed: 4) infections and malignancy post-renal transplantation were seen in recipients who needed immunosuppression; and 5) reduction in immunosuppression may be needed in such post-BMT patients who undergo kidney transplants.     

Dialysis therapy for children with acute renal failure: survey results

We surveyed 123 pediatric nephrologists to investigate the current dialytic management of acute renal failure (ARF) in children. Data collected from 92 responding physicians revealed that hemodialysis (HD), peritoneal dialysis (PD), and continuous renal replacement therapy (CRRT) are currently used as the primary means of acute renal replacement therapy in a nearly equal percentage of centers. The preferential use of CRRT appears to be increasing, while PD usage is decreasing except for the youngest infants and those patients likely to develop end-stage renal disease (ESRD). Additional data correlating patient outcome to dialytic modality should be collected to compare the efficacy of the three techniques.     

Non diabetic renal disease in type 2 diabetes mellitus

AIM: The aim of this analysis of renal biopsies in people with type 2 diabetes was to know the prevalence and nature of non-diabetic renal disease (NDRD) and to note its correlation with the duration of diabetes, extent of proteinuria and presence or absence of retinopathy. METHODS: From January 2000 to December 2004, 160 people with type 2 diabetes with clinically suspected NDRD underwent renal biopsy reported by a single pathologist. The case records of these patients were retrospectively analysed. Based on the biopsy findings, patients were grouped as Group I, isolated NDRD; Group II, NDRD with underlying diabetic glomerulosclerosis; and Group III, isolated diabetic glomerulosclerosis. The relation of histology with clinical profile in each group was noted and statistically analysed using strata 6 software. RESULTS: Of the 160 patients studied, 118 were males and 42 were females (2.8:1). The average age was 51.35 years (30-79). Indications for renal biopsy included: nephrotic syndrome in 55 (34.37%), acute renal failure (ARF) in 49 (30.62%), rapidly progressive renal failure (RPRF) in 24 (15%), absent retinopathy in 19 (11.87%), haematuria in 10 (6.25%) and acute on chronic renal failure (CRF) in three (1.87%) patients. Group I included 68 patients (42.50%), Group II included 48 patients (30%) and Group III included 44 patients (27.50%). The mean duration of diabetes was 5.37, 10.12 and 6.86 years in Groups I, II and III respectively. The duration of diabetes was significantly less in Group I compared with Group II and III combined (5.37 vs 8.53; P < 0.001). Diabetic retinopathy was absent in 61 (38.13%) patients, of whom 41 (67.21%) had isolated NDRD. The most common NDRD were acute interstitial nephritis (18.1%), post infectious glomerulonephritis (17.24%), membranous nephropathy (11.20%) and focal segmental glomerulosclerosis (7.75%). CONCLUSIONS: Prevalence of NDRD (either isolated or superimposed on underlying diabetic glomerulosclerosis) is very high in appropriate clinical settings. The shorter duration of diabetes and the absence of retinopathy, especially when associated with nephrotic proteinuria, strongly predict NDRD.     

Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes

BACKGROUND: Acute renal failure (ARF) is associated with a persistent high mortality in critically ill patients in intensive care units (ICUs). Most studies to date have focused on patients with established, intrinsic ARF or relatively severe ARF due to multiple factors. None have examined outcomes of dialysis-dependent chronic renal failure [end-stage renal disease (ESRD)] patients in the ICU. We examined the incidence and outcomes of ARF in the ICU using a standard definition and compared these to outcomes of ICU patients with either ESRD or no renal failure. We sought to determine the impact of renal dysfunction and/or loss of organ function on outcome. METHODS: We prospectively scored 1530 admissions to eight ICUs over a 10-month period for illness severity at ICU admission using the Acute Physiological and Chronic Health Evaluation (APACHE III) evaluation tool. Patients were defined as having ARF based on the definition of Hou et al (Am J Med 74:243-248,1983) designed to detect significant measurable declines in renal function based on serum creatinine. ESRD patients were identified as being chronically dialysis-dependent prior to ICU admission and the remainder had no renal failure. Clinical characteristics at ICU admission and ICU and hospital outcomes were compared between the three groups. RESULTS: We identified 254 cases of ARF, 57 cases of ESRD and 1219 cases of no renal failure for an incidence of ARF of 17%. Roughly half the ARF patients had ARF at ICU admission and the remainder developed ARF during their ICU stay. Only 11% of ARF patients required dialysis support. ARF patients had significantly higher acute illness severity scores than those with no renal failure, whereas patients with ESRD had intermediate severity scores. ICU mortality was 23% for patients with ARF, 11% for those with ESRD, and 5% for those with no renal failure. There was no difference in outcome between patients who had ARF at ICU admission and those who developed ARF in the ICU. Patients with ARF severe enough to require dialysis had a mortality of 57%. APACHE III predicted outcome very well in patients with no renal failure and patients with ARF at the time of scoring but underpredicted mortality in those who developed ARF after ICU admission and overestimated mortality in patients with ESRD. CONCLUSIONS: ARF is common in ICU patients and has a persistent negative impact on outcomes, although the majority of ARF is not severe enough to require dialysis support. The mortality of patients with ARF from all causes is almost exactly similar to that noted using the same criteria two decades ago. More profound ARF requiring dialysis continues to have an even greater mortality. Nevertheless, acute declines in renal function are associated with a mortality that is not well explained simply by loss of organ function. The majority of ARF patients who did not require dialysis still had a considerably higher mortality than the ESRD patients, all of whom required dialysis; while ARF patients who did require dialysis had a much higher morality than ESRD patients. APACHE III performs well and captures the mortality of patients with ARF at the time of scoring. Development of ARF after scoring has a profound effect on standardized mortality. We were unable to identify a unique mortality associated with ARF, but the presence of measurable renal insufficiency continues to be a sensitive marker for poor outcome.     

Hypertension in chronic kidney failure (the physiopathology, clinical picture and treatment)

Secondary hypertension in CRF is characterized by particular features; hemodynamics--abnormal high vascular peripheral resistance relative to the cardiac output level; circadian variability--absence of nocturnal physiological BP decline. Hypertension is the main risk factor for renal disease progression, irrespective of the underlying etiology, and is one of the major determinants of the impressive cardiovascular morbidity and mortality seen in uraemic patients (> 50% cases). The atherosclerotic risk and severe retinopathy are more important in CRF hypertension compared to other causes (including essential HTA) at similar BP levels. Treatment targets for renal patients should be less than 130/90 mmHg. The main treatment modality for ESRD hypertension are sodium and water removal through diet, diuretics and dialytic ultrafiltration. Pro's and con's of antihypertensive medication classes are discussed.     

Renal failure in Yemen

Renal failure remains a serious cause of mortality in Yemen. Our region has 1.25 million population and our hospital is the central hospital, which has a nephrology department and performs dialysis for the region. Between January 1998 and December 2002, we admitted 547 patients; including children, with acute renal failure (ARF) and chronic renal failure (CRF). CRF was observed in 400 patients, an incidence of 64 per million per year and a prevalence of 320 per million. ARF occurred in 147 persons with an incidence of 23.5 per million per year and a prevalence of 117.5 patients per million. Of all patients, 72% were adults (age range, 20-60 years) with a male preponderance. As a tropical country, malaria (27.9%), diarrhea (13.6%), and other infectious diseases were the main causes. Next most common were obstructive diseases causing CRF and ARF (26.8% and 12.9%, respectively), mainly urolithiasis, Schistosomiasis, and prostatic enlargement. However the cause of CRF in 57.5% of patients was unknown as most persons presented late with end-stage disease (64.7%), requiring immediate intervention. Other causes, such as hepatorenal syndrome, snake bite, diabetes mellitus, and hypertension, showed low occurrence rates. Patients presented to the hospital mostly in severe uremia and without a clear history of prior medications. The major findings were vomiting, acidosis, and hypertension with serum creatinine values ranging between 2.8-45 mg/dL (mean value, 13.4 mg/dL). Anemia was observed in 80.4% of CRF versus 62.6% of ARF patients. Hypertension prevalence was 65.5% among CRF patients, of whom 25% were in hypertensive crisis, whereas among ARF the prevalence was only 26.5%.     

Outcomes of renal transplantation among patients with end-stage renal disease caused by lupus nephritis

BACKGROUND: Although the outcomes of renal transplantation among patients with end-stage renal disease (ESRD) caused by lupus nephritis have generally been found to be comparable to those of patients with other causes of ESRD, some studies indicate that cadaveric graft failure is more common among these patients. However, most previous studies examined small numbers of patients and did not adjust for important confounding factors. METHODS: Graft failure and patient mortality after the first cadaveric renal transplantation were compared between 772 adults with ESRD caused by lupus nephritis and 32,644 adults with ESRD caused by other causes who received a transplant between 1987 and 1994 and were included in the United States Renal Data System. The median follow-up times were 4.9 and 5.0 years in the two groups, respectively. Multivariate Cox regression models were used to adjust the risks of graft failure and mortality for group differences in recipient and donor characteristics. Similar comparisons were performed between 390 adults with ESRD caused by lupus nephritis and 10,512 adults with ESRD caused by other causes after first living-related renal transplantation. RESULTS: In an unadjusted analysis, the risk of graft failure after first cadaveric transplant was slightly but significantly greater among patients with ESRD caused by lupus nephritis than among those with ESRD caused by other causes [hazard ratio (HR), 1.13; 95% CI, 1.01 to 1. 26, P = 0.04]. However, after adjustment for potential confounding factors, the risk of graft failure was not increased in patients with ESRD caused by lupus nephritis (HR, 1.08; 95% CI, 0.94 to 1.23, P = 0.28). Mortality after the first cadaveric transplantation did not differ between groups. The adjusted risks of graft failure (HR, 1.06; 95% CI, 0.84 to 1.32, P = 0.62) and patient mortality (HR = 0. 69; 95% CI, 0.45 to 1.05, P = 0.09) after the first living-related renal transplant were also not significantly higher among patients with ESRD caused by lupus nephritis. CONCLUSIONS: Graft and patient survival after first cadaveric and first living-related renal transplants are similar in patients with ESRD caused by lupus nephritis and patients with ESRD from other causes.     

Acute renal failure in the elderly: experience from a single centre in India

A total of 139 patients with acute renal failure (ARF) werestudied, of which 41 (29.4%) were elderly with mean age of 67.1years and 98 (70.6%) were younger with mean age of 32.3 years.Surgical causes accounted for 65% of geriatric ARF while medicalcauses were predominant in the younger patients (55.1%). Amongstthe surgical causes, prostate-related problems due to obstructionor following transurethral resection of prostate were seen in20 patients (74%). Drugs and sepsis were the predominant causesof medical ARF in the geriatric patients (85.7%). Of all thecauses of geriatric ARF, which included both medical and surgical,nephrotoxic drugs either alone or in combination with otherpredisposing factors were the cause in 22 (51%) patients. Haemodialysiswas needed in 15 of geriatric (36.6%) and 64 of younger (65.3%)ARF patients. Recovery from ARF, as evidenced by normalizationof serum creatinine, was delayed in the elderly as comparedto the younger patients (32.0 versus 11.4 days, P< 0.001).Mortality, though higher in the elderly as compared to the youngerpatients, was not significantly different (9.75% versus 6.1%).     

Parathyroid Hormone as a Marker for the Differential Diagnosis of Acute and Chronic Renal Failure

It is often difficult to distinguish acute renal failure clinically from chronic renal failure, especially in patients who do not have records of their medical history. We investigated the magnitude of iPTH increase in ARF and the potential role of iPTH as a marker for differential diagnosis of ARF and CRF in new patients referred to our renal unit. We prospectively analyzed 122 (ARF n?=?64, CRF n?=?58) patients referred to our renal unit with serum creatinine higher than 2 mg/dL. ROC curve analysis was performed to investigate role of iPTH for differentiating ARF from CRF. The sensitivity, specificity, and positive predictive value of iPTH in discrimination of ARF and CRF were calculated. There was no statistically significant difference regarding the means of age, sex distribution, and serum chemistry between patients with ARF or CRF. But serum iPTH (p < 0.0001) levels were lower in patients with ARF than in those with CRF. A cutoff, set at 170pg/mL for iPTH to discriminate patients with CRF, yielded a sensitivity of 88% and a specificity of 89%. This study confirms that the iPTH measurement is of clinical value in differentiating acute from chronic renal failure.     

Acute interstitial nephritis secondary to infectious mononucleosis

Renal involvement in infectious mononucleosis (IM) is infrequent. In most cases it is self-limited and is rarely associated with loss of renal function. The purpose of this case report is to document a case of acute interstitial nephritis (AIN) leading to acute renal failure (ARF) in a patient with Epstein-Barr virus (EBV) infection and to review literature of EBV infection and its renal manifestation. The patient was managed with hemodialysis and steroids and made an uneventful recovery. Renal involvement in IM may be more common than generally appreciated and may occasionally lead to ARF. Therapy with corticosteroids may have role in the management of IM-induced ARF and may shorten the duration of renal failure.     

Impaired monocyte cytokine production in critically ill patients with acute renal failure

BACKGROUND: Plasma levels of pro- and anti-inflammatory cytokines are predictive of mortality in patients with acute renal failure (ARF). Anti-inflammatory strategies are postulated to be beneficial in treatment. However, there are few studies simultaneously examining monocyte cytokine production and plasma cytokine levels in patients with ARF. METHODS: Study populations consisted of 20 critically ill patients with ARF, 19 critically ill patients without ARF (CRIT ILL), 28 healthy subjects (HS), 19 patients with chronic kidney disease (CKD), and 15 patients with end-stage renal disease (ESRD). Monocyte intracellular content of interleukin-1beta (IL-1beta), interleukin-6 (IL-6), interleukin-8, and tumor necrosis factor-alpha (TNF-alpha) was determined by flow cytometry in whole blood. Plasma interleukin 6 and TNF-alpha concentrations were determined by enzyme-linked immunosorbent assay (ELISA). RESULTS: At baseline, there were no differences in intracellular monocyte cytokine levels between groups. After lipopolysaccaride stimulation, monocyte production of IL-1beta, TNF-alpha, and IL-6 in ARF patients was reduced by 41%, 84%, and 45%, respectively, compared to healthy subjects (P < 0.01 in each case), and similarly reduced compared to CKD and ESRD patients, and were similar to CRIT ILL patients. Plasma IL-6 levels were significantly higher in ARF patients than healthy subjects, CKD, and ESRD patients (all P < 0.001). CONCLUSION: Critically ill patients with acute renal failure have impaired monocyte cytokine production and elevated plasma cytokine levels in a pattern that closely resembles critically ill patients without ARF, and that is dissimilar to CKD and ESRD patients.