Proteinuria is still useful for the screening and diagnosis of overt diabetic nephropathy

Follow-up care and assessment of comorbidities and complications in patients with primary aldosteronism: The clinical practice guideline of the Taiwan Society of aldosteronism

Primary aldosteronism (PA) is the most common form of endocrine hypertension, characterized by excess aldosterone production that leads to an increased risk of cardiovascular events and target organ damage. Both adrenalectomy and medical treatment have shown efficacy in improving clinical outcomes and comorbidities associated with PA, including a specific subtype of PA with autonomous cortisol secretion (ACS). Understanding the comorbidities of PA and establishing appropriate follow-up protocols after treatment are crucial for physicians to enhance morbidity and mortality outcomes in patients with PA. Additionally, the screening for hypercortisolism prior to surgery is essential, as the prognosis of patients with coexisting PA and ACS differs from those with PA alone. In this review, we comprehensively summarize the comorbidities of PA, encompassing cardiovascular, renal, and metabolic complications. We also discuss various post-treatment outcomes and provide insights into the strategy for glucocorticoid replacement in patients with overt or subclinical hypercortisolism. This clinical practice guideline aims to equip medical professionals with up-to-date information on managing concurrent hypercortisolism, assessing treatment outcomes, and addressing comorbidities in patients with PA, thereby improving follow-up care.

Association of urinary C-megalin with albuminuria and renal function in diabetes: a cross-sectional study (Diabetes Distress and Care Registry at Tenri [DDCRT 21])

BACKGROUND

A urinary biomarker sensitive to glomerular functional or structural changes in diabetic kidney disease is required. This study examined whether urinary C-megalin reflects renal function or albuminuria in diabetes.

METHODS

This was a cross-sectional study involving 1576 patients with type 1 or 2 diabetes. The exposure variables were estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (UACR), and the outcomes were urinary C-megalin excretion and concentration. Two-part models were used to examine the associations between eGFR and UACR with urinary C-megalin excretion or concentration.

RESULTS

The UACR was linearly associated with urinary C-megalin excretion (per 100 mg/gCr of UACR; 11.8 fM/gCr [95% CI 8.9-14.7]). There was no association between decreasing eGFR and increasing urinary C-megalin excretion. The UACR was also linearly associated with the urinary C-megalin concentration (per 100 mg/gCr of UACR, 7.7 fM/L [95% CI 5.8-9.6]). At eGFR values > 60 mL/min/1.73 m², the eGFR and urinary C-megalin concentration were inversely linearly related (per 10 mL/min/1.73 m² decline, 7.7 fM/L [95% CI 0.2-15.1]).

CONCLUSION

Urinary C-megalin excretion as well as concentration levels are potentially useful biomarkers to detect early changes in diabetic kidney disease.

Expression of Urokinase-type Plasminogen Activator Receptor and its Soluble Form in Type 2 Diabetic Kidney Disease

BACKGROUND

Urokinase-type plasminogen activator receptor (uPAR) and its soluble form (suPAR) are new injury biomarkers that have been recently suggested to play a vital role in renal diseases.

AIM AND METHODS

We evaluated the expression of uPAR and the serum concentration of suPAR in type 2 diabetes (T₂DM) patients with diabetic kidney disease (DKD) to determine the role of this molecule as a biomarker in DKD. The uPAR immunohistochemical staining was performed in biopsy-confirmed DKD renal tissues. Meanwhile, the serum suPAR, Interleukin-18 (IL-18) and C-reactive protein (CRP) levels of 70 diabetic patients with or without DKD and 15 healthy controls were measured.

RESULTS

The uPAR expression in DKD patients was significantly increased compared to that in healthy controls and was widely colocalized with the podocyte marker WT1. Meanwhile, serum suPAR and IL-18 levels gradually increased as DKD progressed to the advanced stage. Moreover, serum suPAR and IL-18 levels were negatively correlated with eGFR (ρ = ‒0.734, ρ = ‒0.462, p <0.01) and positively correlated with the urine protein to creatinine ratio (UP/CR) (ρ = 0.730, ρ = 0.440, p <0.01). The suPAR AUC performed better than the IL-18 AUC for the diagnosis of proteinuria (0.845 vs. 0.753, p <0.01) and the decline of renal function (0.895 vs. 0.796, p <0.01).

CONCLUSIONS

The uPAR expressed in the renal tissues of DKD patients. The soluble form of uPAR, suPAR, can be detected in the serum of DKD patients and has a better diagnostic efficiency in the diagnosis of proteinuria and renal dysfunction in patients with T₂DM than that of IL-18.

Early short-term intensive multidisciplinary diabetes care: A ten-year follow-up of outcomes

OBJECTIVES

To evaluate the outcome of an early short-term intensive diabetic care program followed by a regular out-patient shared-care education program.

METHODS

We retrospectively reviewed the medical charts of 196 patients newly diagnosed with type 2 diabetes mellitus (DM) who were admitted to the hospital for intensive multidisciplinary interventions. For comparison, we also enrolled 206 patients with type 2 DM newly diagnosed but not receiving short-term intensive program. Both groups all attended an out-patient shared-care education program for more than one year. Outcome measure included average and standard deviation (SD) of glycated hemoglobin (HbA1c) over ten years, serum creatinine (Cr), lipid profile, urine albumin/Cr (UACR), and chronic diabetic complications after 10years later. The Kaplan-Meier event happening rates were used to compare the event rate of two samples. Multivariate Cox proportional-hazards models were used to investigate the influence of different variables on chronic complications.

RESULTS

Patients who received short-term intensive diabetic education had less SD of HbA1cs: (0.7±0.7% vs. 1.0±0.8% (5.3±5.3mmol/mol vs 9.2±6.4mmol/mol), p<0.001), less new-onset coronary heart disease (CHD) (8.2% vs. 13.7%, p=0.005), lower serum Cr (1.4±0.7mg/dL vs. 1.5±0.9mg/dL, p=0.005), less progression of nephropathy was also revealed (13.5% vs. 21.2%, p=0.009) and lower UACR (4.7±1.4mg/g vs. 5.3±1.0mg/g, p<0.001). There were no group differences in age, gender distribution, average HbA1c, lipid profile, and new-onset of neuropathy and retinopathy. The independent predictors of CHD and nephropathy were short-term intensive diabetic education and SD of HbA1cs.

CONCLUSION

Initiation of earlier intensive short-term multidisciplinary interventions in patients with newly diagnosed DM may decrease coronary heart disease and nephropathy. These better outcomes may be related to less fluctuation in blood glucose levels.

Subclinical hypothyroidism and diabetic nephropathy in Iranian patients with type 2 diabetes

PURPOSE

Association of subclinical hypothyroidism with type 2 diabetes and its complications has been previously documented. These reports were, however, inconclusive and mainly gathered from Chinese and East Asian populations. In this study, we aimed to determine the prevalence of subclinical hypothyroidism and its relationship with diabetic nephropathy in Iranian individuals with type 2 diabetes, drawn from a white Middle Eastern population with an increasing prevalence of diabetes.

METHODS

In this cross-sectional study, 255 Iranian participants with type 2 diabetes and without history of thyroid disorders were included. Patients with TSH > 4.2 mIU/L and normal T4 were classified as having subclinical hypothyroidism. Diabetic nephropathy was diagnosed based on abnormal 24-h urinary albumin or protein measurements (24-h urinary albumin ≥30 mg/day or 24-h urinary protein ≥150 mg/day). Multivariate logistic regression was employed to obtain the OR for the relationship between subclinical hypothyroidism and diabetic nephropathy.

RESULTS

We found that subclinical hypothyroidism and diabetic nephropathy were as prevalent as 18.1 and 41.2 %, respectively, among the participants. We also found that subclinical hypothyroidism was independently associated with higher rates of diabetic nephropathy, after multivariable adjustment (OR [95 % CI] 3.23 [1.42-7.37], p = 0.005).

CONCLUSIONS

We found that the prevalence of subclinical hypothyroidism in Iranian diabetic population was among the highest rates reported to date. Our data supported the independent association of subclinical hypothyroidism with diabetic nephropathy, calling for further investigations to evaluate their longitudinal associations.

A New Gender-Specific Formula to Estimate 24-Hour Urine Protein from Protein to Creatinine Ratio

<b><i>Background:</i></b> The quantification of proteinuria with the protein to creatinine ratio (PCR) is influenced by the excretion of creatinine, which, in turn, varies according to muscle mass and hence, to gender. <b><i>Aims:</i></b> To assess the difference between urine PCR and 24-hour urine proteinuria in men and women and to provide a formula to overcome bias caused by gender. <b><i>Methods:</i></b> Four hundred and forty four CKD patients were randomly divided into 2 groups: 70% were used to develop the models, while the remaining 30% were reserved to validate the formula. Epidemiological data were analyzed with chi-square and Student's t tests. Association between 24-hour proteinuria and PCR was studied with Spearman coefficient in men and women separately. Multivariate analysis was used to find variables predictive of disagreement between the 24-hour urine protein and the PCR. Equations to predict 24-hour proteinuria from PCR for men and women were plotted and validated. <b><i>Results:</i></b> Disagreement between 24-hour proteinuria and PCR was more pronounced in men (2.16 and 1.64 g in mean, respectively) than in women (2.00 and 2.06 g in mean, respectively). Age and gender were independent predictors of disagreement. Gender-specific equations for predicting 24-hour proteinuria were: males: 24-hour proteinuria = 1.3350*exp^0.9108*^ln(PCR); females: 24-hour proteinuria = 1.0068*exp^0.9030*^ln(PCR). <b><i>Conclusions:</i></b> Estimation of proteinuria with the PCR improves accuracy if gender-specific equations are used. Use of the PCR without correction for gender leads to the underestimation of proteinuria in men and overestimation in women.

Microbubbles and Ultrasound: Therapeutic Applications in Diabetic Nephropathy

Diabetic nephropathy (DN) remains one of the most common causes of end-stage renal disease. Current therapeutic strategies aiming at optimization of serum glucose and blood pressure are beneficial in early stage DN, but are unable to fully prevent disease progression. With the limitations of current medical therapies and the shortage of available donor organs for kidney transplantation, the need for novel therapies to address DN complications and prevent progression towards end-stage renal failure is crucial. The development of ultrasound technology for non-invasive and targeted in-vivo gene delivery using high power ultrasound and carrier microbubbles offers great therapeutic potential for the prevention and treatment of DN. The promising results from preclinical studies of ultrasound-mediated gene delivery (UMGD) in several DN animal models suggest that UMGD offers a unique, non-invasive platform for gene- and cell-based therapies targeted against DN with strong clinical translation potential.

Diagnosis and treatment of diabetic kidney disease

Diabetic kidney disease (DKD) is the most common cause of chronic kidney disease in the United States. In the last several years, there have been several new developments in the field of the DKD. In 2007, the National Kidney Foundation and Kidney Disease Outcomes Quality Initiative released clinical practice guidelines that included new definitions and summarized diagnostic and therapeutic approaches for DKD. The results of several recent randomized controlled trials provided novel insights regarding effects of glycemic and lipid control on vascular and renal outcomes in patients with diabetes. Additionally, the findings of the Action to Control Cardiovascular Risk in Diabetes-Blood Pressure trial played a critical role in the revision of blood pressure target guidelines in patients with diabetes. The goal of this review article is to summarize recent updates and recommendations for the diagnosis and treatment of DKD.

Urinary total protein as the predictor of albuminuria in diabetic patients

BACKGROUND

In order to detect nephropathy, measurement of total (24 hrs) urinary albumin or albumin/creatinin ratio in random urine samples is being recommended. But methods of albumin measurement are not available in all laboratories and also cost about 6 times more than that of urinary total protein measurement.

OBJECTIVES

This Study was performed to determine appropriate cut off point in 24 hours urine total protein to diagnose micro- and macroalbuminuria in patients with diabetes mellitus.

PATIENTS AND METHODS

In this study, 204 patients with diabetes mellitus type I and II were selected. In collected 24 hours urine from patients, protein and albumin were measured by using Pyrogallol and Immunoturbidimetry methods, respectively.

RESULTS

Normoalbuminuri (albumin < 30 mg/24 hrs urine), microalbuminuri (albumin = 30-300 mg/24 hrs urine), and macroalbuminuri (albumin > 300 mg/24 hrs urine) were detected in 130, 51, and 23 patients, respectively. In 24 hrs urine collections, amounts of protein and albumin were compared to calculate cut off point of exerted protein for nephropathy diagnosis. cut off point of 73 mg/day for urinary total protein had appropriate sensitivity (94.5 %, CI = 91.4 % -97.6 %) and specificity (77.9 %, CI = 72.8 % -82.9 %) for microalbuminuria, while cut off point of 514 mg/day (sensitivity 95.7 %; specificity 98.9 %) was detected for diagnosis macroalbuminuria. Urine protein exertion of 150 mg/day that is currently considered as a normal value in most laboratory kits had a sensitivity of 73.1 % by which 30 % of microalbuminuric cases remained undiagnosed.

CONCLUSIONS

Urinary total protein cut-off points of 73 mg/day and 514 mg/day were diagnostic for micro- and macroalbuminuria, respectively.

Inflammatory and endothelial dysfunction markers and proteinuria in persons with type 1 diabetes mellitus

OBJECTIVE

We examined the relationship of inflammatory and endothelial dysfunction markers with the prevalence and incidence of gross proteinuria (GP) in persons with type 1 diabetes mellitus.

DESIGN

A longitudinal population-based cohort of persons with type 1 diabetes mellitus was followed from 1990-1992 through 2005-2007.

METHODS

Prevalence and 15-year cumulative incidence of GP were defined as outcome variables. Serum high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), soluble vascular cell adhesion molecule-1 (VCAM-1), soluble intercellular adhesion molecule-1, and serum total homocysteine were measured. Multivariate logistic and discrete linear logistic regression modeling was used for data analysis.

RESULTS

After controlling for duration of diabetes and other confounding factors, TNF-alpha (odds ratio (OR) 3.64; 95% confidence interval (CI) 2.33, 5.70), IL-6 (OR 1.41; 95% CI 1.06, 1.88), VCAM-1 (OR 13.35; 95% CI 5.39, 33.07), and homocysteine (OR 2.98; 95% CI 1.73, 5.16) were associated with prevalent proteinuria. Only hsCRP (OR 1.47; 95% CI 1.02, 2.11) was associated with incident proteinuria.

CONCLUSIONS

These findings suggest a role of inflammation and endothelial dysfunction as markers and contributors of the development of diabetic nephropathy in persons with type 1 diabetes mellitus.

Clinical Use and Pathogenetic Basis of Laboratory Tests for the Evaluation of Primary Arterial Hypertension

This review focuses on the laboratory biochemical tests that are useful in the diagnostic approach to the hypertensive patient. A "minimal" diagnostic laboratory work-up, including a small number of tests that are simple and relatively inexpensive, is first described. Because these tests provide basic information on the presence of major cardiovascular (CV) risk factors and target organ damage, and might give some clues to the presence of a secondary form of hypertension (HT), they should be performed on all patients presenting with HT. Other tests that are aimed at assessing the overall CV risk, a major determinant of prognosis that dictates the therapeutic strategy in the individual HT patient, are then discussed. They allow identification of major CV risk factors and associated clinical conditions which, if present, lead to a substantial change of therapeutic strategy. The role of C-reactive protein as a marker of atherosclerosis and its predictive value for CV events are also discussed. Finally, a section is devoted to tests that are currently confined to research purposes, such as markers of endothelial function including endothelin-1, homocysteine and genetic analysis.

Differences in kidney function and incident hypertension: the multi-ethnic study of atherosclerosis

BACKGROUND

Kidney disease and hypertension commonly coexist, yet the direction of their association is still debated.

OBJECTIVE

To evaluate whether early kidney dysfunction, measured by serum cystatin C levels and urinary albumin excretion, predates hypertension in adults without clinically recognized kidney or cardiovascular disease.

DESIGN

Observational cohort study using data from 2000 to 2005.

SETTING

The MESA (Multi-Ethnic Study of Atherosclerosis), a community-based study of subclinical cardiovascular disease in adults age 45 to 84 years.

PARTICIPANTS

2767 MESA participants without prevalent hypertension, cardiovascular disease, or clinically recognized kidney disease (an estimated glomerular filtration rate <60 mL/min per 1.73 m2 or microalbuminuria).

MEASUREMENTS

Cystatin C was measured by using a nephelometer, and urinary albumin and creatinine were measured from a spot morning collection. The primary outcome was incident hypertension, defined as systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, or use of an antihypertensive medication.

RESULTS

During a median follow-up of 3.1 years, 19.7% of the cohort (545 participants) developed hypertension. After adjustment for established hypertension risk factors, each 15-nmol/L increase in cystatin C was associated with a statistically significant 15% greater incidence of hypertension (P = 0.017). The highest sex-specific quartile of urinary albumin-creatinine ratio was associated with a statistically insignificant 16% greater incidence of hypertension (P = 0.192) compared with the lowest quartile. No statistical evidence suggested a multiplicative interaction.

LIMITATIONS

Unmeasured characteristics may have confounded observed associations of kidney markers with hypertension. Follow-up was relatively short. Hypertension that may have occurred between study visits or hypertension that was not captured by standard cuff measurements may have been missed.

CONCLUSION

Differences in kidney function, indicated by cystatin C levels, are associated with incident hypertension among individuals without clinical kidney or cardiovascular disease. These population-based findings complement experimental work implicating early kidney damage in the pathogenesis of essential hypertension.

Prevalence and characteristics of diabetic polyneuropathy in Passo Fundo, South of Brazil

PURPOSE: The aim of the study was to investigate the prevalence of peripheral diabetic neuropathy (PDN) and associated characteristics among type 2 diabetic mellitus (DM2) patients in Passo Fundo, a city on Southern Brazil. BASIC PROCEDURES: A cross-sectional study was conducted with 340 patients with type 2 diabetes mellitus. Tests were performed to evaluate vibration (tuning fork), light touch (10-g monofilament), temperature, and pain (pinprick) sensations, as well as ankle reflexes and heel walking. The condition was classified as peripheral diabetic neuropathy when results in at least three of these tests were negative. The electrically induced Hoffmann reflex test was performed in a group of patients to define the criterion standard used in the assessment of clinical examination sensibility in the diagnosis of neuropathy. Sensitivity was 83%, specificity, 91%, positive predictive value, 63%, and negative predictive value, 90%. The monofilament, pinprick and deep tendon reflex were the most accurate tests in the diagnosis of neuropathy. MAIN FINDINGS: Seventy-five patients (22.1%) had peripheral diabetic neuropathy, nephropathy in 29.5% and retinopathy in 28.8%. CONCLUSIONS: Logistic regression revealed that only duration of diabetes, creatinine and glycated hemoglobin concentrations were significantly associated with neuropathy.

Renal damage in primary aldosteronism: results of the PAPY Study

Primary aldosteronism (PA) has been associated with cardiovascular hypertrophy and fibrosis, in part independent of the blood pressure level, but deleterious effects on the kidneys are less clear. Likewise, it remains unknown if the kidney can be diversely involved in PA caused by aldosterone-producing adenoma (APA) and idiopathic hyperaldosteronism (IHA). Hence, in the Primary Aldosteronism Prevalence in Italy (PAPY) Study, a prospective survey of newly diagnosed consecutive patients referred to hypertension centers nationwide, we sought signs of renal damage in patients with PA and in comparable patients with primary hypertension (PH). Patients (n = 1180) underwent a predefined screening protocol followed by tests for confirming PA and identifying the underlying adrenocortical pathology. Renal damage was assessed by 24-hour urine albumin excretion (UAE) rate and glomerular filtration rate (GFR). UAE rate was measured in 490 patients; all had a normal GFR. Of them, 31 (6.4%) had APA, 33 (6.7%) had IHA, and the rest (86.9%) had PH. UAE rate was predicted (P < 0.001) by body mass index, age, urinary Na+ excretion, serum K+, and mean blood pressure. Covariate-adjusted UAE rate was significantly higher in APA and IHA than in PH patients; there were more patients with microalbuminuria in the APA and IHA than in the PH group (P = 0.007). Among the hypertensive patients with a preserved GFR, those with APA or IHA have a higher UAE rate than comparable PH patients. Thus, hypertension because of excess autonomous aldosterone secretion features an early and more prominent renal damage than PH.

Diabetic nephropathy: diagnosis, prevention, and treatment

Diabetic nephropathy is the leading cause of kidney disease in patients starting renal replacement therapy and affects approximately 40% of type 1 and type 2 diabetic patients. It increases the risk of death, mainly from cardiovascular causes, and is defined by increased urinary albumin excretion (UAE) in the absence of other renal diseases. Diabetic nephropathy is categorized into stages: microalbuminuria (UAE >20 microg/min and < or =199 microg/min) and macroalbuminuria (UAE > or =200 microg/min). Hyperglycemia, increased blood pressure levels, and genetic predisposition are the main risk factors for the development of diabetic nephropathy. Elevated serum lipids, smoking habits, and the amount and origin of dietary protein also seem to play a role as risk factors. Screening for microalbuminuria should be performed yearly, starting 5 years after diagnosis in type 1 diabetes or earlier in the presence of puberty or poor metabolic control. In patients with type 2 diabetes, screening should be performed at diagnosis and yearly thereafter. Patients with micro- and macroalbuminuria should undergo an evaluation regarding the presence of comorbid associations, especially retinopathy and macrovascular disease. Achieving the best metabolic control (A1c <7%), treating hypertension (<130/80 mmHg or <125/75 mmHg if proteinuria >1.0 g/24 h and increased serum creatinine), using drugs with blockade effect on the renin-angiotensin-aldosterone system, and treating dyslipidemia (LDL cholesterol <100 mg/dl) are effective strategies for preventing the development of microalbuminuria, in delaying the progression to more advanced stages of nephropathy and in reducing cardiovascular mortality in patients with type 1 and type 2 diabetes.

Protein-to-creatinine ratio in spot urine samples as a predictor of quantitation of proteinuria

BACKGROUND

Normal individuals usually excrete very small amounts of protein in the urine. Persistently increased protein excretion is usually a marker of kidney damage. Quantifying protein in urine is commonly used in the diagnosis of kidney diseases, detection of treatment effects and evaluation of prognosis. We evaluated the use of the total protein-to-creatinine ratio (P/C) in spot urine specimens as a predictor of urine protein excretion in 24-h collections.

METHODS

The correlation between P/C in first morning and random urine specimens and urinary protein excretion in 24-h collections were analyzed. The cutoff value of P/C in first morning urine specimens for screening urinary protein excretion of 1 and 3 g in 24-h collections was determined by receiver operating characteristics (ROC) curve.

RESULTS

For patients with Ccr<or=10 ml/min, correlation between the urine protein excretion in 24-h collections and the P/C in first morning urine specimens was not significant. For patients with Ccr > 10 ml/min, the correlation was highly significant. Similar results were obtained for random urine specimens. By ROC curve analysis, the P/C of 0.94 and 2.84 g/gcr in first morning urine specimens represent the best threshold to detect urine protein excretion of 1 and 3 g in 24-h collections, respectively. There is a good correlation between P/C in first morning urine specimens and random urine specimens from inpatients and outpatients. But the P/C in random specimens is significantly higher than that in first morning specimens in outpatients.

CONCLUSION

The P/C in spot urine samples could be used as an alternative to urine protein excretion in 24-h collections in patients with Ccr>10 ml/min. The P/C in first morning urine samples is better than that in random specimens, especially for outpatients.

Post-transplant nephrotic syndrome: A comprehensive clinicopathologic study

BACKGROUND

Post-transplant (Tx) nephrotic syndrome (NS) is not well defined.

METHODS

Seventy-four renal transplant recipients with NS were studied.

RESULTS

Biopsies showed chronic allograft nephropathy (CAN) in 31 patients; recurrent glomerular disease (GN) in 15, de novo GN in 18, and undetermined GN in 9. NS developed 0.25 to 384 months post-Tx and was treated with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) in 18 patients; calcium channel blockers in 25; or both drugs in 31. NS remitted in 24% of cases 2 to 28 months after onset, and this persisted in all except 3 patients. The remission rate was lowest (9%) for CAN and highest (47%) for de novo GN. Compared with persistent NS, those with remission showed higher prevalence of de novo GN (53% vs. 17%), lower prevalence of CAN (18% vs. 50%), earlier onset of NS (39 vs. 59 months), lower serum SCr at onset (2.3 vs. 2.9 mg/dL), and higher incidence of treatment with ACE or ARB. The 5-year graft loss rates for CAN, recurrent and de novo GN were 57%, 36%, and 23%, respectively. Compared with the functioning grafts, the failed grafts showed higher prevalence of CAN (60% vs. 16%), lower prevalence of de novo GN (12% vs. 46%), earlier onset of NS (47 vs 65 months post-Tx), higher serum SCr at onset (3.3 vs. 2.0 mg/dL), lower prevalence of remission of NS (5% vs. 48%), and higher proteinuria at follow-up (5.1 vs. 2.5 g/day). Graft survival improved with NS remission (88% vs. 18%).

CONCLUSION

Post-Tx NS displays distinctive clinicopathologic features with pathogenetic and therapeutic implications.

The remission of post-transplant nephrotic syndrome clinicopathologic characterization

Among 67 renal transplant recipients with nephrotic syndrome (NS), nine episodes were reversible in eight patients. Biopsies showed minimal-change disease, focal segmental membranous glomerulonephritis and acute glomerulitis, IgA nephropathy and acute glomerulitis or thrombotic microangiopathy, and chronic transplant nephropathy with or without acute glomerulitis. NS developed 1-4 months post transplant in the four patients with minimal-change disease, but later (33-151 months) in the others. At onset, serum creatinine was normal or elevated. Treatment included calcium-channel blockers, angiotensin-converting enzyme inhibitors, or both, together with routine antirejection therapy. Remission was achieved 4-12 months after onset, when renal function remained normal in four, improved in four, and worsened in one. At last follow-up, six patients still had remission and functional grafts. One lost graft to chronic transplant nephropathy while NS remained in remission. In the remaining patient, proteinuria, which was due to chronic transplant glomerulopathy unrelated to the initial minimal-change disease-associated NS, recurred 50 months post transplant. Remission of post-transplant NS is possible. It is often associated with minimal-change diseases and less frequently with other glomerular lesions, including acute glomerulitis. Reversible post-transplant NS does not have an adverse effect on the renal allografts.

De novo minimal change disease associated with reversible post-transplant nephrotic syndrome. A report of five cases and review of literature

Nephrotic syndrome (NS) is frequent in renal transplant recipients and may be related to a large variety of glomerular lesions. In some of these cases, the transplant biopsy showed no significant glomerular changes and the NS was reversible, but the primary renal disease was not minimal change disease (MCD), suggesting that MCD may develop de novo in renal transplant setting. Knowledge of this entity, however, is limited. Among 67 cases of post-transplant NS encountered in a 12-yr period, five were found to be associated with de novo MCD. A critical review of the literature revealed nine additional cases of de novo MCD. The data from these 14 cases show that patients with de novo MCD had a large variety of primary renal diseases but MCD or focal segmental glomerulosclerosis was not among them. Eight of the 14 transplanted kidneys (60%) were from living related donors, suggesting this as a risk factor. Nephrotic range proteinuria (3-76 g/d) developed immediately or shortly after transplantation (within 4 months for all reported cases, except for one at 24 months). The serum creatinine when NS was first diagnosed was normal or mildly elevated, but acute renal failure occurred in three patients. On biopsy, the glomeruli were normal or, more frequently, displayed mild, focal segmental mesangial sclerosis, hypercellularity, deposition of IgM/C3, or accumulation of mononuclear inflammatory cells in some glomerular capillaries. The tubulointerstitial compartment was normal in cases with normal renal function; displayed mild acute and/or chronic rejection that correlated with a mildly elevated serum creatinine; or showed acute changes including acute rejection, acute tubular necrosis, or acute cyclosporin A toxicity, which accounted for both acute renal failure at presentation and its subsequent reversibility. Under various treatments, including increased steroids, angiotensin converting enzyme inhibitors, calcium channel blockers and angiotensin receptor blockers, sustained remission of NS was achieved in 13 cases, within a year (0.5-12 months) in 10 and later (24, 34 and 98 months, respectively) in three. In the remaining case, the patient died of septic shock 2 months after transplantation. After remission of the NS, the grafts functioned well without or with minimal proteinuria for several years. De novo MCD has characteristic clinical and pathologic features. It represents an important but hitherto underemphasized cause of post-transplant NS, which is potentially reversible and does not adversely affect the renal transplants.

Frequency of proteinuria in type 2 diabetes mellitus seen at a diabetes centre in southern India

The frequency of proteinuria was assessed in a cohort of 1848 diabetic patients attending a diabetes centre in south India. A total of 127 (6.9%) patients had evidence of macroproteinuria and 49 (2.5%) patients had microproteinuria. Thus overall 9.4% of patients had diabetes related proteinuria. In addition, 70 patients (3.8%) had evidence of proteinuria with no evidence of retinopathy. The frequency of both microproteinuria and macroproteinuria increased linearly with duration of diabetes. Multiple logistic regression analysis showed that duration of diabetes, serum creatinine, and glycated haemoglobin were risk factors for macroproteinuria.

Evaluation of a simple, random urine test for prospective analysis of proteinuria in Type 2 diabetes: a six year follow-up study

AIM

To assess the usefulness of an estimated proteinuria (EPE) using the protein to creatinine ratio (P/C ratio) in a random urine sample for follow-up evaluation of kidney function in diabetic patients.

RESEARCH DESIGNS AND METHODS

410 newly registered Type 2 diabetic patients had annual follow-up for 6 years (M:F 263:147). EPE was calculated by estimation of P/C ratio in random urine sample. Based on the EPE they were divided into those with normal protein excretion (<100 mg/dl), mild proteinuria (100 to <500 mg/dl) and nephropathy (persistent proteinuria >500mg/dl) cases. The study subjects were divided into 4 groups based on the proteinuria status at follow-up. Anthropometry, measurement of blood pressure and retinopathy were carried out for all study subjects.

RESULTS

at the baseline, 342 (83.4%) had normal protein excretion, 53 (12.9%) had mild proteinuria and 15 (3.7%) had nephropathy. At the follow-up the respective numbers were 276 (67.3%), 64 (15.6%) and 70(17%). During the study period nephropathy developed in 55 (13.4%) and mild proteinuria in 11 (2.7%). Nephropathy developed in 32 (6.7%) subjects in the non-proteinuria group and in 23 (43.4%) of the mild proteinuric subjects. Conversion to nephropathy was greater in the latter group (chi(2)=41.6, P<0.0001). Nephropathy cases had higher duration of diabetes at the baseline (8.8+/-6.4 years) and at follow-up (7.1+/-6.0 years) and higher prevalence of hypertension when compared with non-proteinuric group (60 and 43.5% compared with 11.1%, P<0.01). New cases of hypertension were detected in 32.8% of proteinuric and 0.7% of normal protein excretion subjects (chi(2)=32. 24, P=0.0001). During the follow-up 55 of the 70 nephropathy subjects (78.6%) developed retinopathy compared with ten out of the 276 subjects with normal protein excretion (3.6%) (chi(2)=200.6, P=0. 0001).

CONCLUSION

EPE is useful in serial evaluation of kidney function. The risk conferred by hypertension, mild proteinuria and duration of diabetes in producing nephropathy are also highlighted. EPE could be used in developing countries to assess the renal function on a follow-up basis.