Secondary hyperparathyroidism and acute tubular necrosis following renal transplantation

In the present study we investigated the relationship betweensecondary hyperparathyroidism in renal graft recipients andpost-transplantation acute tubular necrosis (ATN). Patientswere divided into two groups according to graft function: groupA consisted of 28 patients who had an uneventful postoperativeperiod and did not require haemodialysis. Group B comprised26 patients with primary non-function of the graft due to biopsy-provenATN who required continued haemodialysis for the first postoperativeweek or longer (mean 14.2 ±8.7 days). Both groups hadcomparable donor characteristics, HLA-matching and ischaemiatimes. All patients were given cyclospo-rin and low-dose prednisolonefor immunosuppression. Pretransplant levels of intact PTH weresignificantly greater in group B than in group A (203.5 ±193.1pg/ml versus 81.7±45.2 pg/ml, P<0.01). Group B patientshad more transplant biopsies (50 versus 7) and a longer hospitalizationtime (33.4 ± 10.9 days versus 21.9 ± 11.9 days,P<0.01), although serum creatinine on the day of dischargewas higher in group B (1.77 ± 0.51 mg/dl versus 1.5±0.45mg/dl, P<0.05). We conclude that patients with secondaryhyperparathyroidism as assessed by measuring circulating levelsof intact PTH have an increased incidence of ATN.     

肾移植术中心脏容量负荷变化与移植肾急性肾小管坏死的关系

报告30例尸肾移植应用Swan－GanZ导管监测术中如心静脉压（CVP）、平均肺动脉压（PAP）、肺动脉舒张压（PDAP）、肺毛细血管楔压（PCWP），其中5例取心房血放免法测定心房利销多肽（ANP）。根据开放吻合血管时PDAP水平分为一组。结果PDAP＜2kPa组术后第2～3灭血肌酥水平明显高于PDAP≥2kPa组（P＜0．05），且2例发生急性肾小管坏死（ATN）需血透治疗。开放吻合血管时，ANP水平明显比术前高（P＜0．05），提示满意的心脏容量负荷可以促进肾移植早期功能恢复，降低术后ATN发生。ANP对术后肾功能早期恢复起一定作用。     

Biopsy-proven acute tubular necrosis in a child attributed to vancomycin intoxication

Acute renal failure in children treated with vancomycin typically presents with interstitial nephritis. There is debate as to the extent of direct tubular toxicity attributable to vancomycin, especially in the absence of aminoglycoside treatment. We report a case of acute tubular necrosis (ATN) associated with vancomycin toxicity in an 8-year-old boy where there is no likely alternate explanation for toxic or ischemic injury. Treatment with hemodialysis resulted in the elimination of vancomycin from the circulation and subsequent improvement in renal function.     

Withdrawal of cyclosporine in renal transplant recipients with acute tubular necrosis improves renal function

Abstract In this study, patients with acute tubular necrosis (ATN) after renal transplantation were prospectively randomized to either conventional immunosuppression or withdrawal of cyclosporine and replacement with anti‐thymocyte globulin (ATG). The patients treated with cyclosporine withdrawal and ATG had a significantly shorter duration of ATN (8.9 ± 1.5 vs 10.8 ± 1.4 days; P < 0.05) and better renal function (mean serum creatinine on day 5 postoperatively: 740 ± 49 vs 918 ± 73 μmol/l; P < 0.05). The incidence of acute rejection was lower in the patients with cyclosporine withdrawal and ATG. In conclusion, cyclosporine is toxic to the renal allograft with ATN, and withdrawal of cyclosporine shortens the duration of ATN and improves renal function.     

Renal allograft rupture is associated with rejection or acute tubular necrosis, but not with renal vein thrombosis.

BACKGROUND: Whereas rejection was reported to be the most common cause of renal allograft rupture (RAR) in the pre-cyclosporin era, renal vein thrombosis (RVT) is purported to be the main cause of RAR in patients taking cyclosporin. The extremely low incidence of RVT in our series (0.11%) prompted us to analyse our collective with regard to RAR. METHOD: Between 1974 and 1999, 1811 renal transplants were performed. Patients with RAR, defined as a tear of the renal capsule and parenchyma, were identified and possible underlying factors studied. RESULTS: RAR was diagnosed in nine male and five female recipients (0.8%) with a median age of 36 years. Immunosuppression consisted of azathioprine and prednisolone in seven patients and of cyclosporin-based therapy in the seven others. At exploration five grafts were removed immediately: three because of irreversible rejection, one because of deep wound infection, and one with a twisted renal vein. Six of the nine salvaged kidneys have been functioning after a mean observation time of 45 months. In the pre-cyclosporin era RAR was associated with acute rejection in five out of seven cases as compared with only three of the seven on cyclosporin treatment. Core biopsies might have been the cause in three cases. CONCLUSION: RAR is a rare complication after renal transplantation. Acute rejection still represents the most frequent cause of RAR in the cyclosporin era.     

Renal recovery from acute tubular necrosis requiring renal replacement therapy: a prospective study in critically ill patients.

BACKGROUND: Data on the incidence of end-stage renal disease (ESRD) resulting from irreversible acute tubular necrosis (ATN) are controversial. This prospective cohort study was designed to assess the need for short- and long-term dialysis in critically ill patients with severe ATN and to define risk factors for lack of renal recovery. METHODS: 433 consecutive patients with clinically diagnosed severe ATN necessitating renal replacement therapy were enrolled. Eight patients were excluded because renal biopsy revealed another cause of acute renal failure. None of the remaining 425 patients had pre-existing chronic renal insufficiency. Primary outcome criteria were recovery of renal function at discharge and ESRD status at 1 year follow-up. RESULTS: The overall in-hospital mortality of the cohort was 47%. At discharge, 57% of the 226 surviving patients had normal renal function, 33% had mild to moderate renal failure (serum creatinine: 1.3-3 mg/dl) and 10% had severe renal failure (serum creatinine: 3-6 mg/dl). Multivariate analysis showed that neither patient characteristics (age, gender, comorbid conditions), severity of illness (APACHE III, number of failed organs) nor mode and duration of renal replacement therapy were related to recovery of renal function. After 1 year, 76 of the surviving patients had died and in one patient chronic renal failure had progressed to ESRD. CONCLUSIONS: If critically ill patients with normal renal function prior to the renal insults survive the precipitating cause of ATN, the overwhelming majority will recover sufficient renal function.     

尸肾移植术后急性肾小管坏死的回顾性分析(附14例报告)

目的：探讨尸肾移植术后急性肾小管坏死（ATN）的发病因素和防治措施。方法：回顾性分析14例尸肾移植术后ATN患者的临床资料。结果：14例经过透析治疗,肾功能恢复正常。结论：ATN的发生与热缺血时间长、供肾灌注不良、低温保存不当等多因素有关。重视预防可能减少肾移植术后ATN的发生机会。一旦发生ATN,应尽早恢复透析,同时需预防急性排斥反应和其他并发症。     

祖细胞样肾小管细胞在急性肾小管坏死修复中的作用

目的 观察大鼠缺血性急性肾小管坏死（ATN）后肾脏内溴脱氧尿嘧啶核苷（BrdU）及Pax2阳性细胞的动态变化,探讨祖细胞样肾小管细胞在ATN修复过程中的作用。 方法 钳夹SD大鼠左侧肾动脉60 min后再开放血流,建立缺血性ATN模型。给予细胞分裂增殖标记物BrdU负荷,分别于术后第1、3、5、7、14、21、28天收获肾脏标本,进行BrdU和肾源性标记物Pax2免疫组织化学染色,以及BrdU和Pax2、间充质细胞标记物波形蛋白（vimentin）、细胞凋亡标记物活化caspase-3的双重染色,观察BrdU阳性细胞的数量和分布变化。 结果 ATN组术后左肾出现明显的近端肾小管上皮细胞广泛性坏死,BrdU阳性细胞明显增加,第3天达到高峰,显著高于假手术对照组和右肾（P < 0.01）。而右肾BrdU阳性细胞亦显著高于假手术对照组（P < 0.01）。双重染色显示BrdU阳性细胞同时表达Pax2和波形蛋白,但未见同时表达活化的caspase-3。 结论 大鼠在经历缺血性ATN后,肾脏内祖细胞样小管细胞被动员。其修复可能是通过逆分化、增殖和再分化过程来完成的。而细胞因子可能在这过程中起着调控作用。     

亚致死性过氧化氢损伤致肾小管上皮细胞整合素受体分布的改变

目的探讨急性肾功能衰竭（ＡＲＦ）时活性肾小管上皮细胞脱落现象及管型阻塞的机制。方法用猪肾小管上皮细胞株（ＬＬＣＰＫ１）观察亚致死性Ｈ２Ｏ２损伤致细胞与基质粘附性及整合素受体α３分布的改变。结果细胞与基质间粘附力显著降低（Ｐ＜００５），细胞表面整合素受体α３由原先基侧部分布变为半随机分布（Ｐ＜００５）。结论细胞受亚致死性Ｈ２Ｏ２损伤后，可使整合素受体α３分布改变，细胞基质粘附力降低，致使活性细胞脱落和管腔阻塞。     

Renal tubular dysgenesis: the first case reported in Japan

Renal tubular dysgenesis (RTD) is a fatal congenital disease characterized by a defect in the differentiation of the proximal and distal convoluted tubules. This disorder is clinically associated with oligohydramnios, intrauterine growth retardation, and acute renal failure, and the diagnosis is made only at autopsy. We report a very low birth-weight infant with RTD. The infant was delivered at 32 weeks of gestation by cesarian section, because of fetal distress, and weighed 631 g. She had no micturition after birth and developed acute renal failure on day 3 of life. Because ultrasound scan did not show any abnormalities of the kidneys, she was treated aggressively with various blood purification procedures, but she died of sepsis and disseminated intravascular coagulation (DIC) on day 13 after birth. Postmortem examination of the kidneys showed glomerular crowding and undifferentiated tubules. Positive staining of tubular epithelial cells for epithelial membrane antigen supported a diagnosis of RTD. When renal failure occurs in a neonate without any gross morphological abnormalities of the kidneys on ultrasound imaging, RTD should be considered. A review of the literature showed that this is the first case of RTD reported in Japan. Received: June 4, 2001 / Accepted: June 25, 2001     

Acute Renal Failure in Severe Hypothermia

A patient who developed acute renal failure associated with severe hypothermia is reported. Warm peritoneal dialysis was initiated for core rewarming followed by intermittent hemodialysis till he entered the diuretic phase. The factors which led to acute renal failure in this patient included hypovolemia, hypotension, and acute pancreatitis.     

The use of perioperative Doppler ultrasound as a screening test for acute tubular necrosis

For many years Doppler ultrasound has helped to identify the cause of renal allograft dysfunction. However, Doppler examinations were often performed after the onset of acute renal failure. In the present study we used Doppler ultrasound during grafting to follow changes in renovascular resistance. As early as 30 min after the renal artery had been unclamped, the calculated resistance index (RI) at the hilar part of the renal artery was significantly higher in the group of patients who developed acute tubular necrosis (ATN) than in the group of patients with early normalization of renal function (P=0.05). This result did not correlate with raised cold and warm ischemia times and serum creatinine level on discharge in patients who presented with ATN. RI higher than 0.730 min after unclamping allows for an identification of those grafts at greater risk for the development of ATN and should be an indication for the early introduction of intensive therapy.     

Pediatric acute renal failure: outcome by modality and disease

Two hundred and twenty-six children who underwent renal replacement therapy (RRT) from 1992 to 1998 were retrospectively reviewed. The mean age, at the onset of RRT, was 74±11.7 months and weight was 25.3±9.7 kg. RRT therapies included hemofiltration (HF; n=106 children for an average of 8.7±2.3 days), hemodialysis (HD; n=61 children for an average of 9.5±1.7 days), and peritoneal dialysis (PD; n=59 children for an average of 9.6±2.1 days). Factors influencing patient survival included: (1) low blood pressure (BP) at onset of RRT (33% survival with low BP, vs 61% with normal BP, vs 100% with high BP; P<0.05), (2) use of pressors anytime during RRT (35% survival in those on pressors vs 89% survival in those not requiring pressors; P<0.01), (3) diagnosis (primary renal failure with a high likelihood of survival vs secondary renal failure; P<0.05), (4) RRT modality (40% survival with HF, vs 49% survival with PD, vs 81% survival with HD; P<0.01 HD vs PD or HF), and (5) pressor use was significantly higher in children on HF (74%) vs HD (33%) or PD (81%; P<0.05 HD vs HF or PD). In conclusion, pressor use has the greatest prediction of survival, rather than RRT modality. Patient survival in children with the need for RRT for ARF is similar to in adults and, as in adults, is best predicted by the underlying diagnosis and hemodynamic stability. Received: 15 February 2001 / Revised: 5 June 2001 / Accepted: 8 August 2001     

Acute renal cortical necrosis in pregnancy: Clinical course and changing prognosis

Obstetric cortical renal necrosis is a serious complication that can lead to chronic renal failure and the need for chronic dialysis. The aim of renal cortical necrosis therapy is to restore hemodynamic stability, institute early dialytic therapy, and treat the underlying cause of the disease. Most cases of renal cortical necrosis do not recover a normal renal function despite intensive care. We describe the course of a patient who was diagnosed with acute renal cortical necrosis in pregnancy treated with hemodialysis for three years but then she recovered her renal function.