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Objectives:The mechanisms of cardiac allograft vasculopathy and its predisposing factors are multifactorial and as yet not well established. To determine the influence of endothelial dysfunction on the development of intimal thickening, we prospectively analyzed the vasomotor response to acetylcholine and nitroglycerin, as well as other donor and recipient variables. Findings were correlated with the coronary intimal thickness, which was evaluated by means of intravascular ultrasonography. Methods:Nineteen patients who had undergone heart transplantation 4.89 ± 2.35 years previously and who had angiographically normal coronary arteries were included. Endothelial function was analyzed by quantitative coronary analysis of the vasomotor response of the left anterior descending artery to acetylcholine. An intimal thickness index, reflecting the percentage of intima obstructing the coronary lumen, was calculated. Results:Nine (47%) patients showed endothelial dysfunction, and the remaining 10 (53%) patients had a normal response. Four (44%) of 9 patients with a weight gain of greater than 20% after the operation showed endothelial dysfunction compared with none of the 10 patients with normal responses (P<.04). The severity of the intimal thickness correlated with the years after transplant (r= 0.45, P<.05). Patients with endothelial dysfunction had more intimal thickening than those without (32% ± 17% vs 17% ± 12%, respectively; P<.05). Furthermore, the degree of intimal thickening correlated with the magnitude of the vasomotor response to acetylcholine (r= –0.60, P=.006). No relationship was found between intimal thickness and the vasodilatory response to nitroglycerin. As independent variables for intimal thickness, multivariate analysis detected the magnitude of the response to acetylcholine (P=.0005), years after transplant (P=.01), and ischemic time (P=.03). Conclusions:Cardiac allograft vasculopathy is a multifactorial disease the severity of which increases over time. Endothelial dysfunction is a predictive factor of intimal thickening severity. Predisposing factors that provoke endothelial injury, such as perioperative ischemic time and obesity, may contribute to the development of allograft vasculopathy.

Background: Because myocardial damage determines morbidity and outcomes in heart transplant rejection, assessment of total burden of myocardial damage is highly desirable. In addition to myocyte necrosis, programmed cell death, or apoptosis, has recently been shown to contribute to cardiac allograft rejection. In the present study, we noninvasively determined myocardial damage by antimyosin scintigraphy and compared it with necrotic and apoptotic myocardial damage in endomyocardial biopsy (EMB) specimens. Methods and Results: Forty scintigraphic and histologic studies were simultaneously performed. Of these, 19 patients had no EMB evidence of allograft rejection (group I, International Society of Heart and Lung Transplantation [ISHLT] grade 0/4), 12 had mild rejection (group II, ISHLT grades 1A and 1B), and 9 had evidence of moderate allograft rejection (group III, ISHLT grades 2, 3A, and 3B). None of the biopsies demonstrated severe allograft rejection (ISHLT grade 4/4). The severity of global myocyte damage in 40 patients was assessed by antimyosin scintigraphy. Endomyocardial biopsies were performed in these patients within 48 hours of imaging study; biopsy specimens were characterized for presence of myocyte necrosis and apoptosis. Evidence of myocyte necrosis was observed in 9 (23%) of 40 EMB specimens. Nineteen EMB specimens of group I had no inflammation and no myocyte necrosis, 12 of group II specimens showed interstitial mononuclear cell infiltration (only) but no myocyte necrosis, and all 9 of group III specimens had evidence of cellular infiltration and myocyte damage. Myocyte necrosis was assessed by hematoxylin-eosin and trichrome staining of EMB specimens. On the other hand, apoptosis of myocytes, as assessed by TUNEL staining of DNA fragments, was seen in 22 (55%) of the 40 biopsy specimens: 47%, 58%, and 67% in groups I, II and III, respectively. Abnormal antimyosin scan findings, indicating presence of myocardial damage, were observed in 9 of the 19 patients in group I and in all patients in groups II and III. Although positive antimyosin scan results in group III patients are concordant with the presence of histologic myocardial necrosis, myocardial uptake of antimyosin antibodies in groups I and II (no apparent myocyte damage at light microscopic examination) could reflect either sampling error of the biopsy or ongoing apoptotic myocyte damage. Conclusions: Apoptosis of myocytes is frequently observed during cardiac allograft rejection. The presence of apoptotic myocytes in the absence of histologic rejection activity in patients with antimyosin uptake suggests that apoptosis could be an additional mechanism of transplant-associated myocardial damage.

Las lesiones tricuspídeas secundarias a traumatismos cerrados del tórax son raras y difíciles de diagnosticar. No obstante, han sido descritos más de 100 casos de insuficiencia tricuspídea postraumática en los últimos 35 años. Presentamos tres casos diagnosticados e intervenidos en nuestro centro en los últimos 8 años.

Objectives. We sought to determine the prevalence, intensity and evolving changes of myocardial damage detected by myocardial uptake of antimyosin antibodies in patients with alcohol-induced dilated cardiomyopathy, alcohol addicts attending a detoxification unit and healthy subjects with short-term alcohol consumption.

Iatrogenic coronary artery stenosis as a serious complication of aortic valve procedures is a difficult condition to solve. We present a case in which both ostia were involved. As the patient refused reoperation, percutaneous transluminal coronary angioplasty (PTCA) was used.

In view of the current controversy about the relative merits of subtotal versus total parathyroidectomy plus autograft for the treatment of parathyroid hyperplasia, we reviewed the results of subtotal parathyroidectomy in 6 patients with hyperparathyroidism after successful renal transplantation. All had normal renal function and hypercalcemia (mean 11.4 mg/100 ml). The time elapsed between renal transplantation and parathyroidectomy ranged from 3 months to 10 years (mean 42 months). The indications for subtotal parathyroidectomy were: severe acute hypercalcemia after transplantation (1 case), persistent asymptomatic hypercalcemia (2 cases), allograft lithiasis (2 cases), and bone disease (1 case). Subtotal parathyroidectomy was performed, aiming to leave about 30–50 mg of parathyroid tissue, and included a routine transcervical thymectomy. The weight of resected tissue ranged between 0.6 and 2.4 g per patient (mean 1.58 g). Immediate control of hypercalcemia was achieved in all cases. No patient needed replacement therapy with calcium and/or vitamin D after the operation. The 6 patients were followed from 8 months to 4.5 years (mean 34 months) and all had normal calcium, phosphate, and alkaline phosphatase serum values at the time of their last visit. A reappraisal of the surgical indications for hypercalcemia after renal transplantation is needed because severe longterm complications (allograft lithiasis) may develop in patients with minimal hypercalcemia. Subtotal parathyroidectomy is a good operation for treating hyperparathyroidism in patients with functioning renal allografts.

In view of the current controversy about the relative merits of subtotal versus total parathyroidectomy plus autograft for the treatment of parathyroid hyperplasia, we reviewed the results of subtotal parathyroidectomy in 6 patients with hyperparathyroidism after successful renal transplantation. All had normal renal function and hypercalcemia (mean 11.4 mg/100 ml). The time elapsed between renal transplantation and parathyroidectomy ranged from 3 months to 10 years (mean 42 months). The indications for subtotal parathyroidectomy were: severe acute hypercalcemia after transplantation (1 case), persistent asymptomatic hypercalcemia (2 cases), allograft lithiasis (2 cases), and bone disease (1 case). Subtotal parathyroidectomy was performed, aiming to leave about 30–50 mg of parathyroid tissue, and included a routine transcervical thymectomy. The weight of resected tissue ranged between 0.6 and 2.4 g per patient (mean 1.58 g). Immediate control of hypercalcemia was achieved in all cases. No patient needed replacement therapy with calcium and/or vitamin D after the operation. The 6 patients were followed from 8 months to 4.5 years (mean 34 months) and all had normal calcium, phosphate, and alkaline phosphatase serum values at the time of their last visit. A reappraisal of the surgical indications for hypercalcemia after renal transplantation is needed because severe longterm complications (allograft lithiasis) may develop in patients with minimal hypercalcemia. Subtotal parathyroidectomy is a good operation for treating hyperparathyroidism in patients with functioning renal allografts. En vue d'apprécier les mérites relatifs de la parathyroïdectomie subtotale et de la parathyroïdectomie totale suivie d'autogreffe pour traiter l'hyperplasie parathyroïdienne, nous avons étudié les résultats de la parathyroïdectomie subtotale chez six malades qui présentaient un hyperparathyroïdisme après transplantation rénale suivie de succès. Tous les six présentaient une fonction rénale normale et une hypercalcémie (moyenne 11,4 mg%). Le temps écoulé entre la greffe et la parathyroïdectomie allait de 3 mois à 10 ans (moyenne 42 mois). Les indications de la parathyroïdectomie subtotale furent les suivantes: hypercalcémie aiguë intensive après la greffe (1 cas), hypercalcémie asymptomatique persistante (2 cas), lithiase au niveau du greffon (2 cas), atteinte osseuse (1 cas). La parathyroïdectomie subtotale consista à laisser en place seulement 30–50 mg de tissu parathyroïdien et fut complétée par une thymectomie systématique par voie cervicale. Le poids du tissu réséqué allait de 0,6 à 2,4 g (1,58 g en moyenne). Le contrôle immédiat de l'hypercalcémie en résulta dans tous les cas. Aucun opéré n'eut besoin de recevoir du calcium et/ou de la vitamine D après l'intervention. Les six malades ont été suivis de 8 mois à 4,5 ans après l'intervention (34 mois en moyenne). Tous présentaient lors de leur dernière visite un taux normal de calcium, de phosphate et de phosphatase alcaline. Une nouvelle appréciation des indications chirurgicales concernant l'hypercalcémie secondaire à la transplantation rénale est nécessaire en raison des complications graves à long terme (lithiase au niveau du transplant) qui peuvent se manifester chez les greffés qui présentent une hypercalcémie discrète. La parathyroïdectomie subtotale est une bonne opération pour traiter l'hyperparathyroïdisme chez les sujets dont la greffe rénale présente des fonctions satisfaisantes. En vista de la actual controversia sobre los méritos relativos de la paratiroidectomía subtotal versus la paratiroidectomía total con autotransplante en el tratamiento de la hiperplasia paratiroidea, hemos revisado los resultados de la paratiroidectomía subtotal en seis pacientes con hiperparatiroidismo después de transplante renal. Todos exhibieron función renal normal e hipercalcemia (promedio 11,4 mg%). El lapso entre el transplante renal y la paratiroidectomía osciló entre 3 meses y 10 años (promedio 42 meses). Las indicaciones para paratiroidectomía subtotal fueron: hipercalcemia aguda severa después del transplante (1 caso), hipercalcemia asintomática persistente (2 casos), litiasis en el transplante (2 casos) y enfermedad ósea (1 caso). La paratiroidectomía subtotal fue realizada dejando un remanente de 30–50 mg de tejido paratiroideo y comprendió una timectomía transcervical rutinaria con el objeto de incluir posibles cuarta glándula “ausente” o glándulas supernumerarias. El peso de los tejidos resecados varió entre 0,6 y 2,4 g por paciente (promedio 1,58 g). Control inmediato de la hipercalcemia fue logrado en todos los casos. Ningún paciente requirió terapia de reemplazo con calcio y/o vitamina D después de la operación. Los seis pacientes fueron seguidos desde 8 meses hasta 4,5 años (promedio 34 meses) y todos presentaban valores séricos normales de calcio, fosfato y fosfatasa alcalina en el momento de su última visita. Es necesario hacer una reevaluación de las indicaciones quirúrgicas en el manejo de la hipercalcemia después de transplante renal, puesto que severas complicaciones a largo plazo (litiasis en el transplante) pueden desarrollarse en pacientes con mínima hipercalcemia. La paratiroidectomía subtotal es una buena operación para el tratamiento del hiperparatiroidismo en pacientes con alotransplantes renales funcionantes.

Between May 1983 and April 1986, 318 patients underwent cardiac valve replacement with the Monostrut Björk-Shiley prosthesis. There were 136 aortic valve replacements, 128 mitral valve replacements, and 54 multiple replacements. A total of 373 valves were implanted. Associated procedures were done in 79 (25%) of the patients. Hospital (30-day) mortality rate was 5.6% (18 patients): 2.9% (n = 4) after aortic, 7.8% (n = 10) after mitrals and 7.4% (n = 4) after multiple valve replacement. Follow-up was obtained in all 300 operative survivors, for a total of 500 patient-years (mean 18 months). Actuarial survival rate, excluding operative deaths, at 4 years was 94.7% ± 1.5% (mean ± standard error of the mean). There were 16 thromboembolic episodes (3.2/100 patient-years). Freedom from all valve-related complications was 87% ± 2.4% at 3½ years. Neither valve thrombosis nor structural failure has been observed. Eighty percent of the patients are in New York Heart Association functional class I. Forty-two patients (26 with aortic and 16 with mitral valve replacement) underwent cardiac catheterization a mean of 6½ months after the operation. In the aortic position, peak gradients were an average of 6.9 ± 1.2 mm Hg. Mean systolic gradients were 12.4 ± 6.3 mm Hg and did not increase with exercise. In the mitral position, end-diastolic gradients were an average of 2.1 ± 2 mm Hg and mean gradients, 5.9 ± 2 mm Hg. Discharge coefficient (estimated orifice area/geometric area) was 0.63 ± 0.2 for the aortic and 0.53 ± 0.2 for the mitral prostheses. Disc opening was maximal in most patients. These results indicate that the Monostrut prosthesis has a low rate of thromboembolic events, no structural failures or thrombotic obstructions and excellent hemodynamic performance, especially in the small aortic sizes (discharge coefficient for 19 and 21 mm valves, 0.77).

Con base en la estructura ventricular, evidenciadaa nivel macroscópico por unos trabajos anatómicosllevados a cabo en esta segunda mitad del presentesiglo, se sugieren cuatro procedimientosquirúrgicos para, con un mínimo de invasividad, lograruna eficiente remodelación ventricular en el tratamiento de la miocardiopatía dilatada.

A method of lymphocyte labeling with 111In-oxine was applied for the diagnosis of acute kidney-graft rejection. After the injection of labeled lymphocytes, scintigrams of the graft area, contralateral iliac fossa, and spleen were obtained. Indexes of activity were calculated. No patient without rejection (n=3) showed lymphocyte graft deposition. Twenty-two patients with acute graft rejection and two patients with on abdominal-wall abscess over the graft area showed lymphocyte graft trapping. When acute graft rejection was present, index i (graft/contralateral iliac fossa) increased, and index c (spleen/graft) decreased. The improvement after the rejection crisis occurred parallel to the decrease in index i. Index c remained unchange regardless of rejection evolution. In summary, 111In-oxine-labeled lymphocytes may be used for the diagnosis of acute kidney-graft rejection and for evolving control.

Objectives. The present study was undertaken to prospectively and comparatively evaluate the role of serial myocardial perfusion imaging and coronary angiography for the detection of early vasculopathy in a large patient population and also to determine the short- and long-term efficacy of augmented immunosuppressive therapy in the potential reversal of the early vasculopathy.

A 21-month-old girl with Marfan’s syndrome developed heart failure due to severe mitral regurgitation, which was controlled with medical therapy for 12 months. The mitral valve was excised and replaced with a No. 21 Björk-Shiley prosthesis. The child made an uneventful recovery and is doing well 8 months after the operation.

Beta adrenergic blockade at the time of direct coronary revascularization has theoretical disadvantages and is considered by some to be dangerously depressing to the myocardium in the immediate period after pump oxygenation. A review of 100 consecutive cases of bypass surgery revealed that 25 patients had been taking propranolol to within 24 hours or less before surgery in dosages ranging from 40 to 200 mg. per day. The over-all operative mortality rate was 2 per cent. Neither of the patients who died had been receiving propranolol. Seven of the patients taking the drug required emergency surgery for the preinfarction state. In this group the doses were largest and most proximate to surgery. Nevertheless, none of these patients died. The magnitude of surgery was similar in elective and emergency settings and in those with and without propranolol therapy. We have concluded that coronary revascularization is safe in patients receiving propranolol so long as complete revascularization is done.

Background. Aprotinin reduces blood loss in operations done with cardio-pulmonary bypass, whereas the use of desmopressin remains controversial. We compared aprotinin, desmopressin, and placebo in a double-blind, randomized trial to evaluate bleeding and transfusion requirements. Methods and results. One hundred forty-nine patients (48 received aprotinin, 50 desmopressin, 51 placebo) were included. Blood loss and transfusion requirements were recorded and levels of Factor VIII coagulant activity, von Willebrand's factor, thrombin-antithrombin complexes, and D-dimer were measured. Overall blood loss was 195 +/- 146 ml/m^2 in the aprotinin group, 400 +/- 192 ml/m^2 in the desmopressin group, and 489 +/- 361 ml/m^2 in the placebo group (95% confidence intervals: difference between desmopressin and aprotinin 98 to 312 ml/m^2, p < 0.001; difference between placebo and aprotinin 190 to 398 ml/m^2, p < 0.001). Twenty-six percent of patients treated with aprotinin, 66% of those treated with desmopressin, and 56% of those treated with placebo were given transfusion (95% confidence intervals: difference between aprotinin versus placebo plus desmopressin 51% to 71%, p < 0.001). Fibrinolytic activation throughout cardiopulmonary bypass was markedly higher with placebo or desmopressin administration. D-dimer level correlated with overall blood loss in patients receiving desmopressin or placebo, but not in those receiving aprotinin. Conclusion. Aprotinin administration reduces blood loss and transfusion requirements in cardiopulmonary bypass. This benefit may be explained by a lower activation of fibrinolysis.

Hyperparathyroidism associated with renal failure is due to chronic parathyroid stimulation by hypocalcemia, which, in turn, results from hyperphosphatemia and low circulating 1,25(OH)2D3. If prophylactic measures and medical treatment of hyperparathyroidism fail, parathyroidectomy should be performed to prevent the progression of bone disease. Resolution of renal hyperparathyroidism is often seen after kidney transplantation, but some hypercalcemic patients require prophylactic or therapeutic parathyroidectomy. Hypocalcemia is the most common complication after parathyroidectomy. Our long-term results with subtotal parathyroidectomy are satisfactory. Total parathyroidectomy plus parathyroid autograft should be used in selected cases.

We report 5 cases of renal allograft rupture in which diagnosis was established early through clinical data, laboratory tests and echography. Immediate surgery confirmed the suspicion in all cases. Acute rejection was present in 4 patients and in 1 the previous surgical puncture from the perirenal collection demonstrated serohematic fluid with a biological character similar to that of lymph. This latter case seemed to confirm the suspicion that any process associated with edema in a kidney with obstructed lymphatic tracts (meticulous lymphatic ligatures during donor extraction) is capable of causing a rupture.

The association of xanthogranulomatous pyelonephritis and systemic amyloidosis is extremely rare. To our knowledge, despite innumerable cases of xanthogranulomatous pyelonephritis reported in the literature, this association has been described on only 2 occasions. Clinical, analytical and radiographic findings can be highly suggestive of the diagnosis. We report on 2 patients with xanthogranulomatous pyelonephritis, systemic amyloidosis and the nephrotic syndrome: 1 died 4½ years after diagnosis and 1 was stable with good general health 3 years after diagnosis. The clinical aspects as well as the treatment given to both patients are discussed. We describe the natural history of an association that due to its rarity is not currently well known.

One hundred patients who underwent elective cardiac operations were randomized into two groups. Group 1 had a 20 μm nylon screen filter in the arterial line. In Group 2 no filter was used in the arterial line. Neurologic and neuropsychologic examination of the patients was performed with seven psychometric tests of the Wechsler Memory Scale and the Wechsler Adult Intelligence Scale. These tests were conducted before and a mean of 10 days after the operation. Platelet counts and hemoglobin and total protein levels were measured at the onset and at the end of cardiopulmonary bypass. Two patients died during their hospital stay. Neurologic damage with focal signs was found in the postoperative examination in six patients (three in each group). Twenty-eight patients (28.5%) exhibited signs of mild cerebral dysfunction as assessed by the presence of archaic (primitive) reflexes. Fifteen were in Group 1 and 13 in Group 2 (no significant difference). Sixty patients (61%) had decrements greater than one standard deviation in at least one of the three tests that showed most decreased postoperative scores. There were 32 in Group 1 and 28 in Group 2 (no significant difference). When each test was analyzed individually, there were no significant differences between the two groups. Platelet counts decreased, during cardiopulmonary bypass, a mean of 33% in Group 1 and 34.5% in Group 2 (no significant difference). Both hemoglobin and total protein levels remained virtually unchanged. These results indicate that the addition of a small-pore filter in the arterial line does not prevent the neurologic and neuropsychologic disturbances frequently encountered after cardiopulmonary bypass. The filter itself does not appear to have a direct effect on the blood components. Routine use of an arterial line filter remains questionable.

Although a commonly performed technique, heterotopic renal transplantation may be a cause of late graft failure owing to ureteral stenosis, urinary fistula and vesicoureteral reflux secondary to the immune response. The new retroperitoneal lumbar approach to the splenic vessels has allowed the orthotopic technique to be developed using the splenic artery or aorta, the renal vein and a pyelo-pyelic anastomosis. In this manner the renal graft is located in an anatomical position that is well protected, and with the recipient urinary tract the normal physiology is preserved with comparatively low complication and mortality rates. A third transplant attempt also is simplified. This method is the only alternative in some cases. Transplant ureter pathology symptoms are not observed. The results of 139 consecutive cases are presented.

J Thorac Cardiovasc Surg 1998;115:1378-81

Doppler echocardiography is an established technique for the routine assessment of prosthetic heart valve function; its accuracy in the estimation of pressure valve gradients has been demonstrated in comparative studies with invasive data.1,2Ultrasound examination therefore is an important aid in the clinical follow-up of these patients. Nevertheless, the variability of normal values for transprosthetic Doppler gradients is relatively wide, depending basically on the model and size of the valve.3,4For this reason, the availability of reference values for different valve sizes of a particular model is necessary for a correct assessment of the prosthetic function in every patient. This study reports the normal range of Doppler gradients in a large series of patients with clinically normal-functioning Monostrut Björk-Shiley valves5(Shiley, Inc., Irvine, California) in the aortic or mitral position, obtained either postoperatively or over a long-term follow-up.

The mass transfer area coefficient (MTC) is the best parameter for solute transport evaluation in continuous ambulatory peritoneal dialysis (CAPD) patients.We compared three simplified MTC methods (calculated according Garred, Krediet, or Lindholm) and the peritoneal equilibration test (PET) (Twardowskl) to complex MTC (MTCX) (Randerson and farrell) for urea and creatinine, by means of 29 tests performed In 24 stable CAPD patients.There were no significant differences (paired t-test) between MTCX and each of the simplified MTC, except for creatinine MTC calculated by Krediet's method, which was significantly different (MTCX: 9.36.:1:.4.32, K-MTC: 10.48.:1:.4.55, p<0.05).Likewise, there was an acceptable correlation between complex MTC and each of the simplified methods including the PET.However, a more detailed study of the MTC's categorizations shows poor agreement with complex MTC categorization. Better results are obtained by PET categorization, which reaches good likelihood ratios either for positive or negative events.We conclude that simplified MTC or the dialysatelplasma ratio at 240 minutes for urea and creatinine has an acceptable correlation with complex MTC and can be useful in clinical practice.There is poor agreement between solute transport categorizations of simplified MTC and complex MTC. There Is a better coincidence between the PET (DIPat 240 minutes) and complex MTC categorizations.

Presentamos cuatro casos de hematoma en aortaascendente. El diagnóstico de sospecha inicial fuedisección aórtica en dos de ellos. Todos fueron intervenidoscon carácter de urgencia. Revisamosotras series y concluimos en la conveniencia de tratarlos hematomas en aorta ascendente del mismomodo que las disecciones aórticas.

El diagnóstico clínico de los tumores cardíacos es, a menudo, difícil. Presentamos el caso de un paciente de 17 años en el que se diagnosticó un tumor del ventrículo izquierdo a partir del estudio de un síncope. El estudio anatomopatológico confirmó el diagnóstico de mixoma.

The transperitoneal approach is used systematically for an arterial or a venous splenorenal anastomosis. However, this approach is associated with high morbidity and mortality rates.

An 18-year-old man is described with an aneurysm of the left renal artery diagnosed during study for hypertension. Medical treatment achieved control of the blood pressure. The patient voluntarily interrupted treatment 1½ years after initial diagnosis but the blood pressure remained normal. Angiography at that time revealed almost complete thrombosis of the aneurysm and peripheral plasma renin activity returned to normal in contrast to the high figures registered initially (15ng. per ml., normal values 0.51 to 2.64). The patient had normal blood pressure, received no medication and was on only a salt-free diet 1 year after this event.

A simple technique of translumbar splenectomy during renal and pancreatic transplantation is described. This unique approach was used in 18 patients. Postoperative septic complications must be considered.

TO THE EDITOR. —As suggested by Batlle in the editorial entitled "IgA Glomerulonephritis, Asymptomatic Hematuria, and Systemic Disease," published in the September 1981 Archives (141:1264-1265), IgA nephritis may be one manifestation of a systemic disease. In the same issue, Ramirez et al1 describe the occurrence of IgA glomerulonephritis in two patients with mycosis fungoides.The purpose of this letter is to acknowledge our recent article about a patient with an IgA nephropathy, primary Sjögren's syndrome, and a pseudolymphoma.2Although we cannot make a clearcut statement about this association, we certainly agree with the opinion of Batlle that IgA nephropathy may be one manifestation of a systemic disease.