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The aim of this observational study was to compare the effect of calcium and alfacalcidol supplementation on the regression of hyperparathyroidism and on prevention of osteopenia in patients up to 3 years after renal transplantation. Two historical cohorts were compared for that purpose. One hundred and fifty-nine patients received calcium carbonate supplement (group 1), while 81 patients were treated with alfacalcidol (group 2). Serum Ca, phosphate (P), Mg, creatinine, alkaline phosphatase (AP) and parathyroid hormone (PTH) levels were determined before and after transplantation in the two groups, for 3 years. Femoral neck and lumbar spine bone mineral density (BMD) was measured only at 3 and 6 months and 1, 2 and 3 years after transplantation. At baseline there was no difference in age or sex ratio, but prevalence in post-menopausal women was higher in group 1 (6.9% versus 1.2%). Duration on dialysis was comparable but prevalence of interstitial and undetermined nephropathies was higher in group 1. Baseline serum concentrations of PTH, Ca and P were comparable in both groups. After transplantation, plasma creatinine decreased to comparable levels in both groups. Immunosuppression by triple therapy was more prevalent in group 2, so that cumulative dose of steroid was higher in group 1, especially at 1 month because of higher incidence of acute rejections (51% versus 13%). Mean intact PTH levels decreased in both groups, from 18 pmol/l to 8.4 and 7.9 at 3 years, but the decrease was significantly greater with alfacalcidol at 6 and 12 months. At 3 months, BMD were comparable at both sites. From 3 months to 3 years after kidney transplantation, mean lumbar spine BMD significantly increased from 0.963 to 1.054 g/cm2 in group 1, whereas there was no significant decrease (1.048 to 1.006 g/cm2) in group 2, the difference in changes being significant (P<0.05). Femoral neck BMD was not significantly increased in either group (0.932 to 0.993 g/cm2 in group 1, and 0.850 to 0.907 g/cm2 in group 2). Expressed as percentages, these changes were +9.4% and –4% for lumbar BMD and +6.5% and +6.7% for femoral neck, for groups 1 and 2, respectively. Prevalence of osteopenia was not significantly lower at 3 years in group 1 (45% and 51%) than in group 2. During the follow-up period, osteonecrosis was diagnosed in six patients (3.8%) in group 1 and in nine (11%) in group 2. In conclusion, alfacalcidol compared to CaCO3 supplement suppressed hyperparathyroidism more rapidly and strongly. In spite of higher osteopenia risk in the CaCO3 group, lumbar BMD increase was greater and incidence of osteonecrosis higher in this group, suggesting better bone protection with CaCO3 than with alfacalcidol. [ABSTRACT FROM AUTHOR]

Background: Symptomatic dialysis hypotension (DH) continues to be a common problem. By comparing patients prone and resistant to DH, several dialysis session and patient related characteristics have been identified that confer susceptibility to DH. Less is known, however, about the comparison of patients with frequent and only occasional DH. The aim of the study was to compare clinical and dialysis-session- (complicated by hypotension) related data between those with frequent (fDH) and those with occasional dialysis hypotension (oDH)., Methods: Nine hundred and fifty-eight patients at 11 dialysis units were followed for 10 months and characteristics of patients with fDH (> or = 10 hypotensive events necessitating medical intervention) (n = 96) were compared to that of patients with oDH (1 or 2 events/10 months) (n = 130). Significant and independent predictors of fDH were obtained by multivariate logistic regression., Results: Significant differences between fDH vs. oDH patients were older age (64.4 vs. 56.9 years, p < 0.001), more females (66 vs. 46%, p < 0.005) in fDH. More fDH patients had diabetes (27 vs. 15%, p < 0.05) and less had glomerulonephritis (15 vs. 35%, p < 0.001) as the cause for ESRD. Coronary artery disease (68 vs. 50%, p < 0.01) and long-acting nitrate treatment (51 vs. 30%, p < 0.001) was more frequent while treatment with ACEI (33 vs. 48%, p < 0.05) or Ca-channel blockers (40 vs. 53%, p < 0.05) were less frequent in patients with fDH. Patients with fDH had higher serum phosphorus levels (1.99 vs. 1.79 mmol, p < 0.005). Dialysis session related data were similar but the hypotensive episode occurred earlier during dialysis in fDH (136 vs. 156 min, p < 0.01). In multivariate analysis, significant independent predictors of fDH were older age (OR = 1.04 [1.02-1.07]), lack of glomerulonephritis as renal diagnosis (2.63 [1.18-5.87]), high phosphorus levels (5.0 [2.45-10.0]), lack of use of Ca-channel blockers (2.09 [1.12-3.91]), and the use of nitrates (2.38 [1.24-4.55])., Conclusion: Features of the dialysis sessions complicated by DH seem to be similar between patients with fDH and oDH, while patient characteristics such as older age, renal diagnosis other than glomerulonephritis, higher serum phosphorus levels, use of nitrates, and lack of use of calcium channel blockers are significantly and independently associated with fDH., (Copyright 2002 S. Karger AG, Basel)

Prospective study was performed to measure the changes in calcium metabolism after kidney transplantation. 139 recipients received calcium substitution (1st group) and 81 patients were treated with alfacalcidol (2nd group). Serum Ca, P, Mg, alkaline phosphatase (AP) and intact PTH levels were determined before transplantation and at 1, 3, 6, 12 and 24 months thereafter in the two groups. Femoral and vertebral bone mineral density was measured with bone densitometer at the same period. The serum Ca level elevated and the serum P concentration decreased significantly in both group. The mean serum Mg and AP concentration changed in the normal range after the transplantation. The intact PTH level decreased significantly in both group at 2 years following transplantation. The intact PTH concentration changed from 17.1 pmol/l to 9.3 pmol/l in the 1st group, and it is decreased from 17.7 pmol/l to 7.9 pmol/l in the 2nd group. Bone densitometry showed osteoporosis in both group. At 12 months and at 24 months after kidney transplantation bone mineral density (BMD) of lumbar spine was 90.8% and 86.9% in the 1st group and 85.3% and 81% in the 2nd group. At the same time BMD of the femoral region was 84.4% and 85.5% in the 1st group and 82.0% and 81.3% in the 2nd group. The BMD did not changed significantly in the 1st compared to the 2nd group. During this period osteonecrosis was diagnosed in 6 patients in the 1st group and in 9 cases in the 2nd group. In conclusion, the serum Ca and P levels were in the normal range after kidney transplantation. The alfacalcidol treatment significantly decreased the intact PTH concentration compared to the calcium substitution. Moderate osteopenia was observed in both groups after the transplantation, despite of the administration of alfacalcidol treatment.

Authors examined the serum concentration of creatinine, uric acid, homocysteine, cystatine C, total cholesterol and triglyceride in 115 male and 77 female patients six months after the transplantation. The change of the BMI (Body Mass Index) was studied, fat and water body weight was determined by bioelectrical impedance analysis, and the ratio of intra- and extracellular volume was calculated. Both creatinine and cystatine C levels decreased significantly compared to the levels before the transplantation (p < 0.001) because of the good renal function, and there was a good correlation between creatinine, cystatine C and homocysteine levels (r = 0.5315 in females, r = 0.3189 in males). Elevated BMI (36.49%) and hypercholesterolaemia along with moderate hyperhomocysteinaemia was found in a considerable part of the patients. Increase in body weight was confirmed by the increase in fat body weight and volume determined by bioelectrical impedance analysis. In patients with adequate compliance the ratio of intra- and extracellular volume was between 1.67 and 1.79. Blood pressure values showed frequently the non-dipper phenomenon despite appropriate antihypertensive therapy, and negative diurnal index was found with high nocturnal blood pressure levels. The mean blood pressure was 148/81 +/- 13.2/4.8 mmHg in males and 133/84 +/- 15.3/9.8 mmHg in females. Authors enhance the importance of regular monitoring of cardiovascular risk factors in the prevention of cardiovascular complications.

Serum paraoxonase (PON) is a high-density lipoprotein (HDL)-associated hydrolase, which inhibits low-density lipoprotein oxidation. Uremic and kidney-transplanted patients have an increased risk of atherosclerosis, to which an increased lipoprotein oxidation may contribute. The aim of our study was to determine whether the PON activity or phenotype is altered in uremic and kidney-transplanted patients, and to compare the values with those of healthy controls. 117 uremic patients on long-term hemodialysis treatment, 115 renal-transplanted patients, and 110 healthy controls were involved in the study. The PON activity was significantly reduced in the uremic patients compared to controls (PON 101.36+/-30. 12 vs. control 188.05+/-58.96 U/ml; p < 0.001), while in kidney-transplanted patients the values were almost identical to those of controls (PON 161.5+/-35.39 U/ml). The different immunosuppressive drug combinations did not influence PON activity. To assess whether the altered PON activity was due to a decrease HDL level, we standardized the enzyme activity for the HDL concentration (PON/HDL ratio). We found that the standardized enzyme activity was lower in the uremic (102.7+/-54.8) and kidney-transplanted patients (144.5+/-32.7) when compared to controls (194.5+/-94.5; p < 0.001). The phenotypic distribution of PON in uremic, renal transplant and control patients are as follows: AA 66.67, 56.48 and 66.67%; AB 31. 62, 33.3 and 26.67%; BB 1.71, 10.19 and 6.67%. We conclude that the decreased PON/HDL and PON/apoA-1 ratios may lead to a reduction in the antioxidant capacity of HDL, which might contribute to the accelerated development of atherosclerosis in uremic and kidney-transplanted patients.

Significant portion of the urologic and nephrologic patients in Yemen are treated because of the early and late complications of schistosomiasis (bilharsiasis). During two years 79 patients with renal insufficiency and complications have been examined and treated by the authors. In combination with moderate restricted renal functions hepatosplenomegaly and signs of portal hypertension were observed in female patients. Granulomatous infiltration, calcification and malignous tumour of the urinary bladder was found in men. Stricture of the ureter, uni- or bilateral consecutive hydronephrosis was detected frequently. In addition to inflammatory components bladder, ureteral and renal stones were verified. In the course of treatment 45 percutaneous nephrostomies were performed and an anterograde pyelography was carried out in 60 patients. Ureteral recanalisation was accomplished by means of an ureter stent in 8 cases. Because of serious uremia maintenance haemodialysis was performed in 52 patients. The aim of this work is to contribute to recognise the disease in early stage and emphasize the importance of establishing diagnosis as early as possible and stress the role of the appropriate causal and symptomatic treatment.

Two cases of Goodpasture's syndrome are reported. Intensive therapy, extracorporeal oxygenation by haemodialysis, assisted respiration and short-term pacing were applied together with immunosuppressive treatment and repeated exchange transfusions. By this treatment combined with bilateral nephrectomy a few weeks' remission was attained in a young female patient. An intensive therapy of this kind is recommended in rapid progressive glomerulonephritis of other types as well.

The serum aluminium, zinc, copper, iron and cadmium levels were studied in patients on haemodialysis, by the atomic absorption method and spectrophotometry. The serum concentrations of zinc and copper were found to decrease with the frequency of dialysis treatments, while the serum levels of iron and aluminium increased. Referred to the time elapsed since the start of the dialysis programme, the serum concentrations of zinc decreased, while those of iron, copper and aluminium increased. Attention is drawn to published observations pointing to the hazard of aluminium intoxication and to the symptoms and consequences of copper and zinc deficiency.

Impulse formation and conduction disturbances of the heart were investigated in 23 uraemic patients with transvenous and oesophageal electrodes. Utilizing regular atrial pacing the sinoatrial conduction time (SACT) was obtained and sinus automaticity was evaluated by measurement of the sinus node recovery time (SNRT). The atrial effective refractory period and the Wenckebach point were also determined. The effects of regular haemodialysis treatment on impulse formation and propagation disorders caused by uraemia were observed. In 16 patients transitory or permanent cardiac stimulation had to be carried out because of 2nd and 3rd degree AV block. No complication was observed during simultaneous haemodialysis and pacemaker treatment. It is concluded that the non-invasive, simple bedside oesophageal atrial stimulation method is a good alternative and should be used in the exact diagnosis of heart conduction disturbances of haemodialysed patients.

The authors have examined 27 patients who participate in the chronic haemodialysis programme. It was established that the hyperphosphataemia, the hypocalcaemia and the later hypercalcaemia which developed in consequence of the chronic renal insufficiency are the cause of the calcification of the cornea and of the conjunctiva. In order to pursue this process the slit-lamp examination is recommended as necessary and useful method. The authors consider frequent neither the existence of the "red eye" symptom nor the development of a cataract.

The activity of the leucocyte inhibitory factor (LIF) stimulated with Concanavalin A was examined in chronic uraemic, haemodialysed patients. It was found that the LIF activity decreased in chronic uraemic patients as compared with the normal controls. The absolute T lymphocyte count and active E rosette formation also decreased. In in vitro experiments the authors have also examined the inhibitory effect of the so-called "middle-sized molecule" (MSM) on uraemic materials separated from the serum and the haemofiltrate. They observed that the materials with a molecular weight of 1000-1500 isolated both from the serum and the haemofiltrate significantly inhibited the Con A stimulated LIF production of normal lymphocytes and decreased the ratio of the active E rosette-forming T lymphocytes. On the basis of their experiments the MSM uraemic materials are considered responsible for the decreased immune reactivity of uraemic patients. These uraemic toxins can be dialysed.

In 44 patients (22 females, 22 males, aged 18-61 years, mean 36 years) regular dental screening and treatment were started in January 1982. Two years follow-up revealed that the oral hygiene of these haemodialysis patients was worse than that of the average population. In 42 cases calculus formation and gingivitis, in each case atrophy of the alveolar bone and pocket formation were found. We consider these symptoms as cardinal in uraemic haemodialysis patients. As a consequence, the teeth had a pathologic mobility which was proportional to the bone resorption. Although not very typical, 10 cases were found with clicking of the temporomandibular joint associated with painfulness of the joint and the surroundings. Owing to the increased tendency to caries and the parodontal disease, the majority of patients lost most of their teeth untimely. Therefore special measures should be taken to achieve restoration. We emphasize the need for special dental care of haemodialysis patients.

A total of 168 chronic dialysed patients were subjected to echography; 48% of them presented aneurysmal alterations of the fistula, with a tendency to increase in proportion to the length of the dialysis period. Two examination methods, the audial and the visual, furnish information on the flow within the fistula, the quality and lumen of the created anastomosis, blood yield, formation and position of collateral circulation. The authors emphasize the advantage of the non-invasive technique as against examination with contrast medium, the early performance of anticoagulation, and the significance of thrombectomy to spare a reoperation of the fistula.

It was reported on the results of the cytostatic immunosuppressive treatment during a 6 years' observation time in 100 patients with glomerulonephritis in immunopathogenesis. The diagnosing was made according to the homogeneous opinion: clinical, immunological and histological. Of the 100 patients 33 suffered from SLE and 67 from other nephropathies with immunopathogenesis. In the therapy were used prednisolone, 6-mercaptopurine, azathioprine, cyclophosphamide and their combination, respectively. On the one hand, the therapeutic results were estimated as short-term results, on the other hand as long-term results with regard to the clinical syndromes as well as to the individual histological forms according to the categories of the full remission, the partial remission and also as "unchanged". It was established, whether an optimum result may be achieved in the different clinical and histological types. The best results may be achieved with the combination of 6-mercaptopurine and cyclophosphamide. The cytostatic therapy of the glomerulopathies should be used more aimedly in different clinical syndromes and histological forms.

The activity of LIF after Con A stimulation was examined in patients with hemodialysis and chronic uremia. It was found that LIF activity is reduced in uremia compared with healthy controls. The absolute number of T lymphocytes was reduced as well as the number of active E rosettes. An inhibitory effect was found in vitro by isolated middle molecules from uremic serum and ultrafiltrate. The LIF production of normal lymphocytes and the number of active rosettes are significantly reduced by substances isolated from serum and ultrafiltrate with molecular weight of 1 000 to 1 500 Dalton. The authors think that these uremic middle molecules are responsible for the already known reducing of immune response by uremia. The uremic substances are dialysable.

The joint disorders associated with osteodystrophy of 124 regularly haemodialysed patients are reviewed. The most common signs and symptoms of uraemic osteoarthropathy are summed up. It is pointed out that in osteoarthropathy accompanying chronic renal failure or haemodialysis the bones are generally affected first, arthropathy being secondary to this process. In addition to the classic signs and symptoms of arthropathy (calcification, pain, stiffness) capsulitis, carpal tunnel syndrome and in 3 cases avascular necrosis were observed. The laboratory findings included hypocalcaemia, hyperphosphataemia and hypersecretion of parathormone. The current preventive and therapeutic measures are reviewed and in this context the benefits of combined local lidocaine, and steroid iontophoresis are emphasized in the light of personal observations.

Forty-two patients with chronic renal insufficiency were subjected to Brulamycin therapy to combat complications such as sepsis, infection of the lower respiratory tract (bronchopneumonia) or of the urinary tract, Cimino fistula inflammation or peritonitis when the pathogenic agent was sensitive to nothing but aminoglycosides. The proper Brulamycin dose was selected under close clinical and laboratory control so as to fit the dialysed patient and his state of impaired renal function. The various forms of dialysis have been studied to determine their Brulamycin blood level diminishing effects. Familiarity with these effects is as important as with the patient's age, sex, body weight and actual state of renal function. The results confirm the experience gained by other authors that Brulamycin treatment--in curative non-toxic doses as indicated by the blood level index--is useful against severe infectious complications in anuric patients.