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Background/Aim: The clearest benefit of recombinant human erythropoietin (rHuEPO) in end-stage renal disease is a substantial reduction in transfusion dependency and an improved quality of life. In this report, we describe the efficacy of weekly subcutaneous administration of rHuEPO in 11 elderly patients with anemia secondary to chronic renal failure. Methods: The role of rHuEPO therapy in increasing the patient’s quality of life and in decreasing the hospitalization rates secondary to cardiac morbidity was verified in 11 elderly patients (age range between 66 and 85 years) with anemia due to chronic renal failure. The mean hemoglobin level at the beginning of the study was 8.2 ± (SD) 0.7 g/dl, and the serum creatinine concentration was 4.8 ± 1.36 mg/dl. The patients underwent baseline and annual echocardiography, in addition to an electrocardiogram. Results: Most patients experienced a partial regression of left ventricular hypertrophy, and no congestive heart failure was documented. The mean hemoglobin level during rHuEPO therapy increased to 11.3 ± 1.2 g/dl, while the mean serum creatinine concentration did not change significantly. Conclusions: Our results confirm that early anemia correction in aged chronic renal failure patients permits improvement of the quality of life, of exercise performance, and of cognitive functions. Reduced transfusion need and regression of left ventricular hypertrophy favor a minor incidence of cardiac morbidity and contribute to reduce health costs.

Progressive hereditary nephropathy is described in 6 members of a single family. Renal biopsies, performed in 3 patients, revealed tubular atrophy, interstitial fibrosis, and lymphomonocytic infiltration associated with severe vascular lesions. These features were disproportionately serious when related to age, arterial pressure, and renal function. Similar familial nephropathy has been reported in the literature, generally in association with gout or asymptomatic hyperuricemia. The patients described here had normal blood concentrations of uric acid. It is proposed that the members of the present group of patients are suffering from the same interstitial nephropathy as that described in the literature and that the hyperuricemia found by other investigators is coincidental and does not play a pathogenetic role.

Fifteen patients on regular dialytic treatment for more than 15 years were given X-rays of the skull, spine, shoulders, wrists, pelvis and knees with the purpose of studying the principal skeletal and articular alterations due or not due to the uraemic status. Serum calcium, phosphorus, parathyroid hormone, alkaline phosphatase and basal aluminium were recorded. Osteopenia was evident in all the patients. Ten of whom (67%) showed alterations due to hyperparathyroidism. Nine patients presented the marks of dialysis spondyloarthropathy; in 14/15 cases geodes were present in the wrists, humeral heads or hip-joints; in ten patients there were multiple amyloid lesions. Two patients with serum basal aluminum above 100 μg/L showed the typical radiographic marks of osteomalacia. The majority of the long-term survivors showed multifactorial osteo-articular alterations resulting mainly from the combination of hyperparathyroidism and dialysis-related amyloidosis. The less frequent joint alterations were represented by arthrosis, enthesopathy and Chondrocalcinosis. Disability and decreased articular mobility resulted in being mainly due to amyloid osteo-arthropathy.

Objectives. To analyse by ultracentrifugation in a zonal rotor the plasma lipoproteins in hypertriglyceridaemic patients on long-term haemodialysis. Design. Case-control study. Setting. Tertiary referred care centre. Subjects. Ten consecutive hypertriglyceridaemic patients on haemodialysis and 12 consecutive healthy controls. Main outcome measures. Plasma lipid and lipoprotein cholesterol concentrations, lipoprotein physical properties and compositions, apolipoprotein concentrations. Results. Hypertriglyceridaemia in patients undergoing haemodialysis is characterized by an increased amount of small and slow floating very-low density lipoproteins (VLDL), higher concentrations of intermediate density lipoproteins (IDL) and small and dense low-density lipoprotein (LDL) particles; reduced levels of high-density lipoproteins (HDL), in particular of HDL2. The lipoprotein composition of such patients indicates reduced cholesterol ester and increased triglyceride content. Compared to controls, they have lower levels of plasma apolipoprotein A-I and A-II and higher B, C-II, C-III and E values. Conclusions. The lipoprotein abnormalities observed in hypertriglyceridaemic patients undergoing haemodialysis have recently been associated with an increased incidence of vascular complications and may in part explain the high incidence of vascular disease reported in these subjects.

Atrial natriuretic peptide (ANP), plasma renin activity (PRA), plasma aldosterone and urinary fractional excretion of sodium (%FENa) were measured in 22 athletes before and after 1 h running. After exercise the hormones increased significantly, while %FENa decreased. In fact, the percent PRA increases resulted higher than the percent ANP increases with a significant inverse correlation. It is concluded that hemodynamic changes during strenuous and prolonged physical exercise lead to the inhibition of the natriuretic properties of ANP by stimulating the renin-angiotensin-aldosterone system, although a feedback mechanism of modulation between ANP and PRA seems to occur.

To define the prevalence of non-A, non-B hepatitis, antibodies to HCV were detected in 193 patients on renal replacement therapy (52 transplant and 141 hemodialysis patients) and in 50 staff members of a Nephrology Department. Unequivocal seroconversion was documented in 5 transplant (9.6%) and in 26 dialysis patients (18.4%). In the dialysis population, the prevalence of anti-HCV antibodies was evaluated in patients grouped according to the number of blood transfusions and to the different sections of dialytic treatment. The most striking findings were the marked differences in the prevalence of anti-HCV antibodies among patients treated in different sections (from 0% to 70%), and the presence of a significant increase in alanine-amino-transferase (ALT) concentrations in 14 anti-HCV negative patients. The results suggest that the diffusion of non-A, non-B hepatitis is mainly transfusion-related, with the possibility of significant environmental diffusion related to the violation of infection-control measures. The current immunoassay is probably unable to detect the actual frequency of the infection.

De novo systemic vasculitis after renal transplant is a rare complication. We report a patient who developed rapid, catastrophic necrotizing vasculitis of the gastrointestinal tract 11 months after renal transplant. A 60-year-old man was admitted for persistent pain in the right abdomen and mild intestinal hemorrhage. After some days the patient presented partial intestinal occlusion, severe hypoproteinemia and acute renal insufficiency. The patient was urgently operated with resection of a tract of the jejunum where there was a venous infarct. Laboratory tests were not significant and the search for hepatitis B, C viruses and ANCA was negative. After some days of irrepressible intestinal hemorrhage, total gastrectomy, splenectomy and resection of the duodenum and pancreas were performed. Histological pictures showed vascular lesions pathognomonic of systemic polyarteritis nodosa (PAN). After thirty days the patient died. The autopsy confirmed atypical systemic PAN with involvement of the pulmonary arteries besides the gastrointestinal tract and pancreas. Gastrointestinal (GI) complications are not frequent in renal transplant recipients, but 30% of patients with such lesions die as a direct consequence of visceral vascular damage. To the best of our knowledge, de novo PAN has been reported as the cause of catastrophic gastrointestinal involvement in only one renal transplant recipient. This case therefore raises the number of reports of PAN in kidney transplantation recipients who had no history of underlying connective tissue disease.

Vibrio vulnificus, a particularly virulent halophilic vibrio, has been isolated from the blood and skin necrotic lesion of a hemodialyzed patient with sepsis. The patient has had exposure of the skin to seawater. Various chronic conditions including renal failure have a great risk for developing septicemia due to V. vulnificus. It is necessary to inform persons with liver diseases or immunocompromising conditions of hazards associated with the consumption of undercooked seafood and seawater exposure.

To understand how to prevent the diffusion of hepatitis C virus (HCV) in dialysis units, 289 chronic dialysis patients treated in a renal department from the beginning of 1990 to June 30, 1993, were studied. Patients were screened monthly for alanine aminotransferase values and every 3 months for anti-HCV antibodies. At the beginning of the study the prevalence of anti-HCV antibodies was 24.7%. Two study groups were defined. In the first, anti-HCV-positive patients were treated on separate machines; in the second, 13 anti-HCV-positive and 13 negative patients shared the same machines. Patients in the study were treated with traditional dialysis, employing low-permeability membranes and disposable dialysate circuits on machines without an ultrafiltration control device. The 'universal precautions' were rigorously applied. The use of blood transfusions was markedly reduced. Although new patients starting dialysis treatment revealed a high frequency of HCV positivity (10.8%), the overall prevalence of HCV infection in the department did not increase during the follow-up period. Furthermore, no seroconversion was found in patients on dialysis treatment, not only in the section where anti-HCV-positive patients were treated on separate machines, but also in the section where anti-HCV-positive and anti-HCV-negative patients shared the same machines. The possibility of an intradialytic diffusion of HCV appeared to be very low and the treatment of infected patients on separate machines not strictly necessary.

This cross-sectional study examined bone abnormalities by digital radiography, bone densitometry and biochemical tests in 44 clinically asymptomatic renal transplant recipients 6–195 months after renal transplantation. Abnormal radiographs were obtained in 40 of the 44 patients. Dual-energy X-ray absorptiometry (DXA) performed at the lumbar spine (L2–L4)/showed a negative Z score in all patients, ranging from −1 to −1.9 in 28 patients and less than −2.0 in 16 patients. The severity of osteopenia increased with the length of time after transplantation and there was a significant correlation with parathyroid hormone values in patients with normal and low glomerular filtration rates. Our data suggest that decreased bone density values (Z score less than −2) are present in about one-third of patients with renal transplants. Bone loss appears to continue after transplantation. Steroid therapy and immunotherapy are probably the cause of this bone loss. Bone mineral measurements alone are helpful in identifying asymptomatic patients with low bone mass after transplantation.

Four uremic patients with advanced peripheral arterial occlusive disease (PAOD) of lower limbs causing rest pain and ischemic-necrotic lesions were treated with a four-hour intravenous infusion of Iloprost at doses of 0.75-2.5 ng/kg/min for twenty-eight days. After a week of the therapy all patients experi enced disappearance of rest pain and prolonged walking distance. At the end of the trial a diabetic patient showed a complete regression of the necrotic areas of two toes while the other patients still showed ischemic-necrotic foot lesions that were well demarcated. Iloprost therapy can be effective in uremic patients with severe PAOD.

A complete examination of the skin was performed in 53 kidney transplant recipients. Cutaneous lesions were detected in almost all patients. Papillomavirus infections, premalignant and malignant lesions represent the greatest risk for these patients. Our study underlines the importance of a continuous observation to facilitate early diagnosis and treatment of these lesions.

In 12 hemodialysis (HD) patients with persistently raised serum alanine amino-transferase concentrations, 6 of which with anti-HCV antibodies, a liver biopsy was performed. The histological examination showed chronic persistent hepatitis or less significant changes in 11 patients and mild chronic active hepatitis in only 1. Non-A, non-B hepatitis seems to demonstrate in HD patients a low tendency to induce an active and progressive liver disease.

The effect of intravenous calcitriol (IV-Ct) on parathyroid func tion was evaluated in 17 hemodialysis patients (HDp) with secondary hyperparathyroidism (sHPT). 0.015 μg/kg b. wt of Ct were administered after dialysis trice weekly for two months. Basal levels of serum parathyroid hormone (PTH) fell from 519±272 pg/ml to 317±184 pg/ml (p< .001) after therapy without a significant change in the serum total calcium (CaT) and ionized calcium (Ca++) concentrations.

The mean cellular volume (MCV) of urinary red blood cells was measured with an autoanalyser in 85 patients with definite causes of haematuria (31 had glomerulonephritis, 54 urological disorders). We found that red blood cells of glomerular origin had a smaller volume than non-glomerular cells (59.4 +/- 10.23 vs 87.35 +/- 11.17 fl; P less than 0.001). If an MCV equal to 70 fl was taken as the cut-off value between glomerular and non-glomerular haematuria, a correct assessment of the site of bleeding was made in 78 (91.7%) of the 85 patients studied. 'Microcytic' haematuria (i.e., MCV less than 70 fl) was present in 34 patients and correlated strongly with the diagnosis of glomerulonephritis (five false positives, specificity 90.7%; two false negatives, sensitivity 93.5%). Conversely, the presence of larger red blood cells in the urine coincided with the diagnosis of urological disorders in 96.1% (49/51) of the cases.

A method was developed for aluminium determination in dialysis fluids by graphite-tube furnace atomic absorption spectroscopy utilizing the L'vov platform. Results are reported for various kinds of dialysis fluids. In all cases accuracy and precision of the analytical procedure were ascertained.

The response of plasma aldosterone to sequential ultrafiltration dialysis has been studied during 16 sessions and compared with the response to 12 conventional sessions of hemodialysis. During the isolated ultrafiltration phase an important and significant increase in plasma aldosterone and plasma renin activity was observed. There was a substantial removal of extracellular fluid, but no change in plasma biochemistry. During conventional hemodialysis over the same time scale the concentration of plasma aldosterone decreased significantly, plasma renin underwent a small increase and plasma osmolality and plasma potassium decreased. Several possible pathophysiological mechanisms are discussed. We conclude that rapid isosmotic ultrafiltration without change in plasma potassium or sodium, the maintenance of plasma potassium at normal elevated values, and the increase of angiotensin II are factors favoring aldosterone biosynthesis.

Utilizzando un metodo di dosaggio radioimmunologico dell’angiotensina I, e stata costruita, in un gruppo di 20 uremici in trattamento emodialitico periodico, 1a curva dei valori di attivita renino-plasmatica colti immediatamente prima dell’inserimento del paziente nel circuito extracor-poreo, dopo 3–4 h di ultrafiltrazione ed alla fine della seduta, prima della reinfusione del sangue del dializzatore. I risultati conseguiti hanno evidenziato valori di attivita renino-plasmatica di base indeterminabili o subnormali nel 40 % dei casi, mentre nel restante della casistica i valori sono apparsi normali, elevati o molto elevati. Lo studio delle curve intradialitiche di attivita renino-plasmatica ha poi consentito di identificare un gruppo di pazienti in cui lo stimolo del-l’ultrafiltrazione rapida ha posto in evidenza una reattivita del sistema renina-angiotensina di entita varia, ma comunque sempre evidente o molto evidente. Il momento di maggior significato della curva intradialitica di attivita renino-plasmatica e apparso coincidere con la fase di ultrafiltrazione rapida dimostrandosi in tal modo di valore determinante la deplezione acuta e rapida della volemia, senza peraltro una significative correlazione con l’entita della sottrazione liquida. L’attivita renino-plasmatica di base e apparsa in linea generale disgiunta dal comportamento della pressione arteriosa, pur essendosi piu spesso rinvenuti valori normali o elevati in quei soggetti che erano ipertesi prima della collocazione in trattamento emodialitico periodico; i valori piu elevati di attivita reninica, inoltre, sono occorsi in 2 pazienti portatori di una condizione ipertensiva non correggibile col trattamento dialitico.

Gli AA. riferiscono i risultati ottenuti dall’applicazione di un metodo radioimmunologico di dosaggio dell’angiotensina I quale indice di attivita renino-plasmatica. Vengono sottolineate 1a fedelta del metodo e la sua riproducibilita. Viene inoltre indicato un particolare programma di calcolo che si basa sull’utilizzazione di un elaboratore elettronico.

The post-exercise urine samples from 122 long-distance runners showed evident abnormalities upon microscopic examination in 95% of all subjects. Proteinuria, alone or with microscopic hematuria, was frequently found. Macroscopic hematuria was a rare occurrence. The urine samples collected in 30 runners before, immediately after the race, and 6, 12, 24, 36, and 48 h later showed a significant post-race decrease in the osmolarity and a significant increase in gamma-glutamyl transferase and N-acetyl-beta-glucosaminidase enzyme activity. Plasma renin activity and plasma aldosterone, determined before and after the race in nine runners, showed a significant increase in the post-race samples. The abnormal urinary findings disappeared in all cases within 24-36 h. It can be concluded that urinary abnormalities are very common after exercise. These abnormalities are most often of a "renal" origin, probably due to a temporary hemodynamic impairment, partially of glomerular but principally of tubular function.

Serum erythropoietin (Epo) activity, hemoglobin (Hb), and hematocrit (Ht) were determined in 21 cross-country skiers during the training season. The Epo levels were not significantly reduced in the skiers relative to the normal population (P less than 0.01 and P less than 0.001, respectively). In 11 athletes Epo, Ht, urinary gamma-glutamyltransferase, N-acetyl-beta-glucosaminidase, and microalbuminuria were determined before and after a 50-km ski race at 1600 m above sea level. A significant increase of these variables (except for Ht) was found after the competition (P less than 0.001). It is concluded that while the reductions in Hb and Ht, which are typical of several endurance exercises, are not accompanied by a renal hypoxia sufficient to stimulate Epo overproduction, the renal hypoxia reached during the strenuous exercise of the race at altitude may be effective in determining blood increases in Epo.

To assess hepatitis C virus (HCV) incidence rates and identify determinants of infection among hemodialysis patients, a multicenter study was conducted in 58 units in ITALY: An initial seroprevalence survey was conducted among 3,492 patients already on hemodialysis therapy as of January 1997 and among an additional 434 patients who began dialysis up to January 1998. HCV antibodies were assessed by third-generation enzyme immunoassays. Patients testing seronegative at baseline were enrolled into a 1-year incidence study with serological follow-up at 6 and 12 months. For patients who seroconverted, an HCV RNA assay was performed on stored baseline samples to confirm new infection. A nested case-control study was subsequently performed to investigate potential risk factors. For each incident case, three controls negative for both HCV antibodies and HCV RNA were randomly selected. At enrollment, HCV seroprevalence was 30.0%. During follow-up, 23 new HCV cases were documented, with a cumulative incidence of 9.5 cases/1,000 patient-years. By logistic regression analysis, an increased risk for HCV infection emerged for patients attending the dialysis units with a high prevalence of HCV-infected patients at baseline (odds ratio [OR], 4.6) and for those attending units with a low personnel-patient ratio (OR, 5.4). Among extradialysis factors, a history of surgical intervention in the previous 6 months (OR, 16.7) significantly increased HCV risk. These findings suggest that the combination of understaffing and a high level of infected patients in the dialysis setting increases the risk for HCV nosocomial transmission. This is likely related to an increased likelihood for breaks in infection control measures.

Nine patients undergoing regular dialytic treatment for more than 60 months showed clinical and radiologic features of a noninfective and destructive spondyloarthropathy. The cervical spine was most affected (100%), followed by the dorsal (three patients, 33.3%) and the lumbar spine (two patients, 22.2%). Typically, radiographs and CT scans revealed narrowing of intervertebral spaces, with destruction or sclerosis of the subchondral bone of the vertebral plate. Autopsy was performed on three patients; histologic study demonstrated the presence of large amyloid deposits containing beta 2-microglobulin (beta 2-m) in the discs and peridiscal ligaments. A radiographic follow-up of the cervical spine was performed in seven patients after a period of 12 months and showed that the bone destruction in DSA is very rapid and progressive. The lower biocompatibility of the cuprophan membranes of dialyzers is probably the factor most responsible for hyperproduction of beta 2-m and subsequently osteoarticular deposition of a new type of amyloidosis.

The determination of aluminium in sera in the concentration range 2–1200 µg l–1 was studied using a L'vov platform under optimum conditions in the presence of 0.1%m/V of both Mg(NO3)2 and Triton X-100. The use of less sensitive resonance lines instead of dilution of the sample with water was found to be advantageous, as aqueous dilution of sera to more than 1 + 1 caused a systematic positive error of 20%. Matrix interferences were investigated for all the resonance lines considered in order to evaluate the use of an analytical calibration function rather than the much more time consuming addition technique. Accuracy and precision data and the merits of the analytical procedure are also reported. The aluminium contents of the sera before and after desferrioxamine (DFO) administration to 48 chronic uraemic patients on periodical haemodialytic treatment permit some considerations of the clinical utility of the DFO test.