End-stage renal disease in leprosy

BACKGROUND: Leprosy or Hansen's disease (HAD) undoubtedly remains an emergency in certain countries. It is an ancient deforming disease caused by Mycobacterium leprae. The countries with the highest endemic leprosy rate in 2000 were Brazil, India and Madagascar. In Italy, the old epidemic has been defeated and there are approximately 400 patients under constant monitoring with three to four new cases per year involving Italian residents. The kidney is one of the target organs during the splanchnic localization of leprosy. The histopathological renal lesion spectrum includes glomerulonephritis (GN), renal amyloidosis (RA) and interstitial nephritis (IN). Both proteinuria and chronic renal failure are the main clinical expressions of renal damage in leprosy. To the best of our knowledge, very little is reported concerning end-stage renal disease (ESRD) in leprosy patients both in the most important national and international renal registries and in the available literature. This study aimed to report the long-term experience of our department in this field. METHODS: To achieve this, we analyzed retrospectively the HAD Center (Gioia del Colle) database at ourhospital. RESULTS: Eight leprosy patients were dialyzed from 1980 to June 2003 (six males and two females), with a mean age of 61.0+/-8.9 SD yrs (range: 51-76) and a mean HAD duration of 36.1+/-5.1 yrs. The first clinical nephropathymanifestations were non-nephrotic proteinuria associated with chronic renal failure in four patients, and nephrotic proteinuria in four patients. Kidney biopsies performed in three patients showed two had RA, and one had IN. Two patients were treated initially by peritoneal dialysis; they were then switched to hemodialysis (HD) after 3 and 10 months because of recurrent peritonitis. HD treatment lasted 40.6+/-31.4 months (range: 9-101). Six patients died, one due to hyperkalemia, one because of a technical dialysis accident, and the remainder due to causes unrelated to the dialysis treatment. Two patients are still alive, treated with HD for 17 and 44 months. CONCLUSIONS: Uremia represents a late complication of leprosy and has a multifactorial genesis, although RA is among the most frequent causes, conventional bicarbonate HD appears to offer good results in the treatment of uremia in leprosy patients.     

End-stage renal disease in the Asian-Pacific region

Information on end-stage renal disease (ESRD) is important in assisting health care providers in planning renal replacement therapy. A questionnaire was sent to various countries in the Asian Pacific region and 10 countries responded. Data from Australia and New Zealand was obtained from their registry report. The questionnaire requested information on incidence, prevalence, transplantation rate, demographic data, causes of ESRD, causes of death, and mortality rates for the years 1998 to 2000. All the countries surveyed had national registries and there was a greater than 90% response rate in 7 of 12 countries. The incidence and prevalence rates of ESRD were linked to funding of dialysis, with higher reported rates in countries where dialysis was totally or heavily subsidized by the government. There was an increase in both incidence and prevalence rates between 1998 and 2000, with the mean annual percentage increase of 1.2% to 14.1% for incidence and 4.2% to 17.3% for prevalence. Diabetic nephropathy was the most common cause of ESRD in 9 of the 12 countries surveyed and 6 of the 12 countries had greater than 35% of their dialysis patients age 60 years and older. Peritoneal dialysis (PD) use varied between 3.9% to 81% of the dialysis population and reflected the health care policies of the individual countries. The transplantation rate was influenced by socioeconomic, religious, and cultural attitudes and varied between 3.1 per million population (pmp) to 32 pmp with the percentage of cadaveric transplants ranging between 0% of 85% of total transplants. Cardiovascular mortality remained the most common cause of death in the ESRD patients. Collaboration between the various national registries in the form of specific international studies may yield useful information of ESRD patients in the Asian-Pacific region.     

End-stage renal disease in North Africa

There are many similarities in the profile of chronic renal disease in the five North African countries, reflecting their close resemblance in ethnic background, bioecology and socioeconomic standards. The incidence of renal disease is much higher than that in the West, yet the prevalence is relatively lower, which mirrors the inadequacy of medical care facilities. The principal causes of end-stage chronic renal disease (ESRD) are interstitial nephritis (14 to 32%), often attributed to environmental pollution and inadvertent use of medications; glomerulonephritis (11 to 24%), mostly mesangioproliferative and focal segmental sclerosis; diabetes (5 to 20%) and nephrosclerosis (5 to 21%). Obstructive/reflux nephropathy, attributed to urinary schistosomiasis, is common in Egypt (7%), Libya and Southern Algeria. Primary urolithiasis is a frequent cause of obstructive nephropathy in the western (hyperoxaluria) and middle (cystinuria) regions. The incidence of tuberculosis is increasing, particularly the diffuse interstitial and hematogenous forms. It is responsible also for 10 to 40% of renal amyloidosis. The latter is also frequently associated with familial Mediterranean fever. Sickle cell anemia is an important health problem in the west, leading to a wide range of glomerular and tubulointerstitial nephropathies. Takayasu disease is increasingly recognized as a cause of ischemic nephropathy and renovascular hypertension. The management of ESRD is largely influenced by late referral, co-morbidities and lack of dialysis facilities. Hemodialysis is the most frequent modality of renal replacement therapy (RRT). CAPD is used sporadically. Renal transplantation, largely from live (often unrelated) donors, is offered to less than 5% of patients with ESRD. The reported outcome of RRT generally conforms with international standards.     

End-stage renal disease in liver transplants

Renal dysfunction is one of the most significant problems following orthotopic liver transplantation (OLTx). Since the major risk factor for delayed renal dysfunction following OLTx is presumed to be cyclosporine (CsA) nephrotoxicity, it has been suggested that CsA is the most probably cause of end-stage renal disease (ESRD) in this population of patients. To test this hypothesis the records of OLTx patients in our center who developed ESRD requiring dialysis were reviewed. There were 132 consecutive adult patients with end-stage liver disease (ESLD) who received 146 OLTxs between 1990 and 2000. Five patients (3.4%) developed ESRD requiring dialysis. Four of the five patients developed nephrotic range proteinuria prior to reaching ESRD. Renal biopsy in four patients showed focal segmental glomerulosclerosis, diabetic nephropathy, membranous nephropathy and cyclosporine toxicity. The underlying hepatic and metabolic disease may have played a role in the genesis of glomerular diseases in these OLTx patients. Perhaps if more renal biopsies are performed in OLTx patients with chronic renal failure, we might discover that, although CsA/tacrolimus therapy is a definite risk factor for post-transplantation chronic renal failure, other disease processes may also play a significant role.     

End-stage renal disease in sarcoidosis of the kidney

We describe two cases of black women with biopsy-proven sarcoidosis of the kidney who developed end-stage renal disease. Treatment with high-dose glucocorticoids resulted in a good initial response, followed by progressive deterioration of renal function requiring hemodialysis.     

End-stage renal disease in sub-Saharan and South Africa

The major health problems in Africa are AIDS, tuberculosis, malaria, gastroenteritis and hypertension; hypertension affects about 20% of the adult population. Renal disease, especially glomerular disease, is more prevalent in Africa and seems to be of a more severe form than that found in Western countries. The most common mode of presentation is the nephrotic syndrome, with the age of onset at five to eight years. It is estimated that 2 to 3% of medical admissions in tropical countries are due to renal-related complaints, the majority being the glomerulonephritides. There are no reliable statistics for ESRD in all African countries. Statistics of the South African Dialysis and Transplant Registry (SADTR) reflect the patients selected for renal replacement therapy (RRT) and do not accurately reflect the etiology of chronic renal failure (CRF), where public sector state facilities will offer RRT only to patients who are eligible for a transplant. In 1994, glomerulonephritis was recorded as the cause of ESRD in 1771 (52.1%) and hypertension in 1549 (45.6%) of patients by the SADTR. In a six-year study of 3632 patients with ESRD, based on SADTR statistics, hypertension was reported to be the cause of ESRD in 4.3% of whites, 34.6% of blacks, 20.9% mixed race group and 13.8% of Indians. Malignant hypertension is an important cause of morbidity and mortality among urban black South Africans, with hypertension accounting for 16% of all hospital admissions. In a ten-year study of 368 patients with chronic renal failure in Nigeria, the etiology of renal failure was undetermined in 62%. Of the remaining patients whose etiology was ascertained, hypertension accounted for 61%, diabetes mellitus for 11% and chronic glomerulonephritis for 5.9%. Patients with CRF constituted 10% of all medical admissions in this center. Chronic glomerulonephritis and hypertension are principal causes of CRF in tropical Africa and East Africa, together with diabetes mellitus and obstructive uropathy. The availability of dialysis and transplantation is quite variable in Africa: treatment rates in North Africa are 30 to 186.5 per million population (pmp) in countries with more established programs: Algeria 78.5; Egypt 129.3; Libya 30; Morocco 55.6; Tunisia 186.5 pmp. In South Africa, treatment rates of 99 pmp were reported; Dialysis and transplant programs in the rest of Africa are dependent on the availability of funding and donors. Services are still predominantly urban and therefore generally inaccessible to the poorer, less educated rural patient. There is not enough money for healthcare in the developing world, particularly for expensive and chronic treatment such as RRT. The goal should be to have a circumscribed chronic dialysis program, with as short a time on dialysis as possible, and to increase the availability of transplantation (both living donor and cadaver). Efforts should be made to optimize therapy of renal disease and renal failure globally and particularly in developing countries. Strategies should be developed to screen for and manage conditions such as hypertension and diabetes mellitus at the primary healthcare level in an effort to decrease the incidence of chronic renal failure. Increasingly, health is influenced by social and economic circumstances. Any improvements in health thus demand integrated, comprehensive action against all the determinants of ill health.     

End-stage renal disease and its treatment in Venezuela

In Venezuela there are 3234 new cases (132 per million population [pmp]) requiring renal replacement therapy each year, and only 40% of these are admitted to the different modalities of dialysis. In the year 2000, there were 195 patients pmp in chronic hemodialysis (4700 patients). Diabetes, glomerular diseases, and hypertension account for more than 60% of the patients in chronic dialysis. Gross mortality in hemodialysis is around 20%, and cardiovascular causes are the primary cause of death (39.5%). Hospital admission in the dialysis patients amounts to 4.6 days/patient/year. Rehabilitation is inadequate. Only 45% of the dialysis patients report normal home or work activities. Transplantation in Venezuela has a general graft survival rate of 83% at 1 year (90% for living related grafts) and 50% (64% for living related grafts) at 10 years. Future tendencies include emphasis in preventive strategies, including early detection and treatment of diabetes and hypertension, as well as efforts to increase the rate of renal transplantation.     

End-stage renal disease as the presenting manifestation of renal systemic lupus erythematosus

About one-half of all children with systemic lupus erythematosus have clinical evidence of renal disease at initial presentation, such as proteinuria and acute renal failure. Herein, we report a case of a teenager who presented with end-stage renal disease (ESRD) of uncertain etiology, and who was subsequently determined to have lupus. The purpose of this report is to make health-care professionals aware of this unusual presentation of renal lupus, which has never been reported before. Children presenting in ESRD should be worked-up for autoimmune diseases since the discovery of such a disease process may impact future decision-making, especially with respect to subsequent renal transplantation.     

End-stage renal disease and acute glomerulonephritis in Goajiro Indians

BACKGROUND: Goajiro Indians are a semi-nomad tribe that live on the Goajiro peninsula, in the northwestern part of Venezuela. We investigated the incidence of end-stage renal disease (ESRD) and post-streptococcal glomerulonephritis (PSGN) among Goajiros and to determine if it was increased and whether congenital endowment of low number of nephrons (as indicated by low birth weight) was a contributing factor in their predisposition to chronic renal failure (CRF). METHODS: The incidence of ESRD and the attack rate of poststreptococcal glomerulonephritis (PSGN) among Goajiros during the period December 1991 through December 1998 were evaluated from the records of the University Hospital, in Maracaibo, which is the referral center for Goajiro Indians. Demographic characteristics and birth weight were obtained from the records of the Regional Public Health Service. Subclinical reduction in renal functioning mass was investigated in 11 healthy Goajiros with a standardized tubular stress test that determines the increment in tubular secretion of creatinine (TSCr) resulting from the intravenous administration of a bolus of creatinine. RESULTS: The incidence of ESRD among Goajiros was 220 patients per million inhabitants per year, 1.7 times higher than the incidence for the country. The attack rate of post-streptococcal glomerulonephritis is nearly double among Goajiro Indians (2.9 +/- 1.3 cases/100,000 inhabitants/year) than in the general population in the neighboring Maracaibo city (1.5 +/- 0.3, P < 0.02). Low weight birth was common among Goajiros; as many as 23% of newborns weigh less than 1000 g. The stimulated TSCr in healthy Goajiros was 30% lower than in controls (P < 0.001). CONCLUSIONS: Goajiro Indians have a high incidence of ESRD. A high attack rate of PSGN and low nephron endowment in combination may be responsible, at least in part, for the increased risk of ESRD in this population.     

End-stage renal disease prevention strategies in Latin America

Latin America (LA), defined here as the countries in the Western hemisphere located south of the United States, is a region with a total population of nearly 520,000,000 that increases 1.5% annually and has a human development index of 0.77. The countries that form this region present extreme contrasts. These contrasts are first and foremost within the countries themselves, because extremes of wealth and poverty are present in their social and economic fabric. In addition, in LA a vast variety of government modalities and political systems are represented. Therefore, in order for prevention strategies to be effective, they need to be tailored to the specific characteristics and idiosyncrasies of individual nations. This article will address the following aspects: first, a broad outline of the basic health statistics in LA, with focus on treatment of end-stage renal disease and its derived economic burden. Data from LA countries will be contrasted with 95% confidence interval of corresponding data from 10 industrialized countries (Canada, France, Germany, Italy, Japan, United Kingdom, United States, Spain, Sweden, and Switzerland). Second, we will discuss the prevalence of some risk factors for end-stage renal disease in the nations of the region. For this reason, we will focus on data that provide reliable information. Finally, we will consider general guidelines for the implementation of prevention strategies that may have common applicability in LA countries.     

End-stage renal disease in US minority groups.

Medicare's End-Stage Renal Disease (ESRD) Program makes renal replacement services accessible for the majority of Americans with renal failure. National data from Medicare demonstrate complex and variable patterns of use of renal replacement services among US racial and ethnic groups. The black population has consistently suffered from a greater than 3.5-fold higher rate of treated ESRD than has the white population. The rates of hypertensive, diabetic, and glomerulopathic ESRD are all substantially greater in blacks than in whites, and hypertension has accounted for a far greater proportion of ESRD in blacks than any other diagnosis. There is a paucity of national data on the occurrence of ESRD in Hispanic Americans. However, data from Texas strongly suggest that the incidence rate of treated ESRD is much higher in Mexican Americans than in non-Hispanic whites. Higher rates are apparent for each of the three most important causes of ESRD: hypertension, diabetes, and glomerulonephritis. Native Americans experience ESRD at a rate intermediate between those of whites and blacks, but their rate of diabetic ESRD is higher than in either blacks or whites. However, considerable diversity exists among Native American tribal groups. Significant barriers to the acquisition of preventive care have been identified, especially for blacks. While these barriers to preventive care are accompanied by a significantly impaired health status of the black American population, a specific causal relationship between impaired access to care for blacks and their predisposition to ESRD has not been established.     

End-stage renal disease from glomerulonephritis associated with anti-phospholipid syndrome

Primary anti-phospholipid syndrome (APS) is perceived to be an uncommon disorder, infrequently recognized as a cause of renal disease in childhood. While renal involvement in APS classically manifests as thrombotic events, other renal diseases associated with APS have been reported in adults, including membranous nephropathy and minimal change disease. We report our experience of caring for a child who presented with acute anuric renal failure due to anti-neutrophilic cytoplasmic antibody-negative rapidly progressive glomerulonephritis (RPGN), with concomitant thrombotic microangiopathy (TMA). Recognition of the APS as a cause of the patients TMA facilitated institution of anticoagulation. Our patients renal failure did not improve and the patient remained dependent on dialysis until he was successfully transplanted. The purpose of our report is to make health-care professionals aware of the previously unreported association of pauci-immune RPGN and APS in children; early recognition of APS will allow initiation of anticoagulation to prevent recurrent thromboses and enable successful transplantation.     

End-stage renal disease secondary to renal malignancy: Epidemiologic trends and survival outcomes

Objectives

Loss of renal parenchyma after surgery may contribute to chronic kidney disease; however, the long-term consequences of chronic kidney disease may differ by cause. We analyzed the outcomes of patients with end-stage renal disease (ESRD) based on various medical and surgical causes.