Chronic renal failure after Puumala virus infection

Chronic renal failure has never been described after Puumala hantavirus infection, which usually causes acute renal failure with spontaneous full recovery. We report a 15-year-old boy who presented with Puumala hantavirus infection and initial severe acute renal failure. His renal function gradually improved, but more than 2 years after the acute episode it was still moderately impaired, with a creatinine clearance of about 60 ml/min per 1.73 m² Received: 25 June1998 / Revised: 19 February 1999 / Accepted: 19 February 1999     

Long-term renal allograft function under maintenance immunosuppression with cyclosporin A or azathioprine

In order to evaluate long-term renal graft function, 149 cyclosporin A and prednisolone (CyA/P)-treated renal transplant recipients were compared with 119 azathioprine and prednisolone (Aza/P)-treated patients. Only patients who had a functioning graft for at least 1 year and who were maintained on their initial immunosuppressive protocol were included. The minimum follow-up period was 4 years. Renal graft function was estimated by yearly determinations of serum creatinine and creatinine clearance. The CyA/P-treated patients had a significantly higher serum creatinine and a significantly lower creatinine clearance at every point in time posttransplantation than Aza/P-treated patients (P<0.001). The evolution of renal graft function, as reflected in the line of regression for serum creatinine and creatinine clearance versus time, was estimated for each individual patient. There was an almost stable renal function, as assessed by the median of the slopes of the regression line for serum creatinine versus time in both groups. The median increase in serum creatinine was only 1.4 mol/l per year for Aza/P-treated patients and 2.4 mol/l per year for CyA/P-treated patients (difference NS). The median decline in creatinine clearance was 2.18 ml/min per 1.73 m²/year in the Aza/P group and 1.07 ml/min per 1.73 m²/year in the CyA/P group (P=0.05). In patients with a functioning graft for at least 5 years, creatinine clearance remained unchanged in both groups during the study period. In conclusion, renal graft function, as assessed by measurements of serum creatinine and creatinine clearance, remained essentially unchanged for at least 5 years after transplantation, regardless of the immunosuppressive protocol used. Thus, these data do not indicate a progression with time of the nephrotoxicity observed in CyA-treated patients.     

Renal Function and Serum Albumin at the Start of Dialysis in 514 Chinese ESRD In-Patients

Background. The dialysis population has grown rapidly in recent decades. Despite the high cost and poor outcomes of dialysis treatment for ESRD, there are scant data about the level of renal function and the relationship of renal function and serum albumin at the start of dialysis in Chinese ESRD patients. Method. We report the level of serum creatinine (Scr), glomerular filtration rate (GFR), and serum albumin (Salb) in 514 ESRD in-patients who began their dialysis treatment between January 2001 through December 2007 at two large dialysis centers in Changsha, Hunan, China. Data were obtained through reviewing the case records of all 514 patients. GFR was predicted by an equation developed from the Modification of Diet in Renal Disease Study. In addition, serum albumin was analyzed in relation to levels of predicted GFR. Results. The mean (SD) and median predialysis serum creatinine was 1121.92 ± 458.24 and 1032 μmol/L. The mean (SD) and median predicted GFR was 4.98 ± 2.24 and 4.47mL/min/1.73m². The proportion of patients with predicted GFR of >10, 5 to 10, and <5 mL/min/1.73m² was 3.7, 36.2, and 60.1%, respectively. The mean predicted GFR was significantly lower among younger patients, uninsured patients, unemployed or farmer patients, patients who were employed, students, patients who selected hemodialysis, patients with ESRD caused by diseases other than diabetes, patients with BUN above the mean, and patients with hemoglobulin beneath the mean. Compared with patients who started with GFR >5mL/min, the patients who started with GFR ≤5mL/min had significantly higher plasma urea and creatinine levels but significantly lower creatinine clearance (mL/min per 1.73m²) and parameters of nutritional status, such as serum albumin, body weight, and BMI. Conclusion. A wide variation existed in renal function at the initiation of dialysis in partial Chinese ESRD patients. Most patients start dialysis at very low levels of predicted GFR. The nutritional status in patients who start dialysis early was better than those in patients who start dialysis when GFR ≤ 5mL/min. Further studies are needed to analyze the impact of level of renal function and nutritional status at the start of dialysis on the outcomes of ESRD.     

Renal functional reserve after acute poststreptococcal glomerulonephritis

 We evaluated renal functional reserve (RFR) in 36 patients aged 5 – 21 years, who had recovered from an acute episode of poststreptococcal glomerulonephritis (PSGN) 1 – 16 years previously, without apparent sequelae, as evidenced by normal serum creatinine, blood pressure, and urinary sediment. The control group consisted of 12 children aged 2 – 12 years with recurrent urinary tract infections or nocturnal enuresis, without active infection or anatomical anomalies. The basal creatinine clearance was similar in the PSGN and control groups: 140.0±27.4 ml/min per 1.73 m² and 142.9±15.5 ml/min per 1.73 m², respectively. The RFR in the PSGN group was significantly reduced compared with that of the control group: 18.6±12.9 ml/min per 1.73 m² and 41.1±25.3 ml/min per 1.73 m², respectively (P <0.02). In 7 PSGN patients (19.4%), no RFR was found. In 69% of patients who had recovered from PSGN more than 10 years before the protein loading tests, a significantly reduced RFR (less than 10% of baseline) was found. The same degree of reduction in RFR was found in only 26% of patients who had suffered from PSGN less than 10 years ago. Received May 23, 1996; received in revised form November 11, 1996; accepted November 27, 1996     

Validation of the Center for Medicare and Medicaid Services algorithm for eligibility for dialysis

The Center for Medicaid and Medicare Services (CMS) has recently revised their end-stage renal disease (ESRD) Medical Evidence Report, Medicare Entitlement, and Patient Registration CMS 2728 Form. The modified algorithm calls for the use of formulae to estimate glomerular filtration rate (GFR). The new criterion is defined as estimated GFR of less than 20 ml/min per 1.73 m². GFR is either estimated by Schwartz formula (C_SCH) in children or Modification of Diet in Renal Disease formula (C_MDRD) in adults. The purpose of this communication is to test the validity of the new CMS GFR algorithm in detecting children who need renal replacement therapy. We evaluated two cohorts of children. Group I included single-center data from 626 ¹²⁵I-iothalamate clearance studies (C_IO) that were compared with the simultaneous estimation of GFR by C_SCH. Group II included data on 659 children from the patient incidence registry obtained from the ESRD Network of Texas between February 1996 and October 2003. In group I there were 76 children (76 C_IO) with C_SCH less than 20 ml/min per 1.73 m² of whom 50 (67%) had C_IO less than 15 ml/min per 1.73 m². Of children with C_IO less than 15 ml/min per 1.73 m², 62% had a C_SCH less than 20 ml/min per 1.73 m². The ability of C_SCH greater than 20 ml/min per 1.73m² to predict C_IO greater than 15 ml/min per 1.73 m² (negative predictive value) is 0.95. The number of children who were started on dialysis in Texas within the study period was 659 (group II). The mean C_SCH±SD was 10.8±7.7 ml/min per 1.73 m². Of the patients who were initiated on dialysis, 94% had C_SCH less than 20 ml/min per 1.73 m². The results were sustained when race, gender, age range, and type of diagnosis were considered. The new CMS algorithm provides a good negative predictive estimate of GFR less than 15 ml/min per 1.73 m². Disclaimer The analyses upon which this publication is based were performed under contract number 500–03-NW14 entitled End-Stage Renal Disease Networks Organization for the State Texas, sponsored by the Centers for Medicare and Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare and Medicaid Services, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.     

Adequacy of peritoneal dialysis in children following cardiopulmonary bypass surgery

Acute renal failure requiring renal replacement therapy can complicate cardiopulmonary bypass in children. Peritoneal dialysis has been shown to stabilize electrolytes and improve fluid status in these patients. To assess dialysis adequacy in this setting, we prospectively measured Kt/V and creatinine clearance in five patients (6–839 days of age) requiring renal replacement therapy at our institution. Median dialysis creatinine clearance was 74.25 L/week/1.73m² (range 28.28–96.63 L/week/1.73m²). Residual renal function provided additional solute clearance as total creatinine clearance was 215.97 L/week/1.73m² (range 108.04–323.25 L/week/1.73m²). Dialysis Kt/V of >2.1 (median 4.84 [range 2.12–5.59]) was achieved in all patients. No dialysis-associated complications were observed. We conclude that peritoneal dialysis is a safe, simple method of providing adequate clearance in children who develop acute renal failure following exposure to cardiopulmonary bypass.     

Glomerular function and microalbuminuria in children with insulin-dependent diabetes

Renal function has been evaluated in 45 diabetic children (age 12.5±4 years) with a mean diabetes duration of 4.9±3.5 years. Glomerular filtration rate (GFR; inulin and creatinine clearances), renal plasma flow (RPF; PAH clearance), resting urinary albumin excretion (UAE) were measured and compared with indexes of metabolic control: Hb A₁C and blood glucose values (mean, post-prandial and maximal excursion) on the same day. GFR (inulin clearance) and RPF were significantly increased in the diabetic group (171±31 and 778±172 ml/min per 1.73 m²) compared with controls (124±18 and 631±128 ml/min per 1.73 m²). Both parameters were strongly correlated (r=0.73;P<0.001). Creatinine clearance was not correlated to inulin clearance. Hyperfiltration (inulin clearance above 160 ml/min per 1.73 m²) was noted in 61% of the patients and was independent of diabetes duration. Five diabetic children had a UAE level above 15 g/min. No relationship could be established between UAE and any of the metabolic indexes; GFR was weakly correlated to HbA₁C (r=0.35;P<0.05), to mean (r=0.35;P<0.05) and post-prandial blood glucose (r=0.37;P<0.05). In contrast, there was a strong correlation between GFR and the maximal blood excursion (r=0.62;P<0.001). The study shows that renal abnormalities can be detected with a high frequency in diabetic subjects characterized by both an early onset and a short duration of diabetes and suggests the need for a more systematic evaluation of renal parameters in this population.     

Progression of chronic renal failure in children with dysplastic kidneys

The aim of this study is to describe progression of chronic renal failure (CRF) in children with renal malformations and to study factors influencing this progression. We reviewed retrospectively 176 children with CRF secondary to renal dysplasia, reflux nephropathy or renal obstruction with at least 5 years of follow-up. Serum creatinine was recorded at least every third month, and an estimated glomerular filtration rate (eGFR) was calculated. Number of febrile urinary tract infections (UTI), blood pressure, albuminuria (UaUc), and number of functioning kidneys was also recorded. We found that the development of renal function could be separated into three time periods: (1) During the first years of life, 82% of the children showed early improvement of their kidney function, which lasted until a median age of 3.2 years (median improvement 6.3 ml/year). (2) From the age of 3.2 years until 11.4 years, 52.5% of the studied children showed a stable kidney function, whereas in 47.5%, kidney function immediately started to deteriorate. (3) Around puberty, 42.9% started deterioration in kidney function, whereas 57.1% even after puberty showed a stable function. Patients with UaUc >200 mg/mmol deteriorated faster (−6.5 ml/min per 1.73 m² per year compared with −1.5 ml/min per 1.73 m² per year) in those with UaUc <50 mg/mmol. Children with more than two febrile UTIs, hypertension or an eGFR at onset of less than 40 ml/min per 1.73 m² deteriorated faster than the others. Most children experienced early improvement of kidney function. The further prognosis, early or late deterioration of kidney function or stable function during the whole follow-up, was related to albuminuria, number of febrile UTIs, eGFR at onset of deterioration, hypertension and puberty.     

Frequently relapsing nephrotic syndrome: treatment with mycophenolate mofetil

Long-term treatment with cyclosporin A (CyA) of children with frequently relapsing steroid-sensitive nephrotic syndrome (SSNS) carries the risk of nephrotoxicity. We have analyzed renal function in 23 children with SSNS during CyA therapy. Repeated measurements of glomerular filtration rate (single-shot ⁵¹Cr-EDTA clearance) showed a decline from 131±21 ml/min per 1.73 m² to 116±27 ml/min per 1.73 m² at last follow-up. Similarly, effective renal plasma flow (simultaneous ¹²³I-hippurate clearance) was correlated with duration of CyA treatment, and showed a decline from 980±318 ml/min per 1.73 m² to 724±242 ml/min per 1.73 m². In a pilot study we investigated the effect of mycofenolate mofetil (MMF) in 7 children with a median age of 12.7 years [6 with minimal change nephrotic syndrome (MCNS), 1 with focal segmental glomerulosclerosis (FSGS)] with signs of nephrotoxicity because of long-term CyA therapy. Only 1 patient with SSNS showed a relapse during MMF therapy. In the patient with FSGS, MMF was started in addition to CyA, resulting in complete remission for a follow-up of 28 months. This preliminary study demonstrates that children with MCNS treated with CyA may be successfully converted to MMF without major side effects. In all cases, including FSGS, MMF had a beneficial effect on renal function. These data should be confirmed by a prospective randomized clinical trial.     

Chronic renal insufficiency in children: The 2001 Annual Report of the NAPRTCS

End-stage renal disease (ESRD) is a major cause of morbidity in children. Besides its high cost to society, ESRD carries significant mortality. Chronic renal insufficiency (CRI) often precedes ESRD. Identifying factors that correlate with the rate of progression to ESRD is beneficial in the management of children with CRI. Since 1994 the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) has extended its registry to include children with CRI, defined as creatinine clearance (C_Cr) <75 ml/min per 1.73 m². As of January 2001, our database registered 4,666 children (<20 years of age) with CRI. Data analysis showed that at least 40% of patients entered had congenital urological anomalies; 39% of patients were followed for at least 3 years. Follow-up data showed that 31% of all registered patients progressed to ESRD by the end of the reporting period. There was a correlation between CRI and several co-morbid clinical factors: low hematocrit, hypoalbuminemia, hypocalcemia, hyperphosphatemia, and hyperparathyroidism, and the rate of progression to ESRD. Primary clinical diagnosis and the age at entry into registry were additional factors that correlated with the rate of progression to ESRD. The main cause of hospitalization in this registry was infection, which accounted for 45% of hospital admissions. Growth delay measured by standard deviation score at baseline was –1.40 at the time of registration. Our data suggest potential areas of improved care that could impact the onset of ESRD.A. Tejani is deceased.     

Low-dose cyclosporin A therapy in cadaver renal transplantation in children

Fifty-one pediatric patients undergoing a first cadaveric kidney transplantation were followed for at least 2 years after grafting. They were divided into two groups: those treated with methylprednisolone plus azathioprine (AZA) and those treated with methylprednisolone plus low-dose cyclosporin A (CyA; median dose 109 mg/m² per day ≙ 3.4 mg/kg per day after 1 year). The steroid dosage given was significantly lower in the second group. The 4-year graft survival rate was 68% for the AZA group and 78% for the CyA group. Renal function did not differ significantly in the two groups; after 1, 2, and 3 years, the median 24-h creatinine clearance was 79, 69, and 51 ml/min/1.73 m², respectively, for the AZA group and 78, 63, and 68 ml/min/1.73 m², respectively, for the CyA group. Linear growth was similar in the two groups. We conclude that in pediatric patients the results of low-dose CyA immunosuppression do not differ significantly from those obtained with AZA in terms of graft survival, renal function, or growth.     

Renal function recovery after radical nephroureterectomy for upper tract urothelial carcinoma

Purpose

To understand the longitudinal renal function trends in patients undergoing radical nephroureterectomy (RNU) and identify clinicopathologic characteristics associated with estimated glomerular filtration rate (eGFR) recovery.

Methods

147 patients were available for analysis. Longitudinal eGFR trends were assessed by plotting each patient’s eGFR measurements over time. The patient population was dichotomized using eGFR < 60 ml/min/1.73 m² versus ≥ 60 ml/min/1.73 m². Cumulative incidence and competing risk regression analysis were used to estimate recovery of postoperative eGFR to the preoperative level and identify clinicopathologic characteristics associated with eGFR recovery.

Results

Median age was 68.7 years and median preoperative eGFR was 55.9 ml/min/1.73 m². 63.6% were male and 95.8% were white. The cumulative incidence of eGFR recovery was significantly higher in patients with baseline eGFR < 60 ml/min/1.73 m² compared to those with baseline eGFR ≥ 60 ml/min/1.73 m² (p = 0.01), with recovery rates at 2 years of 56.6% vs. 27.7%, respectively. Multivariable analysis revealed that preoperative hydronephrosis (HR 1.80) and preoperative eGFR < 60 ml/min/1.73 m² (HR 1.87) were associated with increased chance of eGFR recovery.

Conclusion

Over half of patients with preoperative eGFR < 60 ml/min/1.73 m² achieved eGFR recovery within the first 3 years after RNU, and hydronephrosis was a significant predictor of recovery. These findings should be considered when counseling patients regarding chronic kidney disease progression after RNU and timing of perioperative chemotherapy for high risk tumors.

     

Enalapril in children with Alport syndrome

Ten pediatric patients with Alport syndrome received enalapril for 5 years. There were nine boys. Eight patients have the X-linked form of the disease and two the autosomal recessive form. The median age at the start of treatment was 10.25 years. Only one patient was hypertensive. The starting dose of enalapril was 0.05 mg/kg; the target dose was 0.5 mg/kg per day. The median dose given effectively was 0.24, 0.37, 0.45, 0.43, and 0.49 mg/kg per day at years of study 1, 2, 3, 4, and 5, respectively. The median urinary protein/creatinine ratio was 1.58 g/g (range 0.49–4.60) before treatment. This decreased to 0.98, 1.09, 1.35, 1.11, and 1.38 g/g after 1, 2, 3, 4, and 5 years, respectively. The median creatinine clearance at baseline was 100 ml/min per 1.73 m² (range 82–133) and after 5 years 92 ml/min per 1.73 m² (range 22–115). Three patients did not reach the target dose of enalapril because of orthostatic hypotension. One of them was the only patient to develop chronic renal failure within 5 years. The present study indicates that enalapril reduces urinary protein excretion and preserves glomerular filtration in Alport patients as a group. However, there was individual variation, as in most studies of patients with proteinuric nephropathies given inhibitors of the angiotensin-converting enzyme.     

Deferasirox-induced renal impairment in children: an increasing concern for pediatricians

Background

Deferasirox (DFX) is an oral iron chelator with an established dose-dependent efficacy in transfusion-related iron overload. Whereas emerging long-term data confirm the safety of the drug, with transient moderate elevation of serum creatinine level, several authors have reported renal tubular dysfunction. The aim of this study was to evaluate tubular and glomerular function before and after the initiation of DFX therapy in a pediatric patient population.

Methods

Ten children (4 girls, mean age 12.4?±?3.9?years) enrolled in a routine blood transfusion program were treated with 24.8?±?9.6?mg/kg per day of DFX, and renal function was assessed before and 17.2?±?8.9?months after the initiation of DFX therapy.

Results

Prior to treatment with DFX, all patients had a normal glomerular function rate (GFR) (125?±?15?ml/min per 1.73?m²) and normal tubular function. Following the initiation of DFX therapy, the GFR decreased by approximately 20?% with one patient with a GFR of?<80?mL/min per 1.73?m² and seven patients with a GFR of?<100?mL/min per 1.73?m². Two patients experienced a generalized proximal tubular dysfunction whereas nine patients presented at least one sign of proximal tubular dysfunction.

Conclusions

Renal toxicity is a frequent adverse event of DFX treatment, presenting as both glomerular and proximal dysfunction. A routine renal assessment is therefore required to prevent chronic kidney disease that may result from prolonged tubular injury.     

Proteinuria and Rate of Change in Kidney Function in a Community-Based Population

Proteinuria identifies patients at risk for adverse clinical outcomes, but it is unclear whether proteinuria correlates with the rate of renal decline. We examined the association between proteinuria and rate of change in estimated GFR (eGFR) in a cohort of 638,150 adults from a province-wide registry in Alberta, Canada, who had a measure of proteinuria and three or more outpatient serum creatinine measurements over a period of ≥1 year. An adjusted sex-specific linear mixed-effects model was used to determine the rate of change in eGFR per year for patients with normal, mild, and heavy proteinuria, stratified by baseline kidney function (eGFR ≥90, 60–89.9, 45–59.9, 30–44.9, and 15–29.9 ml/min per 1.73 m²). In men, heavy proteinuria and a baseline eGFR of 45–59.9 ml/min per 1.73 m² correlated with a change in eGFR of −2.16 (95% confidence interval [CI], −2.37 to −1.95) ml/min per 1.73 m² per year, whereas mild proteinuria and a baseline eGFR of 30–44.9 ml/min per 1.73 m² correlated with a change in eGFR of −0.51 (95% CI, −0.70 to −0.32) ml/min per 1.73 m² per year. Similar trends were observed for female, elderly, and diabetic patients. Notably, normal protein levels and a lower baseline eGFR (15–29.9 ml/min per 1.73 m²) correlated with stable or improved renal function. In conclusion, our results suggest that proteinuria of increasing severity is associated with a faster rate of renal decline, regardless of baseline eGFR, and the combined effect should be considered in patients with CKD.Reduced kidney function is a marker of adverse clinical outcomes.^1,2 Emphasis has been placed on early detection and implementation of strategies to slow the diminution of kidney function, despite a limited understanding of the rate of change in kidney function and factors affecting progression. Although previous studies have examined progression of kidney function, these reports were predominantly based on selected patient populations (older adults) or involved a relatively small number of participants.^3–6The presence of proteinuria, a marker of kidney damage, identifies patients at increased risk of adverse clinical outcomes, including progression to ESRD.^7–12 However, whether the effects of proteinuria on earlier signs of kidney damage, namely the rate of change in estimated GFR (eGFR), vary by baseline level of kidney function is less clear. A more detailed understanding of the relationship among proteinuria, kidney function, and progression of renal disease would permit the identification of those who are at greatest risk of a progressive decline in kidney function and aid in implementation of interventions to slow the progression or prevent the development of ESRD.We sought to determine the association between proteinuria and rate of change in eGFR among a large cohort of individuals receiving routine care in a single Canadian province. We also evaluated whether the association between proteinuria and rate of change in eGFR varied by baseline level of kidney function, and among prespecified subgroups stratified by sex, age, and diabetic status.     

Renal Functional Reserve in Pregnancy

Creatinine clearance has been evaluated under baseline conditionsand after acute protein load in five normal and 29 pregnantwomen at different stages of pregnancy without evidence of renaldisease. After a 3-h period in which creatinine clearance wasmeasured hourly (resting GFR), a meal containing 80 g of proteinswas administered and creatinine clearance was measured hourlyfor 4 h (test GFR). Resting GFR in normal sub jects averaged104±22.5 ml/min per 1.73m², the wide variation beingdue to different dietary, protein intake (from 0.3 to 1.2 gof protein per kg body weight). In the pregnant women the resting GFR increased progressivelyfrom the first month (99.8±12.8m1/min per l.73m²) tothe last month of gestation (149.6±12.5 ml/min per 1.73m²) All subjects showed a significant increase of GFR afterprotein load although the greatest difference between the restingand the test GFR was detected in the first trimester. Inulinclearance was also measured in seven subjects after proteinloading to compare creatinine and inulin clearance values. Thetwo clearance values did not differ significantly, showing thatcreatinine can be safely used as a reliable marker for measuringGFR. Test GFR averaged 163.3±4.1 mI/min per 1.73 in normalsubjects and l63.8±6.5 ml/min per l.73m² in pregnantwomen without any relationship with the stage of pregnancy.The identity of test GFR both in normal subjects and in pregnantwomen suggests that this parameter is likely to be related tothe functioning renal mass, and represents the filtration capacityof the kidney. The difference between the test GFR and the resting GFR representsthe renal functional reserve. The progressive increase of theresting GFR during pregnancy suggests a progressive utilisationof the renal functional reserve under the stimuli of gestation.It is evident that only subjects with intact renal functionalreserve may increase their GFR during pregnancy, under specificmetabolic requirements. Acute protein load might be used, therefore,as a simple test to evaluate renal functional reserve and topredict the renal response during future pregnancies. Sincethe test may detect the existence of renal disease even in theearly phases when the reduction of the functioning nephronsis not clinically evident, it might be utilised in some casesto prevent or predict possible pregnancies at risk.     

Facteurs prédictifs de dysfonction rénale postopératoire après arthroplasties totales de hanche

Introduction

Postoperative renal dysfunction (PRD) is well-documented after cardiovascular surgery but there are only limited available data concerning major orthopedic surgery, although patients may have several risk factors prone to impair renal function. We designed an epidemiologic prospective study to assess the incidence of PRD after total hip arthroplasty (THA) and to determine risk factors.

Patients and methods

Were included in the study 755 patients scheduled for THA in a single centre, over a 14 months period. Thirty-one demographic, clinical and biological parameters were collected for each patient. PRD was defined by a value of glomerular filtration, determined by the Cockroft and Gault formula ≤ 60 ml/min per 1.73 m², on the seventh postoperative day. Risk factors were determined by univariate and then multivariate analyses using a linear regression model.

Results

Pre- and postoperatively (POD7), respectively 22.4% and 31.4% of the patients, had a creatinine clearance less than 60 ml/min per 1.73 m². Univariate analysis documented age, ASA score, diabetes mellitus, chronic hypertension, the use of diuretics and NSAID, anemia, and an increased value of plasma urea as risk factors. Risk factors documented by multivariate analysis were: preoperative creatinine clearance less than 60 ml/min per 1.73 m², (OR: 5.8, 95% confidence interval: [1.6–8.1], p = 0.0006), preoperative plasma urea greater than 7.49 mmol/l (2.1 [1.4–11.1], p = 0.04), age above 70 years (1.8 [1.1–4.3], p = 0.02), and duration of NSAID's treatment beyond 5 days (3.2 [1.4–7.1], p = 0.02).

Conclusion

PRD is common after THA and is prone to develop in aged patients with comorbidities. Duration of NSAID's administration should be limited in those patients.     

Growth failure associated with sirolimus: case report

An 11-year-old girl, who was a renal transplant recipient, developed linear growth failure associated in time with sirolimus (SRL) treatment. After 5 years of functional graft [creatinine clearance (CCr) 90 ml/min per 1.73 m² body surface area], she developed acute renal failure due to calcineurin inhibitor-related hemolytic uremic syndrome, and cyclosporine A was replaced by SRL. Before the drug change, she had been growing normally (5.5 cm/year) and had reached the 33.9 percentile (P) of height (z-height −0.41), similar to her target. Two years later, her height had decreased to P 6th (z-height −1.54), as her growth velocity had diminished to 2.2 cm/year, despite optimal renal function (CCr 68 ml/min per 1.73 m²). Human recombinant growth hormone was needed to promote her catch-up growth and achieve the P 49th of height (z-height −0.03). SRL may have deleterious effects on growing children due its characteristic anti-proliferative and anti-angiogenic properties. Pediatric transplant recipients’ linear growth should be cautiously monitored while they are being given SRL.     

Delayed Recovery of Renal Function After Donor Nephrectomy

Background

Many living kidney donors are still at risk of chronic kidney disease (CKD) 1 year after nephrectomy. Although some donors still experience poor renal function, many exhibit delayed recovery of renal function afterwards. We studied the factors related to delayed recovery of renal function in patients with CKD at 1 year after nephrectomy.

Renal function during and after childhood acute poststreptococcal glomerulonephritis

It is still debatable whether acute poststreptococcal glomerulonephritis (APSGN) can lead to permanent renal impairment. The clinical, immunological, and histological findings during the acute disease have been described thoroughly, however, the hemodynamic events are still poorly understood. In this retrospective study, the inulin and p-aminohippurate clearances were measured to evaluate glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) within a month of onset of the disease (acute stage) in 26 children, and 2–12 months after onset (follow-up) in 22 children with APSGN. During the acute stage, the mean GFR was 77±23 (SD) ml/min per 1.73 m², the mean ERPF 537±138 ml/min per 1.73 m², and the filtration fraction (FF) 14%±3%, compared with values for controls of 115±11 ml/min per 1.73 m², 607±72 ml/min per 1.73 m², and 19%±2%, respectively (n=42). At follow-up, GFR was 114±15 ml/min per 1.73 m², ERPF 600±68 ml/min per 1.73 m², and FF 19%±3%. Thus, during the disease both GFR and ERPF fell below values for controls, but later were restored. The GFR, however, was more reduced than the ERPF, as indicated by the reduced FF. This might reflect a relative hyperperfusion of individual nephrons, which might start processes later deleterious to the nephrons. This finding, however, needs to be further investigated and we have therefore started a long-term follow-up of these patients. Received: 24 June 1998 / Revised: 4 December 1998 / Accepted: 7 December 1998