Primary hyperaldosteronism causing posttransplantation hypertension: localization by adrenal vein sampling

A 58 year-old man with end-stage renal disease who had received a cadaveric renal transplant presented with persistent hypertension and hypokalemia. Allograft renal artery stenosis, rejection, and cyclosporine effects were excluded. Hypokalemia persisted despite potassium supplementation and antihypertensive medications with hyperkalemic effects. The biochemical findings of primary hyperaldosteronism with a normal adrenal anatomy imaged by magnetic resonance imaging (MRI) necessitated adrenal vein sampling to lateralize a left adrenal adenoma. His hypokalemia was cured by the removal of the adenoma, and his blood pressure (BP) control was easily achieved with a less complex regimen of antihypertensives. We suggest that the concomitant existence of resistant hypokalemia and posttransplantation hypertension, especially in the cyclosporine era, should stimulate a search for hyperaldosteronism; once transplant renal artery stenosis has been excluded, the patient should be investigated for primary hyperaldosteronism. When imaging studies fail to show adrenal pathology, adrenal vein sampling will likely do so.

Profound persistent eosinophilia in a patient with spontaneous renal atheroembolic disease

We describe an elderly women who died of renal failure secondary to spontaneous renal atheroembolic disease. The sole clinical clue to this diagnosis was a profound eosinophilia up to 19,100/mm3 and a relative eosinophil count of 80%. Renal atheroembolic disease should be a prominent consideration in any patient with both renal insufficiency and peripheral eosinophilia.

Lack of amyloid in abdominal fat aspirates from patients undergoing long-term hemodialysis

Recent reports describe the carpal tunnel syndrome (CTS) due to amyloid infiltration of the beta 2 microglobulin protein as a frequent complication of long-term hemodialysis. Carpal synovial and cystic bone lesion amyloid deposits have been reported; however, the extent of systemic amyloid deposition has not been determined. We examined 30 patients undergoing long-term hemodialysis for CTS and performed abdominal fat tissue aspiration for amyloid staining to evaluate the presence of systemic amyloid disease. In this group, CTS was frequent (37%) and its prevalence correlated with the duration of hemodialysis. In all patients, the abdominal fat tissue, stained with Congo red, was negative for amyloid deposits. These results confirm that CTS is a frequent complication of long-term hemodialysis; however, in this study, no detectable amyloid deposits were found in abdominal subcutaneous fat tissue. Thus, abdominal fat aspiration may not be a reliable screening test for hemodialysis-associated amyloidosis.

Transplant ureteral obstruction masquerading as recurrent rejection episodes: management by percutaneous antegrade balloon dilatation

We report a 52-year-old male renal transplant recipient who had three "rejection episodes." The first of these responded to conventional antirejection therapy; however, the next two episodes showed incomplete responses to treatment for rejection. At subsequent presentation with deteriorating renal function, ureteral obstruction was evident and was relieved with percutaneous antegrade balloon dilatation with a return of his plasma creatinine to normal. Obstruction of the ureter was a major component in our patient's course given the lack of response to conventional antirejection therapy and the normalization of renal function with relief of the documented ureteral stenosis. This case illustrates that ureteral obstruction can mimic rejection in the renal transplant recipient. Management of ureteral stenosis in transplant patients with percutaneous antegrade balloon dilatation appears to be an effective procedure and can supplant the need for open surgical procedures.

Local steroids in dialysis-associated pericardial effusion. A single intrapericardial administration of triamcinolone

Five patients receiving maintenance hemodialysis for end-stage renal disease underwent therapeutic pericardiocentesis for pericarditis manifested by either cardiac tamponade or effusion unresponsive to conservative therapy. Pericardiocentesis was followed by a one-time instillation of triamcinolone hexacetonide, a nonabsorbable corticosteroid, into the pericardial space with subsequent needle withdrawal. All patients had prompt hemodynamic and symptomatic improvement. Serial echocardiograms showed resolution of the pericardial effusion in all patients. Follow-up evaluation for six months to six years has shown no clinical or postmortem evidence of recurrence. This procedure appears safe and effective and potentially can obviate the need for prolonged catheter drainage or more invasive surgical procedures as therapy for these patients.

Anaphylaxis: an unusual complication of hemodialysis

Anaphylaxis is a rare complication of hemodialysis. Unless there is a high index of suspicion, symptoms may not be immediately recognized as a manifestation of hypersensitivity and prompt attention may be delayed. To improve physician awareness of this problem we report a patient who developed a severe anaphylactic reaction within minutes of beginning dialysis. Review of the literature indicates that hypersensitivity reactions are most commonly associated with Cuprophan dialyzers. Although the etiology has not been established, recurrence can be prevented by selection of a different type of dialysis membrane.

Depressed spontaneous cellular cytotoxicity associated with normal or enhanced antibody-dependent cellular cytotoxicity in patients on chronic haemodialysis

Lymphocyte function as assessed by spontaneous cellular cytotoxicity (NK) and antibody-dependent cellular cytotoxicity (ADCC) was studied in a group of 23 patients with end-stage renal disease who were being maintained on haemodialysis. The mononuclear cells from 12 (50%) of these patients were markedly reduced in their ability to effect NK activity. When mononuclear cells from 13 patients were examined for ADCC activity, however, only two displayed reduced cytotoxicity. The remainder showed either normal or enhanced ADCC activity against erythrocyte targets. Five patients with consistently low NK cell function demonstrated a significantly enhanced ADCC function when compared with normal controls. Several patients were tested repeatedly over a period of 6 months and we found that these two mononuclear cell functions remained consistent during this time. A reduction in NK activity may reflect a lessened capability for immunosurveillance in these patients.

Transposed basilic vein-brachial arteriovenous fistula. A reliable secondary-access procedure

Over a two-year period, 25 transposed basilic vein-brachial arteriovenous fistulas were created as secondary vascular access procedures in patients undergoing chronic hemodialysis. The operative technique is described in detail. One-year patency rate by life-table analysis was 85%. There were two minor complications. The procedure is advocated as a reliable secondary-access procedure when a radial-cephalic arteriovenous fistula cannot be constructed or has failed.

De novo development of membranous nephropathy in cadaver renal allografts

Glomerulonephritis in transplant recipients often reflects recurrence of the immunopathogenetic mechanism causing the original renal disease. Membranous nephropathy (MN), a progressive immune complex mediated glomerular disease and the commonest cause of idiopathic nephrotic syndrome in adults, has been virtually unreported in transplant recipients. Two cases are reported here of typical MN (by clinical, light, immunofluorescent and electron microscopic criteria) developing de novo in the transplants of patients whose original diseases were anti-GBM nephritis and focal glomerular sclerosis. NM developed following episodes of viral hepatitis and renal infarction respectively. Possible mechanisms by which this lesion might develop in these patients are investigated and discussed. Chronic immune complex nephropathy (MN) can develop de novo in immunosuppressed transplant recipients apparently initiated by events in the post-transplant period.

Prognosis in steroid-treated idiopathic nephrotic syndrome in adults. Analysis of major predictive factors after ten-year follow-up

This long-term study analyzes the prognostic value of the quantitative urinary protein excretion during and following steroid administration, the renal functional status three years after the onset of disease, and the degree of histologic damage in adult patients with steroid-treated idiopathic nephrotic syndrome (INS). No patient who had a complete (proteinuria less than 0.1 gm/day) or partial (proteinuria less than 2.0 gm/day) remission during steroid administration progressed to renal failure. Furthermore, no patient in whom urinary protein excretion subsequently fell to below 2.0 gm/day ever progressed to renal failure. Only 3 of 49 patients in whom renal function was normal three years after the onset of INS developed renal failure. Finally, renal failure occurred in only 2 of 28 patients with mild abnormalities by light microscopy, compared with 12 of 21 patients with more advanced glomerular abnormalities. Thus, a partial, as well as a complete remission during steroid administration, subsequent reduction in proteinuria to below 2 gm/day, persistence of normal renal function beyond three years, or the presence of mild histologic abnormalities auger a favorable long-term prognosis in patients with INS.

Renal failure in Burkitt's lymphoma

A case of Burkitt's lymphoma with renal failure due to massive infiltration of the kidney is reported. There was a striking initial response to chemotherapy with a parallel improvement in renal function and decrease in renal size. The rare occurrence of renal failure due to lymphomatous infiltration of the kidney parenchyma in the absence of urinary tract obstruction is reviewed.

Beneficial effects of methylprednisolone "pulse" therapy in diffuse proliferative lupus nephritis

Seven patients with diffuse proliferative lupus nephritis were subjected to highdose intravenous methylprednisolone (pulse) therapy. Following the pulse, five patients with rapidly deteriorating ranal function improved within three days and their serum-creatinine levels returned to baseline by one month. All seven patients demonstrated reversal of severe immunological abnormalities including increased serum D.N.A binding, decreased serum C3 levels, and reduced number of T lymphocytes in the peripheral blood. This form of therapy may make it possible to maintain patients with lupus nephritis on lower doses of steroids than is normally feasible.

Successful renal transplantation in focal glomerular sclerosis: report of two cases

The fate of renal allografts has provided much useful information about the pathogenesis of certain glomerular diseases. Idiopathic nephrotic syndrome with focal glomerular sclerosis (FGS) has been reported to recur in transplants. Two patients are reported with idiopathic nephrotic syndrome who progressed to renal failure. Immunopathologic and ultrastructural studies appeared to exclude immune pathogenic mechanisms in both patients, and light microscopic findings were characteristics of FGS. The nephrotic syndrome in one patient was initially steroid-dependent. Both patients underwent bilateral nephrectomy prior to renal transplantation. Graft function and urine protein excretion were normal in both patients 2 and 4 years respectively after transplantation, and transplant biopsies revealed no evidence of recurrent FGS. These results indicate that renal transplantation in patients with idiopathic nephrotic syndrome and FGS is not invariably followed by recurrent glomerular disease and suggest that the responsible pathogenetic mechanism(s) may not always persist.

Nephrotoxicity associated with cephalothin administration

Variable degrees of acute renal failure developed in three patients receiving therapy with cephalothin sodium. The course and findings were consistent with acute tubular necrosis of the oliguric and nonoliguric types. One patient had protracted oliguria, a second experienced transient oliguria, and one had normal urine output. All had urinary sediment changes consistent with tubular necrosis, and the two oliguric patients had elevated urine sodium concentrations. No other causes for renal failure could be detected, and all recovered after discontinuation of cephalothin therapy, although peritoneal dialysis was required in one patient. These observations indicate that cephalothin is capable of inducing renal damage in man.

Effect of rabbit ALG on cadaver kidney transplant survival

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