Urological management of indinavir-associated acute renal failure in HIV-positive patients

Introduction Indinavir, a protease inhibitor that is commonly used to treat HIV infection, may cause crystal formation within the renal tubules when urine pH is above 3.5. Crystallization in the urine may lead to intrarenal crystal deposition and acute renal failure (ARF). Aim To establish the beneficial urological management of acute renal failure caused by indinavir treatment of HIV/AIDS patients. Patients––methods Five HIV positive patients (four men, one woman) with a mean age of 32 years (range 28–36 years) were referred to our Department of Urology from an AIDS outpatient Clinic, because of the development of postrenal acute renal failure with continuously elevated creatinine and urea plasma levels after indinavir therapy. Among the initial therapeutic maneuvers, indinavir administration was interrupted for 1 week while bilateral double-J ureteral stents were inserted in all the HIV/AIDS patients, during the first 24–72 h to secure upper-tract drainage. Concurrently urine has been acidified by oral administration of the amino acid l-methionine and oral fluid intake was increased. Results All the patients responded well to the treatment and their renal function was effortlessly restored to normal within a few days. Conclusion HIV-positive patients receiving indinavir therapy might be complicated by acute renal failure, mainly due to intrarenal crystal deposition (tubules) or urolithiasis (postrenal obstruction). This adverse effect may simply manage by the discontinuation of indinavir administration, urine acidification, as well as the possible early insertion of bilateral double-J ureteral stents.     

Evaluation of conservative treatment of non specific spondylodiscitis

The objective of this study was to analyse the presentation, aetiology, conservative management, and outcome of non-tuberculous pyogenic spinal infection in adults. We performed a retrospective review of 56 patients (35 women and 21 men) of pyogenic spinal infection presenting over a 7-year period (1999–2006) to the Department of Spinal Surgery of Hesperia Hospital. The medical records, radiologic imaging, bacteriology results, treatment, and complications of all patients were reviewed. The mean age at presentation was 47.8 years (age range 35–72 years), the mean follow-up duration was 12.5 months. The most common site of infection was lumbar spine (n: 48), followed by the thoracic spine (n: 8). Most patients were symptomatic for between 4 and 10 weeks before presenting to hospital. The frequently isolated pathogen was Staphylococcus aureus in 31 of 56 cases (57.6%). Percutaneous biopsies were diagnostic in 57% of patients; the open biopsy was indicated if closed biopsy failed and when the infection was not accessible by percutaneous technique. The patients were managed by conservative measures alone, including antibiotic therapy and spinal bracing. The mean period of antibiotic therapy was 8.5 weeks (range 6–9 weeks), followed by oral antibiotics for 6 weeks. All patients had a supportive spinal brace for mean 8 weeks (range 6–10 weeks). The duration of the administration of oral antibiotics was dependent on clinical and laboratory evidence (white cell count, erythrocyte sedimentation rate, C-reactive protein) that the infection was resolved. The follow-up MR gadolinium scans were essential to monitor the response to medical treatment. The diagnosis of pyogenic spinal infection should be considered in any patient presenting with severe localised unremitting back and neck pain, especially when accompanied with systemic features, such as fever and weight loss and in the presence of elevated inflammatory markers. The conservative management of infection with antibiotic therapy and spinal bracing was very successful.     

Early erythropoietin reduced the need for red blood cell transfusion in childhood hemolytic uremic syndrome—a randomized prospective pilot trial

Childhood hemolytic uremic syndrome (HUS) is most often caused by enterohemorrhagic Escherichia coli (EHEC). Due to severe hemolysis, red blood cell (RBC) transfusions are often necessary, and anemia is aggravated by low erythropoietin (EPO) levels caused by acute renal failure. In a single center, prospective study, we randomized ten children with EHEC-positive HUS into two therapeutic groups: one receiving EPO treatment (median age 2 years, age range 1–3 years) and the other receiving standard therapy (median age 2 years, age range 1–6 years). Red blood cell transfusions were performed when the hemoglobin level (Hb) fell below 5 mg/dl. The number of RBC transfusions was compared in both groups. The Hb level at admission was comparable between both groups (6.4 vs. 8.1 mg/dl, P > 0.05, t-test). However, children in the EPO group required a significantly lower mean number of RBCs than those in the non-EPO group (0.2 vs. 1.4, P < 0.04, t-test). Based on these results, we suggest that the early administration of EPO at the time of hemolytic anemia and beginning renal failure may attenuate renal anemia in children with EHEC-induced HUS and thereby reduce the number of RBC transfusions required. The results of this pilot study will have to be confirmed in a larger multicenter trial.     

Outcomes of Laparoscopic Bariatric Surgery after Renal Transplant

Obesity has been associated with poor graft and patient survival after kidney transplantation, requiring functional increase of anti-rejection drugs. Weight loss surgery may be a good alternative in this clinical scenario. The aim of this report is to describe the outcomes of bariatric procedures performed in patients after kidney transplantation at our institution. A retrospective chart review of a prospectively collected database was conducted to analyze the outcomes of morbidly obese patients after kidney transplantation who underwent laparoscopic bariatric procedures between November 2004 and October 2007. Our series included five patients who underwent a bariatric procedure following kidney transplantation. All patients were females, with a mean age of 40.8 years (range 30–48) and mean body mass index (BMI) of 52.2 (range 48–69). Percent of excess weight loss (%EWL) at 2 years was over 50% for all patients; other comorbidities that might affect postoperative renal function were diabetes mellitus in 2/5 patients, hypertension in 5/5 patients, and chronic heart failure in 1/5 patients. Four patients had laparoscopic Roux-en-Y gastric bypass and one had laparoscopic sleeve gastrectomy. There were no postoperative complications in any patients, and no alteration to the dosages of the immunosuppressant drugs were recorded after bariatric surgery. Laparoscopic bariatric surgical techniques may be used safely and effectively to control obesity in renal transplant patients.     

Pyogenic vertebral osteomyelitis: identification of microorganism and laboratory markers used to predict clinical outcome

The aim of this study is to determine the predictive values of laboratory indicators of pyogenic vertebral osteomyelitis (PVO) and a potential cure if the microorganism cannot be identified. Forty-five consecutive patients with PVO were enrolled. Antibiotic therapy with or without surgery was performed according to microorganism. In the negative-culture (NC) group, cefazolin was administered in cases of hematogenous PVO, and vancomycin was administered in cases of postoperative or procedure-related PVO. The clinical, laboratory, and radiological findings were followed up with regard to an appropriate response to antimicrobial therapy. Nine patients were treated with antibiotics alone. We were able to identify the microorganism in 34 cases (75.6%). Ten cases in NC group were cured without recurrence, but one was not. Identification of the microorganisms did not have any significant influence on the treatment outcome, duration of antibiotic administration or normalization of laboratory profiles. For erythrocyte sedimentation rate (ESR) values over 55 mm/h and C-reactive protein (CRP) values of 2.75 mg/dL at fourth week after antibiotic administration by means of ROC curve analysis, we expect significantly high rates of treatment failure by Pearson χ² test (χ² = 4.344, Odds ratio = 5.15, p = 0.037, 95% CI 1.004–26.597). Even in patients with negative culture findings, it is expected that a good outcome will be achieved by the administration of cefazolin or vancomycin for about 6 weeks. It is concluded that antibiotics selected according to the etiological setting can be initiated without the need to start empirical antibiotics. In every instance at fourth week after the initiation of antibiotic therapy, the values of CRP and ESR can provide meaningful information regarding whether clinicians need to reevaluate the effectiveness of antibiotics by performing follow-up imaging studies and monitoring the patient’s clinical manifestations.     

The Role of Arterio-Venous Shunt in the Pathogenesis of Pulmonary Hypertention in Patients with End-stage Renal Disease

Pulmonary hypertension (PHT) is an overlooked cardiovascular morbidity in patients with end stage renal disease. The pathogenesis of PHT in this group of patients is not explained satisfactorily. The aim of our study to evaluate the prevalence and the role of AV shunt in pathogenesis of pulmonary hypertention. Our study included 58 patients with ESRD without a known cause of PHT who were either in the predialysis period (stage 1V CKD) (14 patients) or maintained on chronic hemodialysis (stage V CKD) (44 patients) in Theodor Bilharz Research Institute (TBRI), Cairo, Egypt. In the chronic hemodialysis group, there were 27 males and 17 females with a mean age of 57.11 ± 12.31 years (range 28–65). In the predialysis group, there were 8 males and 6 females with a mean age 53.45 ± 9.41 years (range 28–66). Pulmonary arterial pressure (PAP) and cardiac output were evaluated by Doppler echocardiography in the 14 pre-dialysis patients without PHT few (4.3 ± 0.8) months after creation of AV fistula and in the 44 hemodialysis patients (33.6 ± 4.2 months) after creation of AV fistula within 1 h of completion of hemodialysis session. Arteriovenous fistula (AVF) flow was measured by Doppler sonography. PHT (systolic PAP ≥35 mm Hg) was observed in 25 (56.8%) patients receiving hemodialysis with a mean systolic PAP of 46.4 ± 13.6 mm Hg. In the predialysis group after creation of AV fistula, PHT was found in 6 (42.9%) patients with a mean systolic PAP of 42.8 ± 12.8 mm Hg. The cardiac output and AV shunt flow were found to be increased in patients with elevated systolic PAP in both groups (p < 0.05). CRF duration and AV fistula duration were positively correlated with systolic PAP in patients receiving hemodialysis (p < 0.05). After compression of AV fistula in 11 hemodialysis patients, the mean value of PHT decreased (from 43.98 ± 15.6 to 33.22 ± 11.7 mm Hg). This study demonstrates a high prevalence of PHT among patients with ESRD in predialysis period after creation of AV fistula and on chronic HD via a surgical A-V fistula. Cardiac output, AV shunt flow and duration, and ESRD duration may be involved in the pathogenesis of PHT. The development of PHT following access formation represents a failure of the pulmonary circulation to accommodate the access-mediated elevated CO. Pre-dialysis patients scheduled for access formation should be screened for the presence of sub-clinical PHT.     

Retroperitoneal robotic renal surgery: technique and early results

We describe a robotic retroperitoneal approach to renal surgery, optimized in porcine and cadaveric models, and applied to human patients. A retroperitoneal approach for robotic kidney surgery was developed in nonsurvival porcine and a fresh cadaver models, and then utilized in ten patients (three partial nephrectomy, three radical nephrectomy, two simple nephrectomy, one pyeloplasty, one cryoablation). Retroperitoneal access was successfully achieved for robotic renal procedures in six pigs and a human cadaver. Ten human patients (mean age 56 years, range 36–72 years) then underwent a successful retroperitoneal approach for robotic renal surgery. Mean console time was 166 (120–300) min. Mean blood loss was 82 (50–100) ml and average hospital stay was 2.6 (1–5) days. Pathology demonstrated clear cell renal cell carcinoma (four), papillary renal cell carcinoma (two), and xanthogranulomatous pyelonephritis (two). One patient with xanthogranulomatous pyelonephritis required open conversion for failure to progress due to dense adhesions. A retroperitoneal approach is a safe and feasible alternative to a transperitoneal approach for robotic renal surgery, including radical nephrectomy, partial nephrectomy, pyeloplasty, and cryoablation. M. N. Patel and S. A. Kaul contributed equally to this work.     

Postoperative Prophylactic Antibiotics and Surgical Site Infection Rates in Breast Surgery Patients

Background  A single preoperative prophylactic dose of an intravenous antibiotic with antistaphylococcal activity is standard of care for breast and axillary surgical procedures. Some surgeons also prescribe postoperative prophylaxis for all patients with drains to prevent infection despite its lack of proven efficacy. Methods  A retrospective chart review of patients with breast and/or axillary surgical procedures between July 2004 and June 2006 were included. Data were collected on patient demographics, procedure types, and use of prophylactic antibiotics. Surgical site infection (SSI) was defined by means of Centers for Disease Control and Prevention criteria, including patients meeting the physician diagnosis criterion if an antibiotic was prescribed for a clinical diagnosis of cellulitis. χ² and Fisher’s exact tests were used to compare SSI rates. Results  Three hundred fifty-three patients with 436 surgical sites who received either preoperative or both pre- and postoperative antibiotic were analyzed. Overall, the SSI rate was 7.8% (34 of 436 surgical sites). Eighty-five patients (24%) with 127 surgical sites were provided both preoperative and postoperative prophylactic antibiotics. The SSI rates did not differ statistically (P = .67) for the groups that did (95% confidence interval, 4.8–15.0; 11 of 127 surgical sites, 8.7%) and did not receive postoperative antibiotic prophylaxis (95% confidence interval, 5.0–11.0; 23 of 309, 7.4%). Conclusions  Although the overall number of patients who developed SSI was relatively small, there was no reduction in the SSI rate among those who received postoperative antibiotic prophylaxis. Because of the potential adverse events associated with antibiotic use, further evaluation of this practice is required. Presented in part at the 62nd Annual Cancer Symposium of the Society of Surgical Oncology.     

Minimally Invasive Surgical Treatment of Sigmoidal Esophagus in Achalasia

Background  The appropriate surgical intervention for sigmoidal esophagus in the setting of achalasia remains controversial. The objective of this study is to review our experience with minimally invasive myotomy (MIM) and minimally invasive esophagectomy (MIE) in the treatment of these patients. Methods  We reviewed the records of 30 patients (19 men, 11 women); mean age 59.1 years (range 25–83 years) who underwent MIM (n = 24) or MIE (n = 6). Primary variables included perioperative and long-term outcomes. Univariate and multivariate analyses were performed to identify clinical variables predictive of myotomy failure. Results  The operative mortality was zero and median hospital stay was 2 days (MIM) and 7 days (MIE). On follow-up (mean 30.5 months), nine (37.5%) patients undergoing primary MIM had failure requiring redo myotomy (n = 1) or esophagectomy (n = 8). Univariate analysis showed that previous myotomy and duration of symptoms were significant predictors of failure of MIM, with patient age trending toward significance. Multivariate analysis showed age and longer symptom duration to be significant. Conclusions  MIM affords symptomatic improvement in many patients. Age and symptom duration may be preoperative indicators of MIM failure. MIE offers similar symptom relief but is associated with a longer hospital stay. Further prospective studies are required to define the optimum treatment algorithm in the management of these patients. The Society for Surgery of the Alimentary Tract 48th Annual Meeting, Washington DC, May 19–23, 2007.     

Chronic kidney disease in the VACTERL association: clinical course and outcome

Approximately 60% of VACTERL (vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula with atresia, renal defects/radial limb dysplasia) patients have renal anomalies that can be associated with chronic kidney disease (CKD). With improved medical care, a large proportion of these patients survive into adulthood. Longitudinal follow-up data regarding the management of kidney disease in these children is lacking. Twelve VACTERL patients with CKD stage 2–5 and 12 age-matched controls with similar urologic anomalies and CKD [mean follow-up period 15.0 ± 1.4 (SE) and 11.9 ± 2.1 years, respectively] were identified in a single center. Eight VACTERL patients progressed to end-stage renal disease (ESRD) compared to four controls (66.7 vs. 33.3%, respectively). Six VACTERL patients were dialyzed pre-transplant. Of the four patients on peritoneal dialysis (PD), three had to be switched to hemodialysis due to complications, whereas two of the three controls on PD did not experience significant problems. Seven VACTERL patients underwent renal transplantation compared to four controls. Mean creatinine clearance 2 years post-transplant was 65.8 ± 6.3 in VACTERL patients vs. 87.8 ± 7.1 ml/min per 1.73 m² in controls (p = 0.03). VACTERL patients had a significantly lower mean height standard deviation score than the controls (−2.34 ± 0.41 vs. −1.27 ± 0.24, respectively; p < 0.05). Based on these results, VACTERL patients with CKD develop ESRD more frequently, experience more complications with dialysis, may have a poorer transplant outcome, and have more severe growth failure than controls.     

Self-reported quality of life in children and young people with chronic kidney disease

Chronic kidney disease (CKD) would be expected to impact upon the quality of life (QoL) of children and young people; therefore, it is important that they are given the means to express their opinions about how they perceive their own QoL. We used the Generic Children’s Quality of Life Measure (GCQ) in 225 paediatric renal patients (118 male, mean age 13.6 years, range 6.2–18.9 years) from seven UK centres. Of these, 47 were on dialysis (23 on haemodialysis), 128 were post-transplant (47 pre-emptive) and 49 had advanced CKD. A comparison between the 124 renal patients (65 male, mean age 11.2 years) in the same age range as the general population (6–14 years) showed a higher GCQ QoL score for the renal patients (p = 0.02). Analysis of the whole group of renal patients (n = 225) revealed no significant difference between the mean GCQ scores of participants in various treatment modalities (p = 0.26) and no significant differences between gender (p = 0.90) and age group (p = 0.44). The results indicate that young people can perceive their QoL as good despite living with what others may perceive as severe limitations. This may seem counter-intuitive, but QoL is a subjective measure and thus may be difficult to predict from observable limitations (health status). The GCQ is an ideal measure for use in annual departmental audits of generic paediatric QoL and may help to individualise the work of psychosocial teams with each patient.     

Renal function in predialysis children with chronic renal failure treated with erythropoietin

To assess the effect of long-term administration of human recombinant erythropoietin (EPO) on renal function, 11 anemic children aged 1.4 – 17.2 years were followed for 10 – 61 (mean 31) months on treatment. During EPO therapy the mean hemoglobin rose from 8.1 to 11.1 g/dl at the last observation. The final maintenance dose ranged between 70 and 300 U/kg per week. The rate of deterioration of renal function was calculated by comparing the slope of the regression lines of reciprocal serum creatinine values (SCr) derived from a mean of 20 values per patient obtained over 8 – 50 (mean 29) months before and a mean of 24 SCR values during EPO therapy. The individual slopes improved after initiation of EPO therapy in all but 3 patients, but the mean change of slope (from –0.0521 to –0.0299) was not significant. The study suggests that in most children with predialysis chronic renal failure long-term administration of EPO is not associated with accelerated deterioration but rather with delayed deterioration of renal function. Received August 30, 1995; received in revised form November 16, 1995; accepted April 10, 1996     

Hemorrhagic risk factors during beta-lactam antibiotics therapy

Any type hemorrhagic manifestation may occur 12 hours to 5 weeks after the administration of beta-lactam antibiotics. The mechanisms of blood losses proved to be by: 1) immunologic thrombocytopenia (penicillins); 2) alteration of platelet functions (semisynthetic penicillins); 3) hypoprothrombinemia (cephalosporins). The risk factors for the occurrence of hemorrhage under beta-lactam antibiotics therapy are: concomitant administration of cytostatics for a neoplastic malignancy; b) acute or chronic renal failure; c) concomitant treatment for duodenal and gastric ulcer; d) malnutrition; e) dosage and duration of antibiotic administration. The frequency of bleeding under beta-lactams is not determined as yet. A severe case diagnosed at the IIIrd Medical Clinic of Iasi presenting spontaneous daily nasal bleedings that occurred 24 hours after the initiation of the treatment with cephalosporins (Kefurox) is presented. In this patient the risk factor was chronic renal failure.     

Flexible ureteroscopy and holmium laser lithotripsy for treatment of upper urinary tract calculi in patients with autosomal dominant polycystic kidney disease

The objective of the study was to investigate the safety and efficacy of flexible ureteroscopy and holmium laser lithotripsy for the management of patients with autosomal dominant polycystic kidney disease (ADPKD) and associated nephrolithiasis. Between 2005 and 2010, flexible ureteroscopic stone treatment was attempted in 13 patients with ADPKD. Two patients had bilateral renal stones. Most of the stones were located in the renal pelvis and/or calices with a stone size 1.7 cm in the largest diameter. The success rate and morbidity and complications were recorded. A total of 45 intrarenal calculi with a mean stone size of 5.6 mm (range 3–17) were identified. The mean number of stones per patients was 3.2 (range 2–5). The mean number of primary procedures was 1.2 (range 1–2). The overall stone-free rates after one and two procedures were 84.5 and 92.3%, respectively. Complications occurred in three procedures and consisted of low-grade fever in one procedure, flank pain in another procedure and stent pain in another procedure. No patient died. Flexible ureteroscopy with holmium laser lithotripsy is a safe and effective method for the treatment of patients with ADPKD and associated nephrolithiasis.     

Is Electron Beam Intraoperative Radiotherapy (ELIOT) Safe in Pregnant Women with Early Breast Cancer? In Vivo Dosimetry to Assess Fetal Dose

Electron beam intraoperative radiotherapy (ELIOT) is a new technique permitting breast radiotherapy to be completed in a single session. Since ELIOT is associated with much reduced irradiation to nontarget tissues, we carried out a study on nonpregnant breast cancer patients to estimate doses to the uterus during ELIOT to better evaluate the possible use of ELIOT in pregnant breast cancer patients. We performed in vivo dosimetry with thermoluminescence radiation detectors (TLDs) in 15 premenopausal patients receiving ELIOT to the breast (prescribed dose 21 Gy) using two mobile linear accelerators. The TLDs were positioned subdiaphragmatically on the irradiated side, at the medial pubic position, and within the uterus. A shielding apron (2 mm lead equivalent) was placed over the viscera from the subcostal to the subpubic region. TLDs showed mean doses of 3.7 mGy (range 1–8.5 mGy) at subdiaphragm, 0.9 mGy (range 0.3–2 mGy) pubic, and 1.7 mGy (range 0.6–3.2 mGy) in utero, for beam energies in the range 5–9 MeV. These findings indicate that ELIOT with a mobile linear accelerator and shielding apron would be safe for the fetus, as doses of a few mGy are not associated with measurable increased risk of fetal damage, and the threshold dose for deterministic effects is estimated at 100–200 mGy. We conclude that studies on the use of ELIOT in pregnant women treated with conservative breast surgery are justified.     

Acute liver failure due to leptospirosis successfully treated with MARS (molecular adsorbent recirculating system) dialysis

Background Leptospirosis is a re-emerging infectious disease, which may lead to multiple organ failure (MOF)and death. Case presentation We report the first case of severe leptospirosis complicated with acute renal and liver failure, successfully treated with albumin dialysis––molecular adsorbent recirculating system (MARS). Despite antibiotic therapy, optimum medical supportive treatment and timely initiated haemodialysis, the outcome was complicated by severe liver failure: hepatic encephalopathy grade III, hypoglycemia, prominent hyperbilirubinemia (TBIL 31.3 mg/dl, DBIL 28.6 mg/dl)and hepatic cytolysis (ALT 535 IU/l, AST 179 IU/l) and prolongation of the prothrombine time (68.4 sec). The patient underwent two sesions of albumin dialysis with the MARS procedure with complete recovery of hepatic and renal function. Conclusion Albumin dialysis may confer a significant survival benefit on patients with leptospirosis-induced acute liver failure (ALF).     

Renal Toxicity Associated With Resection and Spacer Insertion for Chronic Hip PJI

BackgroundTwo-stage exchange arthroplasty with high-dose antibiotic-loaded bone cement spacer and intravenous (IV) antibiotics is the most common method of managing infected total hip arthroplasties. However, the contemporary incidence, risk factors, and outcomes of acute kidney injuries (AKIs) in this cohort are unknown.MethodsWe identified 227 patients treated with 256 antibiotic-loaded bone cement spacers after resection of an infected primary total hip arthroplasty between 2000 and 2017. Mean age was 65 years, mean body mass index was 30 mg/kg², 55% were men, and 16% had pre-existing chronic kidney disease (CKD). Spacers were in situ for a mean of 15 weeks, concomitantly associated with IV or oral antibiotics for a mean of 6 weeks. AKI was defined as a creatinine ≥1.5X baseline or ≥0.3 mg/dL. Mean follow-up was 8 years.ResultsAKI occurred in 13 patients without pre-existing CKD (7%) vs 10 patients with CKD (28%; OR 5; P = .0001). None required acute dialysis. Postoperative fluid depletion (β = 0.31; P = .0001), ICU requirement (β = 0.40; P = .0001), and acute atrial fibrillation (β = 0.43; P = .0001) were independent predictors for AKI in patients without pre-existing CKD. Duration of in situ spacer, mean antibiotic dose in cement, use of amphotericin B, and type of IV antibiotics were not significant risk factors. At last follow-up, 8 AKIs progressed to CKD, with one receiving dialysis 7 years later.ConclusionAKIs occurred in 7% of patients with normal renal function, with 5-fold greater risk in those with CKD, and 4% did develop CKD. Importantly, causes of acute renal blood flow impairment were independent predictors for AKI.Level of EvidenceLevel III, comparative study.     

Cyclosporin A therapy for Henoch�CSch?nlein nephritis with nephrotic-range proteinuria

To evaluate the therapeutic role of cyclosporin A (CyA) for the treatment of Henoch–Sch?nlein nephritis (HSN), 29 patients (18 boys, 11 girls) with nephrotic-range proteinuria were analyzed retrospectively. Mean age was 8.6 years (range 2.0–15.5 years) at diagnosis of Henoch–Sch?nlein purpura (HSP). All patients had developed the nephrotic-range proteinuria at a mean interval of 4.4 months (range 0–50.7 months) after the diagnosis of HSP. Mean duration of CyA treatment was 12.3 months (range 2.6–55.0 months). Mean follow-up times were 3.7 years (range 1.2–12.9 years) from the beginning of the CyA treatment. Steroids were tapered off and stopped gradually after initiation of CyA. All patients responded to the CyA treatment within a mean of 1.8 months (range 1 week to 3.5 months). Twenty-three patients achieved stable remission with mean follow-up duration of 3.2 years and 6 patients seemed to become CyA-dependent, since they developed proteinuria when the treatment was stopped. Renal function was preserved in all patients but one who developed end-stage renal disease after poor compliance with CyA. We concluded that CyA treatment for HSN showing nephrotic-range proteinuria is very effective and a safe method, although some patients become CyA-dependent.     

Plasmapheresis treatment for recurrent focal sclerosis in pediatric renal allografts

Recurrence of focal segmental glomerulosclerosis (FSGS) in pediatric renal allografts is associated with a poor graft survival. This study reports on plasmapheresis for the treatment of recurrent FSGS in pediatric renal transplant recipients. The records of 100 consecutive pediatric (age <21 years) renal transplants were reviewed. Twenty patients had FSGS as the cause of renal failure. Eight of these (40%) had a recurrence (protein-uria >1 g/m² per day) within 1 month of transplantation. Five of six patients treated with plasmapheresis went into remission (<0.2 g/m² per day), receiving a total of 42±26 (12–73) sessions, with the mean number of sessions required to achieve a remission being 24±17 (8–51). One patient had a second recurrence 1 year following cessation of plasmapheresis and responded to another course of plasmapheresis. The 1 patient who did not respond to plasmapheresis had a delay in initiation of therapy of 42 days. Plasmapheresis initiated within 48 h of recurrence resulted in earlier remissions and improved graft survival among our patients. Plasmapheresis appears to be effective in treating recurrent FSGS following kidney transplantation and should be started as soon as possible. The number of plasmapheresis sessions used to achieve remission should be adjusted according to response rather than adhering to a fixed protocol. Received: 22 November 1999 / Revised: 2 March 2000 / Accepted: 6 March 2000