The Nephrotoxicity of Drugs Used in Causal Oncological Therapies

In recent years, a dynamic development of oncology has been observed, resulting from the increasingly frequent occurrence of neoplasms and therefore, increasing population of patients. The most effective form of therapy for cancer patients is complex multidisciplinary specialized disease management, including nephro-oncology care. Different forms of renal function impairment are frequently diagnosed in cancer patients. They are caused by different co-morbidities existing before starting the oncologic treatment as well as the direct undesirable effects of this therapy which may cause temporary or irreversible damage of the urinary system-especially kidneys. According to different therapeutic programs, in such cases the degree of renal damage is often crucial for the possibility of further anti-cancer treatment. Medical personnel responsible for delivering care to oncology patients should be properly educated on current methods of prevention and treatment of renal complications resulting from anti-cancer therapy. The development of oncologic medicines design, including especially immuno-oncological agents, obliges us to learn new patomechanisms determining potential adverse effects, including renal complications. This publication is focused on the most important undesirable nephrotoxic effects of the frequently used anti-cancer drugs.

Cystinuria poorly responding to treatment - the risk of chronic kidney disease

Cystinuria is the genetic condition for the increased excretion of cystine in the urine. Patients mainly suffer from afflictions related to the presence and passage of kidney stones. The currently available treatment methods include conservative treatment based on increased fluid intake, appropriate diet, medications and urological procedures. The causal treatment has not yet been invented.

A CASE REPORT

A patient case was described whose first symptomatic kidney stones appeared after the second year of life. Urinary cystine excretion was significantly increased - 25,431 μmol/1g creatinine (norm: 167-333 μmol/1g creatinine), which was also shown, but lower, in both parents of the patient. Despite the early initiation of therapy including low sodium diet, abundant hydration, alkalization, captopril and compliance with stringent restrictions, the level of urinary cystine excretion was still not within the normal range. There have been many modifications to the therapy and dose increases of drugs, but without visible results. The patient underwent several urological procedures, including: ESWL (Extracorporeal shock wave lithotripsy), URSL (Ureteroscopic lithotripsy), PCNL (Percutaneous nephrolithotomy) and open surgery to remove cystine deposits that were still produced in the kidneys. In addition, for many years the disease was complicated by recurrent urinary tract infections, underweight and lesions like epithelial metaplasia in the bladder. Renal parameters were repeatedly examined. Elevated results such as: serum creatinine 0.9 mg/dl, cystatin C concentration 1.10 mg/l, albumin-creatinine index 0.197, creatinine clearance 50.7 ml/min /1.73 m2 and eGFR 73 ml/min/1.73 m2 allowed for the diagnosis of chronic kidney disease before the age of 18. After many years of conservative treatment, only the introduction of thiopronine, still little known in Poland, reduced the level of cystine excreted in the urine. The inclusion of the drug reduced the tendency to produce kidney stones, which allowed to inhibit the progression of renal failure.

CONCLUSIONS

Despite many years of research and modern drugs, cystinuria is still a disease with which patients are associated for the rest of their lives. The ongoing research, along with attempts to understand the genetic and epigenetic mechanisms responsible for the emergence of mutations in the main genes causing the disease and the course of the disease, gives hope for finding a method of causal treatment for cystinuria.

Continuous renal replacement therapy as a treatment of selected acute intoxications

The methods of extracorporeal elimination remain a particularly useful therapy of selected, most severe intoxications caused by drugs and other chemical substances. The hemodialysis (HD) is the most commonly used therapy, which results from the widest availability of this method. However, due to the gradual spread of modern continuous dialysis techniques, continuous veno-venous hemodialysis (CVVHD) in particular creates a new opportunity of treatment of severe intoxications - especially in patients with cardiovascular complications. The review of literature dealing with the experience in using continuous methods of treatment of selected severe intoxications is presented in the article. Taking into account a lack of analyses assessing the efficacy of different toxicological methods used in large populations of patients, the experiences are mainly based on individual case reports. The presented data indicate that CVVHD may be treated as the preferred method of treatment of severe intoxications in hemodynamically unstable patients. Moreover, CVVHD may be useful as a continuation of therapy following the initial HD treatment.

Application of the Molecular Adsorbent Recirculating System in Type 1 Hepatorenal Syndrome in the Course of Alcohol-Related Acute on Chronic Liver Failure

BACKGROUND This study aimed to evaluate the Molecular Adsorbent Recirculating System (MARS) effectiveness in patients with alcohol-related acute-on-chronic liver failure (AoCLF) complicated with type 1 hepatorenal syndrome (HRS). So far, MARS efficacy and safety has been demonstrated in various acute liver failure scenarios. MATERIAL AND METHODS Data from 41 MARS procedures (10 patients with type 1 HRS, in the course of alcohol-related AoCLF were considered for this study. Biochemical tests of blood serum were performed before and after each procedure. The condition of patients was determined before and after the treatment with the use of the model for end-stage liver disease - sodium (MELD-Na) and the stage of encephalopathy severity based on the West Haven criteria. RESULTS During the observation period (20.5±13.9 days), 5 patients died, and the remaining 5 surviving patients were discharged from the hospital. In the group of 10, the 14-day survival, starting from the first MARS treatment, was 90%. The MARS procedure was associated with a 19% reduction in bilirubin (27.5±6.1 versus 22.3±4.0 mg/dL, P<0.001), 37% reduction in ammonia (44.1±22.5 versus 27.6±20.9 P<0.001), 27% reduction in creatinine (1.5±1.0 versus 1.1±0.6 mg/dL, P<0.001) and 14% reduction urea (83.8±36.1 versus 72.1±33.3, P<0.001) in blood serum samples, with stable hemodynamic parameters. In the group of patients discharged from the clinic (n=5), the MARS treatments resulted in an improvement in hepatic encephalopathy (West Haven; P=0.043), as well as a reduction in the MELD-Na score (P=0.015). CONCLUSIONS MARS is a hemodynamically safe method for supporting the function of the liver and the kidneys. Application of the MARS reduces the symptoms of encephalopathy in patients with alcohol-related type 1 HRS.

Infective endocarditis in chronic hemodialysis patients is it still a growing clinical challenge?

Patients requiring chronic dialysis are at increased risk for a severe complication such as Infective Endocarditis (IE). Infections, immediately after cardiovascular diseases, are the second leading cause of deaths in this group of patients. In the Polish population, the incidence of IE in hemodialysis patients is unknown.

AIM

The aim of the study was to present epidemiology, clinical and echocardiographic characteristics and microbiological profile of infective endocarditis with the evaluation of the suitability of the modified Duke criteria for the diagnosis of IE in hemodialysis patients.

MATERIALS AND METHODS

The aim of the study was to present epidemiology, clinical and echocardiographic characteristics and microbiological profile of infective endocarditis with the evaluation of the suitability of the modified Duke criteria for the diagnosis of IE in hemodialysis patients.

RESULTS

Ten cases of IE in HD patients were diagnosed. The incidence of IE was 1.55/10,000 dialysis sessions/year. The incidence rate for IE in the dialysis population was 2,000/100,000 patients/year, while the incidence rate for IE in all hospitalized individuals was 5/100,000 patients/year. Hemodialyzed patients had significantly higher odds of having IE compared to other hospitalized individuals (odds ratio [OR] = 69; 95%; CI: 35.92-132.06,p<0.0001). Mitral valve involvement was the most frequent. The most common IE etiology was Staphylococcus species. Based on the modified Duke criteria, the "definite IE" was recognized in one case whereas remaining 9 cases were classified as the "possible IE".

CONCLUSIONS

In hemodialyzed patients the risk of IE is approximately 69 times higher than in the general hospitalized population. Right heart valve involvement occurs seldom despite the presence of vascular catheters. The modified Duke criteria have a limited applicability in the diagnosis of infective endocarditis.

[The role of high cut off membranes in renal replacement therapy of acute kidney injury in the course of sepsis - the current state of knowledge]

Sepsis as a systemic inflammatory reaction to infection is an important interdisciplinary clinical problem. Over the past 20 years, the number of patients who have contracted sepsis has doubled. The occurrence of acute kidney injury in the course of sepsis increases mortality twice, while chronic kidney disease develops in 50% of the patients who survived sepsis. The pathophysiology of acute kidney injury (AKI) development in the course of sepsis is not fully understood. Some researchers, to emphasize the distinctiveness of AKI in the course of sepsis, describe the changes that occur in the kidneys in its course as sepsis induced-AKI. In the last decade, the theory regarding the possibility of modulation of inflammatory pathways through extracorporeal blood purification methods (HCO - using high cut off membranes) from pro-inflammatory cytokines and attempts to restore homeostasis in this way has gained great recognition. The basis for the implementation of this type of treatment was the "maximum concentration" hypothesis, which assumes that, avoiding the onset of the early peak of circulating proinflammatory molecules is possible to prevent and modulate the clinical effects of an excessively expressed inflammatory reaction in the course of sepsis. This study is an attempt to analyze and summarize the current state of knowledge on the effectiveness of using HCO membranes in patients with sepsis who have developed AKI. For this purpose, the resources of MEDLAIN/Pubmed bases from 1965 to April 2018 have been analyzed, taking into account only the full versions of articles in English, using a combination of the following words: super high-flux, high cut-off, dialysis, renal replacement therapy, filtration, diafiltration, hemodialysis, hemofiltration, hemodiafiltration, sepsis, cytokine, inflammatory mediators, inflammation.

[Sepsis - still valid economic and epidemiological problem]

The recognition of sepsis is connected with potentially bad prognosis, high mortality rate and high costs of the therapy. A new definition of sepsis was introduced in 2016. The main role of dysfunction of organs in the course of infection, the potential threat for life and necessity to perform quick diagnosis result from this definition. The review of worldwide literature on sepsis epidemiology and therapy costs was done in the current article. It was observed that the data concerning incidence of sepsis in Polish hospitals are incomplete, related to single observations, and in most cases they come from retrospective analyses. Therefore, the nation-wide registry comprising the data of the sepsis cases should be established.

Removal of Procalcitonin and Selected Cytokines during Continuous Veno-Venous Hemodialysis Using High Cutoff Hemofilters in Patients with Sepsis and Acute Kidney Injury

INTRODUCTION

The purpose of this study was to evaluate the impact of continuous veno-venous hemodialysis (CVVHD) using high cutoff (HCO) hemofilters on the removal of procalcitonin (PCT), and other inflammatory markers in the treatment of patients during septic shock with acute kidney injury (AKI).

MATERIALS AND METHODS

Thirty-six patients with septic shock and AKI were included in the study. Before and after the 24-h HCO-CVVHD, PCT, native C-reactive protein (CRP) and cytokines (interleukin-1β, interleukin-6, interleukin-12, interleukin-17, tumor necrosis factor-α) in serum and effluent were assessed.

RESULTS

After the HCO-CVVHD serum concentrations of PCT, CRP and selected cytokines were significantly lower. The decrease in PCT was bigger than in CRP (p = 0.007). The change in PCT concentration was significantly influenced by PCT and IL-17 clearances (R2 = 0.525; p < 0.001).

CONCLUSION

In contrast to the native CRP, monitoring of PCT during HCO-CVVHD is less useful because it reflects the clearance of this marker and anti-inflammatory effectiveness of the method.

Dynamic tissue perfusion assessment reflects associations between antihypertensive treatment and renal cortical perfusion in patients with chronic kidney disease and hypertension

PURPOSE

Renal cortical perfusion measured in noninvasive, dynamic ultrasonic method is connected with the hemodynamic cardiac properties and renal function. Antihypertensive drugs affect the functioning of the heart and kidneys. The aim of the study was to evaluate the effect of a chronic use of antihypertensive drugs on ultrasound parameters of renal cortical perfusion.

METHODS

The study included 56 consecutive patients (49 M + 7 F, age 54.0 ± 13.3) with stable chronic kidney disease and hypertension. Color Doppler dynamic tissue perfusion measurement was used to assess renal cortical perfusion.

RESULTS

Patients were treated with a mean of 2.7 ± 1.4 antihypertensive drugs, of which diuretics accounted for 25%, angiotensin-converting enzyme inhibitors (ACE-I) together with angiotensin receptor blockers (ARB) 24%, beta-blockers (BB) 23%, calcium channel blockers 16%, alpha-1 blockers (α1B) 9% and centrally acting drugs 3%. All investigated groups of drugs correlated significantly with parameters of renal perfusion. In multivariable regression analyses adjusted to age, diuretics were connected with the decrease (r = - 0.473) and ACE-I + ARB (r = 0.390) with the improvement of proximal and whole renal cortex perfusion (R² = 0.28; p < 0.001), whereas BB (r = - 0.372) and α1B (r = - 0.280) independently correlated with worsened perfusion of renal distal cortex (R² = 0.21, p < 0.01).

CONCLUSIONS

The type of antihypertensive therapy had a significant influence on the ultrasound parameters of renal cortical perfusion. Noninvasive, ultrasonic dynamic tissue perfusion measurement method appears to be an adequate tool to assess the impact of drugs on renal cortical perfusion.

Ultrasonic evaluation of renal cortex arterial area enables differentiation between hypertensive and glomerulonephritis-related chronic kidney disease

PURPOSE

Identifying the primary etiology of cardio-renal syndrome in a timely manner remains an ongoing challenge in nephrology. We hypothesized that hypertensive kidney damage can be distinguished from chronic glomerulonephritis at an early stage of chronic kidney disease (CKD) using ultrasound (US) Doppler sonography.

METHODS

Fifty-six males (age 54 ± 15, BMI 28.3 ± 3.5 kg/m2) with hypertension and stable CKD at stages 2-4 [38 with essential hypertension (HT-CKD); 18 with glomerulonephritis (GN-CKD)] were studied. Blood tests, UACR, echocardiography, ABPM, carotid IMT, and an ultrasound dynamic tissue perfusion measurement (DTPM) of the renal cortex were performed.

RESULTS

HT-CKD patients had reduced proximal renal cortex perfusion as well as reduced total and proximal renal cortex arterial area. Proximal renal cortex arterial area ≤0.149 cm2 identified hypertension-related CKD with a sensitivity of 71% and a specificity of 78% (AUC 0.753, p < 0.001).

CONCLUSIONS

Evidence of diminished arterial vascularity or perfusion of renal proximal cortex, both derived from US Doppler, could be helpful in differentiating hypertensive nephropathy from glomerulonephritis-related CKD.

Left ventricular end-diastole hemodynamics is strongly associated with spontaneous cardiac baroreflex in humans

BACKGROUND

In animals, hemodynamic conditions during left ventricular (LV) end-diastole are crucial for the excitation of autonomic afferents distributed throughout cardiac chambers and large thoracic vessels. The objective of the study was to select the echocardiographic indices of LV diastolic function that are the most potent predictors of the heart's spontaneous baroreflex in humans.

METHODS

In 47 untreated hypertensive patients (26 with normal and 21 with increased left atrium diameter) and 24 healthy controls, baroreflex sensitivity (BRS) was assessed in the low (αLF; 0.04-0.15 Hz) and high frequency (αHF; 0.15-0.4 Hz) components in the supine and during tilting. The [Formula: see text] normalized to LV end-diastolic diameter (the [Formula: see text] index) is a marker of the septum late diastolic distension rate ([Formula: see text] denotes peak late diastolic velocity at the septal mitral annulus) under the corresponding transmitral pressure gradient that determines the peak velocity of blood flow (A) into the LV chamber.

RESULTS

The [Formula: see text] markedly stronger than [Formula: see text] ratio correlated with the BRS. In the best-fit models of multivariable linear regression, the [Formula: see text] index was the independent predictor of the αLF BRS at tilting (β = -0.3; p = 0.01). Independent of clinical and echocardiographic parameters, the [Formula: see text] index predicted also both the αHF BRS in the supine position (β = -0.23; p = 0.01) and the αHF BRS reinforcement due to increased preload (β = -0.28; p = 0.001).

CONCLUSIONS

The [Formula: see text] index is a reliable marker of diastolic dysfunction that evokes significant heart's baroreflex impairment and is markedly stronger than [Formula: see text] ratio associated with these systemic consequences of altered LV diastole hemodynamics.

Effectiveness of High Cut-Off Hemofilters in the Removal of Selected Cytokines in Patients During Septic Shock Accompanied by Acute Kidney Injury-Preliminary Study

Background

In recent years there have been attempts to treat sepsis using various methods of extracorporeal blood purification in order to eliminate selected mediators of inflammation.

Material/Methods

This retrospective study assessed 28 patients (17 males, 11 females, age 60.3 ± 14.5 years) in septic shock, treated with continuous venovenous hemodialysis (CVVHD). Oligoanuric patients with acute kidney injury were qualified for 24-hour CVVHD using high cut-off (HCO) hemofilter. Before the start of dialysis and after 24 hours of treatment, the concentration levels of selected cytokines (IFN-α, IFN-γ, TNF-α, IL-1β, IL-2, IL-6, IL-10, IL-12) in serum were assessed. After 12 hours and 24 hours of treatment, the concentration of the same cytokines in the dialysis fluid was assessed. The aim of our study was to evaluate the effectiveness of HCO-CVVHD in the removal of selected cytokines.

Results

After 24-hour HCO-CVVHD treatment, IL-10 and IL-12 levels in serum were significantly lower. Concentrations of INF-α, IL-1β and IL-2 in dialysis fluid significantly increased during HCO-CVVHD, which corresponded with the parallel rise of related clearances. Clearance of IL-6 was approximately four times higher than IL-10. The rise of IL-6 during HCO-CVVHD significantly correlated with mortality due to sepsis.

Conclusions

Continuous venovenous hemodialysis using high cut-off hemofilter proved to be effective in the removal of IFN-α, IL-1β, IL-2 and IL-6, IL-10 and IL-12 from serum in patients during septic shock. The rise of IL-6 during HCO-CVVHD seems to be a marker of bad prognosis in septic shock patients.

Cystatin C as a predictor factor in patients with renal cell carcinoma treated by everolimus

BACKGROUND

We evaluated the influence of serum cystatin C (CysC) with respect to other glomerular filtration rate (GFR) markers on the treatment effect of everolimus in a phase II study in patients with metastatic renal cell carcinoma (mRCC).

MATERIALS AND METHODS

Outcomes were from the study's primary analysis. GFR was calculated according to CKD-EPI-sCr equation, CKD-EPI-CysC equation and CKD-EPI-sCr-CysC equation, Modification of Diet in Renal Disease (MDRD) equation and Cockcroft-Gault (CG) equation, serum levels of creatinine (sCr) and CysC before the treatment.

RESULTS

We observed in 56 patients analysed patients high correlation (R Spearman from ±0.69 to ±1.00; P < 0.0001) between CysC level and GFR markers: sCr, CKD-EPI-sCr, CKD-EPI-CysC, CKD-EPI-sCr-CysC, MDRD, GFR (CG) before everolimus therapy. We observed that the adverse independent predictors for everolimus therapy were increased CysC level [HR: 2.85 (95 % CI 1.34-6.05), P = 0.0065], histologic grade G1/2 [HR: 3.38 (95 % CI 1.59-7.20), P = 0.0016] and increased LDH level [HR: 5.59 (95 % CI 2.52-12.40), P < 0.0001]. Worse OS was seen in multivariate analysis in patients with increased cystatin C level before treatment [HR: 2.60 (1.03-2.60), P = 0.0428], increased corrected calcium level [HR: 2.78 (95 % CI 1.03-7.54), P = 0.0441] and increased LDH level before treatment [HR: 2.34 (95 % CI 1.11-4.97), P = 0.0262].

CONCLUSION

Increased serum CysC level in contrast to other studied GFR markers had predictive significance in patients with mRCC.

D-Galactosamine Intoxication in Experimental Animals: Is it Only an Experimental Model of Acute Liver Failure?

Background

Short-term administration of Galactosamine to experimental animals causes liver damage and acute liver failure (ALF), as well as acute renal failure in some cases. The aim of our study was to describe kidney disorders that developed in the course of galactosamine-induced liver failure.

Material/Methods

Sprague-Dawley rats were randomly divided into 2 groups: a study group administered galactosamine intraperitoneally and a control group administered saline.

Results

All the animals in the study group developed liver damage and failure within 48 h, with significant increase of alanine (p<0.001), aspartate aminotransferases (p<0.0001), bilirubin (p<0.004), and ammonia (p<0.005) and decrease of albumin (p<0.001) concentrations. Acute renal failure was observed in all test animals, with a significant increase in creatinine (p<0.001) and urea (p<0.001) concentrations and a decrease in creatinine clearance (p<0.0012). Moreover, osmotic clearance (p<0.001), daily natriuresis (p<0.003), and fractional sodium excretion (p<0.016) decreased significantly in this group of animals. The ratio of urine osmolality to serum osmolality did not change. Histopathology of the liver revealed massive necrosis of hepatocytes, whereas renal histopathology showed no changes.

Conclusions

Acute renal failure that developed in the course of galactosamine-induced ALF was of a functional nature, with the kidneys retaining the ability to concentrate urine and retain sodium, and there were no renal changes in the histopathological examination. It seems that the experimental model of ALF induced by galactosamine can be viewed as a model of hepatorenal syndrome that occurs in the course of acute damage and liver failure.

Renal perfusion index reflects cardiac systolic function in chronic cardio-renal syndrome

BACKGROUND

Cardiac dysfunction can modify renal perfusion, which is crucial to maintain sufficient kidney tissue oxygenation. Renal cortex perfusion assessed by dynamic ultrasound method is related both to renal function and cardiac hemodynamics. The aim of the study was to test the hypothesis that Renal Perfusion Index (RPI) can more closely reflect cardiac hemodynamics and differentiate etiology of chronic cardio-renal syndrome.

MATERIAL AND METHODS

Twenty-four patients with hypertension and chronic kidney disease (CKD) at 2-4 stage (12 with hypertensive nephropathy and 12 with CKD prior to hypertension) were enrolled in the study. Blood tests, 24-h ABPM, echocardiography, and ultrasonography with estimation of Total renal Cortical Perfusion intensity and Renal Perfusion Index (RPI) were performed.

RESULTS

In the group of all patients, RPI correlated with left ventricular stoke volume (LVSV), and cardiac index, but not with markers of renal function. In multiple stepwise regression analysis CKD-EPI(Cys-Cr) (b=-0.360), LVSV (b=0.924) and MAP (b=0.376) together independently influenced RPI (R2=0.74; p<0.0001). RPI<0.567 allowed for the identification of patients with chronic cardio-renal syndrome with sensitivity of 41.7% and specificity of 83.3%.

CONCLUSIONS

Renal perfusion index relates more strongly to cardiac output than to renal function, and could be helpful in recognizing chronic cardio-renal syndrome. Applicability of RPI in diagnosing early abnormalities in the cardio-renal axis requires further investigation.

Effect of nitric oxide pathway regulation on water/sodium balance and renal function in a rodent model of acute liver and renal failure

BACKGROUND

The pathomechanism of acute hepatorenal syndrome (HRS), a particular form of acute renal failure that occurs in the course of acute liver injury, is still poorly understood. The aim of our study was to estimate the influence of the activation and inhibition of the nitric oxide pathway on the water/sodium balance and development of acute renal failure in the course of HRS.

MATERIAL AND METHODS

We used male Sprague-Dawley rats in the acute galactosamine (Ga1N) model of HRS. The nitric oxide synthase (NOS) inhibitors L-NAME and L-arginine were administered intraperitoneally before and after liver damage.

RESULTS

HRS developed in all tested groups. L-NAME increased osmotic clearance and urine volume more effectively before liver injury. Furthermore, administration of L-NAME increased creatinine clearance both before and after Ga1N injection. A double dose of L-NAME did not yield further improvement before Ga1N injection, but improved creatinine clearance after Ga1N intoxication. Injection of L-arginine increased sodium excretion and urine volume, but only after liver injury. Moreover, L-arginine injected after Ga1N caused significant improvement of the creatinine clearance in a dose-dependent manner.

CONCLUSIONS

Our study shows that inhibition of the nitric oxide pathway improves parameters of water and sodium balance and prevents development of acute renal failure in the course of acute liver injury and liver failure. Activation of the nitric oxide system also has a favorable influence on water/sodium balance and renal failure, but only after liver injury.

[Case of young woman with Graves' disease and incomplete distal renal tubular acidosis with severe progress and cardiac arrest]

Diagnostic of renal tubular disorders can be often difficult. Incomplete form of distal Renal Tubular Acidosis (dRta) in course of Graves' disease was de novo recognized in a young woman hospitalized with a deep deficiency of potassium in blood serum complicated with cardiac arrest. Series of tests assessing the types and severity of water-electrolyte, acid-base and thyroid disorders were performed during a complex diagnosis. During the treatment of acute phase of the disease we intensified efforts to maintain basic life functions and to eliminate deep water-electrolyte disturbances. In the second phase of the treatment we determined an underlying cause of the disease, recognized dRTA, and introduced a specific long-term electrolyte and hormonal therapy. To confirm the diagnosis oral test with ammonium chloride (Wrong-Davies' test) was performed. After completion of the diagnostic and therapeutic process, the patient was included in the nephrological supervision on an outpatient basis. The basic drug for the therapy was sodium citrate. After a year of observation and continuing treatment we evaluated therapeutic results as good and permanent.

[Acute renal failure in the course of renal-ocular syndrome]

Acute tubulointerstitial nephritis with uveitis is described as TINU syndrome. This syndrome, known as a renal-ocular disease, is a rare problem. Until now there have been described 200 cases of TINU all over the world. The most frequent morbidity concerns girls and young women although it may occur at any age. Etiology of this syndrom is unknown. Diagnosis is often difficult as in approximately 65% of cases, ocular symptoms occur later than tubulointerstitial nephritis. General symptoms (fever, weight loss, weakening, fatigue) are frequently nonspecific. There are no randomized studies dealing with treatment of TINU syndrome. Glucocoticosteroids and immunosuppressive drugs are mainly administered. The prospects are generally good, particularly among young children. However, in some patients chronic renal failure develops. Uveitis is treated locally with steroids. The prospects are good as well but inflammation process returns. A study of TINU syndrome has a general purpose of reminding of this disease which is often forgotten by doctors and the problems connected with diagnostics and treatment.

[Acute renal injury in the course of renal-ocular syndrome - case report]

Renal-ocular syndrome is a rare cause of tubulointerstitial renal diseases. A case of 52 years old woman with acute renal injury in the course of acute tubulointerstitial nephritis and uveitis (TINU syndrome) is presented. For diagnosis of kidney disease a kidney biopsy and renal tubular function tests were used. Progression of the renal disease was the cause of the general intensive steroid treatment inclusion. In a short time after treatment initiation, a significant improvement of renal function was observed. Until the time of handing over the article (5 months), no relapse of the disease was noticed. The aim of the study was to present the case of TINU, which is a rarely recognized syndrome as a cause of acute kidney injury and to describe a treatment method.

[The treatment of septic shock with continuous venovenous hemodialysis using high cut-off dialyzer in patient after immediate circulatory arrest]

The decreased immunity which occurs frequently in severely intoxicated patients may led to sepsis. The sepsis may be caused by bacterial toxins in unconscious patients with toxic coma which generate decreased immunity. Apart from the wide spectrum antibiotic therapy, crystalloids, colloids, vasopressin and corticosteroids, the renal replacement therapy may be useful in treatment of sepsis due to its complexes pathophysiology. Taking into account the role of cytokines in sepsis pathomechanism, the trials of treatment using high cut-off (HCO) membranes were performed in the recent years. These membranes remove molecules with mass up to 60 kDa, including cytokines typical for severe sepsis. The usefulness of continuous veno-venous hemodialysis--CVVHD with HCO dialyzer in the treatment of patient in septic shock and multiorgan damage--including damage caused by cardiac arrest was presented in the study. The concentration of IL-1P, IL-2, IL-4, IL-6, IL-10, IL-12, INF-alpha, INF-gamma, TGF-alpha in blood were determined before and after the 24-hours procedure. After the procedure the most evident decrease was observed for IL-4, 6, 10, 12 (17.3%, 31.8%, 83.4% i 22.3% respectively). During the following days the general status of patient improved gradually. The patient was discharged from the hospital after 20 days of hospitalization. His general condition was good, the values of inflammatory parameters were normal and the renal function was correct. There are very few studies describing HCO membranes effectiveness and they were performed on limited populations of patients. The presented case study may contribute to the discussion on the usefulness of dialysis with HCO membranes in the treatment of severely intoxicated patients complicated by serious sepsis resistant to standard antibiotic therapy.

Albuminuria and hyperhomocysteinemia as cardiovascular risk factors in potentially healthy soldiers: A long-term observation

Background

To assess the relations between albuminuria and selected cardiovascular risk factors.

Material/Methods

The study population comprised 200 apparently healthy soldiers aged 28.8±8.1, observed for 36 months.

Results

Albuminuria was revealed in 9% of the studied group at the beginning of the study and in 12.7% at the end of the observation. Albumins increased from 97.0±61.0 mg/24 hours to 165.0±25.7 mg/24 hours after 36 months of observation. The increase of diastolic blood pressure, body mass, C-reactive protein (CRP), and low-density lipoprotein (LDL) was found in the “albuminuria subgroup” after 3 years of observation. This subgroup also presented significantly higher homocysteine and CRP serum concentrations in comparison with the “non-albuminuria group” in the first phase of the study and after 3 years of follow-up.

Conclusions

Albuminuria was found to be a relatively frequent and persistent abnormality in the studied group. The study demonstrated the relationship between the occurrence and the severity of albuminuria and selected biochemical and demographic cardiovascular risk factors. Determination of albuminuria is a useful, early marker of cardiovascular risk in young male professional soldiers.

Acute kidney failure complicating carbon monoxide poisoning

BACKGROUND

Carbon monoxide, albeit common, is rarely associated with renal failure. We report a case of CO-associated kidney failure requiring short-term dialysis.

CASE REPORT

A 33 year-old male was found unconscious in a bathroom equipped with a propane-gas heater. The duration of exposure to carbon monoxide was unknown. The patient was transported to a regional hyperbaric centre;the carboxyhaemoglobin concentration in the blood on admission was 38.3%. After 60 min of exposure to hyperbaric oxygen, he regained consciousness and was transferred to the toxicology department. Mild rhabdomyolysis with acute kidney failure was diagnosed and despite two subsequent hyperbaric sessions, haemodialysis was necessary.The kidney failure resolved within two weeks, and the patient made a full recovery.Discussion and conclusions. Carbon monoxide mainly affects the central nervous system and the myocardium;renal failure may occur due to rhabdomyolysis and hypoxia. Therefore, all CO-poisoned patients should be closely monitored for their renal function.

[Acute kidney injury (AKI) requireing renal replacement therapy in a patient treated with intravenous immunoglobulin]

A case of 49 year old male patient with diabetic nephropathy is presented in whom the use of immunoglobulin in a 5-day regiment of 0.4 mg/kg/day because of diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) cause acute kidney injury requireing hemodialysis treatment. One hemodialysis was conducted. AKI is a rare complication of immunoglobulin treatment and occurs with the coexistence of risk factors. The prognosis--as in described patient--is good.

Translumbar inferior vena cava cannulation

BACKGROUND

The aim of the study was to review our three year experience with translumbar insertion of dialysis catheters.

METHODS

In five adult patients (4 males and one female, mean age 45 yr), requiring dialysis due to end-stage chronic renal failure, the inferior vena cava was cannulated because of the impossibility of using any other approach. All procedures were performed under fluoroscopy. After visualisation of the inferior vena cava by injection of contrast medium into a peripheral vein, the vena cava was punctured with a 20 cm long needle, at the L3 level. The position of the needle was confirmed by injection of contrast medium, and the vein was then cannulated with a peel-away cannula, using a standard Seldinger technique. Subsequently, a pre-tunneled silastic catheter was introduced and secured.

RESULTS

The catheters were used for from 3 to 10 months. No case of permanent catheter dysfunction was noted. Three episodes of temporary thrombosis, in two patients, were successfully treated with heparin and urokinase. Three catheters became contaminated, but they were treated without the necessity for catheter removal.

CONCLUSION

The described method is a safe and effective way of securing haemodialysis access in patients where a standard approach is not possible.

[Nephrotic syndrome in the course of primitive neuroectodermal tumor--case report]

Case of Primitive Neuroectodermal Tumor (PNET) in a 47 years old woman with renal failure and nephrotic syndrome is presented. Few similar cases in adults reported in the literature with a variable, nonspecific clinical presentation and an aggressive course are discussed.

[Translumbar cannulation of vena cava inferior as an alternative method of vascular access for hemodialysis]

The aim of our report is description of the first in Poland translumbar cannulation of vena cava inferior used as an alternative vascular access for hemodialysis in 62 years old patient without further access for hemodialysis and no access for peritoneal dialysis.

[Hemorrhage from stomach ulceration in chronically hemodialysed patient after planned tonsillectomy]

We present a chronically hemodialysed patient who developed an acute throat hemorrhage after standard tonsillectomy, planned as a standard surgery for purulent tonsillitis being contraindication to kidney transplantation in this case. Hemorrhage diagnosed firstly as a local post tonsillectomy complication proved to be caused by in the acute stomach ulcer. In the discussion we present the differentiate diagnosis as well as procedures which should be undertaken in hemodialysed patients who develop acute hemorrhage episodes from upper respiratory tract after tonsillectomy.

[Mediastinal cyst in a patient on continuous ambulatory peritoneal dialysis successfully treated with video-assisted thoracic surgery (VATS)]

Renal transplantation is the most effective form of renal replacement therapy of irreversible renal insufficiency. Due to posttransplant long term immunosuppressive treatment careful evaluation of the recipient is essential, especially detection and elimination of all potential sources of malignancy. In this paper, we describe successful video assisted thoracoscopic surgery of mediastinal cyst in peritoneal dialysis patient prepared for renal transplantation.

[New diagnostic and therapeutic methods in pseudoaneurysm of arterio-venous fistula for hemodialysis--case report]

On the basis of case of 78 years old female patient being on chronic hemodialysis we present the usefulness of spiral computed tomography in the diagnosis of pseudoaneurysm complicating arterio-venous fistula for hemodialysis as well as usefulness of endovascular stent for closing such pseudoaneurysm.

[Pseudoaneurysms after femoral arteries cannulations in hemodialysed patients--preliminary data]

Patients undergoing chronic haemodialysis (HD) therapy have higher risk of arterial injury during cannulation for diagnostic and therapeutic procedures. Aim of our study was to evaluate frequency of femoral pseudoaneurysms (FPA) occurring after femoral artery (FA) cannulation (FAC) as well as presentation of ultrasound guided compression (USGC) of FPA.

MATERIAL AND METHODS

From the group of 340 HD patients in our Centre in years 1996-2003 37 consecutive HD patients (23M, 14F, aged 55, 5 +/- 8, 2years, on HD 24, 2 +/- 22,6 months) after FAC, indicated from cardiological point of view, underwent regular femoral colour duplex USG.

RESULTS

In 21 pts we found no local complications. In 16 of 37 pts 7 hematomas (HM) and 9 femoral pseudoaneurysms (FPA) were found. All HM were treated conservatively. From 9 FPA cases, 2 thrombosed spontaneously and the remaining 7 pts were treated firstly with USG guided controlled compression (UGCC). UGCC resulted in successful thrombosis of FPA in 3 pts with mean volume of FPA 40 +/- 12 ml but failed in 4 other pts with mean volume of FPA 39 +/- 17 ml.

CONCLUSION

Our preliminary results show, for the first time in the literature, that occurrence of FA damage might occur rather often in HD pts qualified for this procedure from cardiological point of view. Pseudoaneurysms of FA, being in our material the most frequent pathology, should be promptly diagnosed with colour duplex USG and subsequently treated non surgically with USG guided controlled compression.

[Microalbuminuria and atherosclerosis risk factors in potentially healthy men--preliminary data]

The aim of the study was the assessment of occurrence of microalbuminuria (MI) and selected biochemical atherosclerosis risk factors in the group of potentially healthy men.

MATERIAL AND METHODS

In the studied group were 200 men in mean age 28.7 +/- 8.1 years. In the first part of the study all participants filled environmental inquiry concerning the cardiovascular risk factors. On the basis of qualitatively and then quantitatively MI measurement the whole studied group was divided in two subgroups: A (18 men with MI) and B (182 men without MI). In the second part of the study, in both groups we investigated occurrence of abnormal levels of atherosclerosis risk factors such as: total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, uric acid, glucose, homocysteine (HCYS), C reactive protein (CRP). In the whole group we measured blood pressure, BMI and WHR.

RESULTS

In the group with MI we found mean HCYS levels 14.75 micromol/ml. This value was higher then in the group without MI (p < 0.0007). Mean level of CRP in group with MI was 0.24 mg/dl and was higher than in the group without MI (p < 0.04). Levels of HDL and ApoA in the group with MI were 49.05 mg/ml and 1.46 mg/ dl and were lower than in the group B (p < 0.03 and p < 0.036 respectively). The most important factors preceeding MI were age and level of LDL cholesterol.

CONCLUSIONS

Our preliminary data suggest that MI might be important atherosclerosis risk factor in potentially healthy men.

[Chlamydia pneumoniae antibodies and other atherosclerosis risk factors in haemodialysed patients. Preliminary report]

Nowadays, it is considered that viral or bacterial infections can influence atherosclerosis development rate. One of them is infection by Chlamydia pneumoniae. The aim of the study was to assess the occurrence of anti-Chlamydia pneumoniae antibodies (AChPA) and their relationship with biochemical and clinical atherosclerosis risk factors in haemodialysed patients. There were 38 patients (24M, 14F) at the mean age 63.3 +/- 14.5 years, haemodialysed for 30.9 +/- 26.1 months. Previous Ch. Pneumoniae infection was assessed based on AchPA IgA and IgG concentrations determined using SIMPLE INDEX. The following risk factors for atherosclerosis were checked in the study group: total cholesterol. CRP and iPTH. AChPA indicative for Ch. pneumoniae infection in the past were detected in 28 patients (74%). The study group was divided into two subgroups; A- (n = 28 patients) with serological features of previous Ch. pneumoniae infection and B- (n = 10 patients) without serological features of Ch. pneumoniae infection. We found no statistical difference between the groups in the studied biochemical factors. We found no correlation between AChPA and other atherosclerosis risk factors. Our preliminary report does not confirm the prognostic value of AChPA presence as an atherosclerosis risk factor in haemodialysed patients.

[Spiral computed tomography in evaluation of arteriovenous fistula for hemodialysis. Preliminary report]

Failure of arteriovenous fistula (AVFf) still remains the "Achilles'heel" of chronic haemodialysis (HD) programme. Therefore, early, potentially non-invasive diagnosis and prompt surgical correction of AVFf are needed. For these purposes spiral computed tomographic angiography (SCTA) was used for evaluation of clinically suspected AVFf in 19 patients (10M/9F, aged 58.6 +/- 14.6 years, on HD for 34.4 +/- 29.3 months). SCTA was performed using Marconi MX8000 scanner covering whole AVF. After intravenous administration to the peripheral vein of the other leg of 100 ml of non-ionic lomeron 350 contrast (3 ml/s), axial CT images were obtained helically covering whole surface of AVF. Time delay was measured by Trigger function. Maximum Intensity Projections (MIP), 4D-Angio and virtual endoscopy (VE) techniques were used for reconstruction. MIP images demonstrated contrast-enhanced vascular structures and other high-density tissues (calcifications). VE enabled non-invasive simulation of endoscopic procedures and interactive intravascular navigation. Total number of 24 SCTA were performed. We found normal patency of AVF in 5 patients. In the remaining 14 subjects, the following abnormalities were found: stenosis of AVF at the site of anastomosis or in distal segment of efferent vein in 6 SCTA examinations, dilatation in 7 SCTA, acute or chronic thrombosis of AVF in 9 SCTA procedures including total occlusion of AVF in 2 cases. In 2 cases pseudoaneurysms of AVF were found. In 7 SCTA examinations more than one reason of AVFf was found. Photographs of every AVF complication are presented. We noted only one complication of SCTA-rupture of venous vessel on the opposite arm during contrast injection. There were no hypersensitivity reactions to the contrast.

[Report on the Second International Course of Critical Care Nephrology, Vicenza, Italy, May 22-25, 2001]

This report is devoted to the Second International Course of Critical Care Nephrology with special interest to epidemiology, pathogenesis, diagnosis and intensive renal replacement therapy of acute renal failure in patients hospitalised in intensive care units.

[Pseudoaneurysm of arteriovenous fistula for haemodialysis]

On the basis of two cases of haemodialysed patients we present the usefulness of spiral computed tomography in the diagnosis of pseudoaneurysm as a complication of arteriovenous fistula for haemodialysis.

[Biochemical risk factor for atherosclerosis in young men. Preliminary report]

Atherosclerotic damage of cardiovascular system, including kidneys, is an increasing problem not only in the modern cardiology but also in nephrology and dialysotherapy. The purpose of our study was to evaluate the frequency of particular biochemical risk factors for atherosclerosis (RFfA) in young men being over-pressed with psychological stress because of decisive character of their professional job. There were 68 men in mean age 33.3 +/- 7.4 years, being employed in the state administration for mean 10.9 +/- 7.5 years. On the basis of the results of environmental questionnaire the studied group was divided into two subgroups: subgroup A "passive" (30 persons) which was physically passive (employed in the administration) and subgroup B "active" (38 persons) whose professional job was connected with physical activity. The following biochemical RFfA in the blood were examined: cholesterol and its fractions, triglycerides, urea acid, glucose, fibrinogen, C-reactive protein, homocysteine and antibodies against Chlamydia pneumoniae. The results were as follows: total cholesterol above 200 mg/dl in 63%, LDL cholesterol above 130 mg/dl in 60% and HDL cholesterol below 50 mg/dl in 31% of men. Among "new" RFfA we found "cardiological" (above 0.2 mg/dl) levels of CRP almost in 25% of the whole group. There were no statistically significant differences with respect to the studied RFfA between "active" and "passive" group. On the basis of these preliminary results we presume, that potentially healthy men over-pressed with psychological stress because of decisive character of their professional job, are characterized--independently on the proclaimed physical activity--by high frequency of risk factors for premature atherosclerosis.

[Diagnostic and therapeutic problem of infected arteriovenous fistula for hemodialysis-case report]

On the case of 48 old patient with chronic renal failure, treated with repeated hemodialyses, we described diagnostic and therapeutic problems of infected arterio-venous fistula of severe clinical course and rare epidemiology (Staphylococcus warneri). Special attention was paid to the difficulties in the confirmation of bacterial etiology of this infection as well as practical usefulness of ultrasonography in the monitoring of clinical course and therapy of infected arteriovenous fistula.

[Doppler sonography assessment of renal arteries against the cardiovascular risk factors in young men--preliminary report]

The purpose of this study was to find out a relationship between cardiovascular risk factors (CVRF) and abnormal results of Duplex Doppler sonography (DD), suggesting renal artery stenosis (RAS). The group of 30 potentially healthy men (age: 35.5 +/- 7.9) randomly selected from population of 200 young men, underwent DD of renal arteries. Abnormal results of DD study, suggesting RAS were found in 19 of 30 men (63%). In this group, occurrence of 3 or more CVRF was significantly higher (15/19) than in the group with normal results of DD (5/11; p < 0.05). The significantly higher (77%; p < 0.05) occurrence of the abnormal DD and the significantly longer (p < 0.001) duration of habitual tobacco smoking were also found out in the group with RR > or = 130/85 mm Hg, in comparison to the group with RR < 130/85 mm Hg. Emphasizing preliminary character of this study and the need of confirmation on larger population, it seems reasonable to consider the assessment of renal arteries with DD in the population of men with cardiovascular risk factors.

[Coping style with stress against chosen biochemical risk factors of atherosclerosis in potentially health men]

The aim of the study was to assess the relationship between some psychological variables and biochemical and inflammatory risk factors for atherosclerosis in healthy men. Studied group, 70 potentially healthy men randomly selected from the group of 200 potentially healthy men previously screened for atherosclerosis risk factors, workers of state administration in mean age of 33.3 +/- 7.4 years, with mean duration of job employment 10.9 +/- 7.5 years, was divided into two groups of 35 persons each, according to physical activity: "active" and "passive". For psychological examination we used Coping Inventory for Stressful Situations Questionnaire (CISS) and State and Trait Anxiety Inventory (STAI). "Passive" group had better results in scales: I--task oriented coping; II--emotion oriented coping; III--avoidance oriented coping; IV--distraction. "Active" group had better results in scales: IIIB--social diversion, LS--anxiety as a state; LC--anxiety as a trait. These differences were not statistically significant. Among biochemical atherosclerosis risk factors mean levels of LDL, triglycerides (TRIG) and C-reactive protein (CRP) were higher in "passive" group. HDL was higher in "active" group. There were no statistical significant differences between both groups, too. Statistical analysis showed positive correlation of LC with scale II in both groups (r > 0.6, p < 0.002). In "passive" group significant negative correlation was found between: TRIG and III (r = -0.562; p = 0.025); TRIG and IIIB (r = -0.497; p = 0.036). LS correlated positively with LC (r = 0.476; p = 0.046) and scale IIIA correlated positively with scale IIIB (r = 0.550; p = 0.018). In "active" group positive correlation was found between: CRP and LC (r = 0.476; p = 0.021) and negative correlation between CRP and scale I (r = -0.437; p = 0.037); LS correlated positively with IIIA (r = 0.443; p = 0.039) but LC correlated negatively with scale I (r = -0.424; p = 0.049). We conclude, that men using in stressful situations task oriented coping style are less prone for atherosclerosis. This hypothesis needs to be confirmed on the larger population of potentially healthy men.

[Enhanced neuroticism in relation to cardiovascular risk factors in men]

Chronic stress is well known as a cardiovascular risk factor in men. There are few reports referred to the relationship between cardiovascular risk factors and level of neuroticism in the psychological examination. We analysed 77 healthy men in mean age of 33.3 +/- 7.4 years being at risk of chronic professional stress. Level of neuroticism was examined by Geras scale and expressed as: low (1-4 sten)--group 1, mean (5-6 sten)--group 2 and high (7-10 sten)--group 3 level of neuroticism. The common biochemical, clinical and environmental cardiovascular risk factors were examined. In the whole group of 77 probands we identified 24 (31%) (group 2) and 10 (13%) (group 3) persons with mean and high level of neuroticism. In the group 2 we find the highest cholesterol (222.7 +/- 39.4 mg/dl), LDL cholesterol (147 +/- 35.1 mg/dl, triglicerydes (144.9 +/- 93.8 mg/dl) and apolipoprotein B (1.11 +/- 0.31 g/l) levels statistically higher than in the other group of neuroticism. In group 3 we find the highest glucose (96.5 +/- 7.4 mg/dl) and fibrinogen (353.8 +/- 39.2 mg/dl) levels. The worst results of the environmental inquiry were obtained in the group 2 (obesity (BMI > 30 kg/m2) in 25%, hypertension in 12.5%, nicotinism in 54%, low physical activity in 79% and positive to cardiovascular disease family history in 91%). Because we found correlation mostly in the group of mean level of neuroticism these results must be confirmed in the larger group of probands using other psychological tests.

[Stress as a risk factor for cardiovascular disease]

This review refers to the experimental and clinical investigations on stress as a important risk factor of cardiovascular diseases.

[Late cellular potentials in patients after myocardial infarction--a result of left ventricular diastolic disfunction?]

The link between left ventricular dysfunction and arrhythmogenesis is commonly known. However, so far, only the systolic left ventricular dysfunction has been evaluated. Because of the controversial results of those studies, we decided to assess if is there a link between late potentials (LP) and left ventricular diastolic dysfunction. Our material consisted of 56 patients: 11 women and 45 men, mean age was 61.12 +/- 10.07 years. Signal averaged ECG and ECHO were performed in each patient, 2-3 months after myocardial infarction. For high pass filter of 40 Hz, LP were defined as 2 or 3 abnormal SAECG variables (the averaged QRS > 114 ms, the low amplitude signal duration LAS > 38 ms and root mean square voltage of the terminal 40 ms RMS40 < 20 microV). During ECHO study, we assessed E and A waves E/A ratio, left ventricular end-diastolic volume (LVEDV), ejection fraction (EF), acceleration (AT) and deceleration times (DT). The patients were divided into 2 groups: group I-30 patients LP positive and group II-26 patients LP negative. There were no significant differences between the groups in terms of age, EF, and heart rate. We presented significant differences between group I and II in terms of E wave velocity (0.75 +/- 0.19 vs 0.64 +/- 0.19 p < 0.03) E/A ratio (2.13 +/- 1.56 vs 1.0 +/- 0.5 p < 0.05) respectively. We did not confirm significant differences as regards A wave velocity, AT, isovolumetric time (IVRT) and LVEDV between both tested groups. In group I we revealed a significant correlation between E wave (r = 0.45), E/A ratio (r = 0.62), AT (r = -0.42) E/A ratio (r = 0.56), DT (r = 0.55) and QRS, as well as DT and LPD (r = 0.40) and between IVRT and RMS40 (r = -0.43). The results of our study suggest that in patients after myocardial infarction: 1/incidence of LP depends on the degree of left ventricular filling pattern like in impaired relaxion, quite well correlated with filtered QRS time 3/in LP positive patients there was predominance of restrictive left ventricular filling pattern, quite well correlation with RMS40 amplitude.

Pattern, flicker, and flash electroretinography in human immunodeficiency virus infection: a longitudinal study

To study electroretinographic (ERG) changes in the course of human immunodeficiency virus (HIV) disease, 42 eyes without retinitis were examined twice or more. During 9.6 months of mean observation time the visual acuity did not change. We found progressive functional impairment for the first, second, and third neurons of the visual pathway: the pattern-ERG amplitude (retinal ganglion-cell function) decreased by 11%, the b-wave amplitude (bipolars mediated by Müller cells) decreased by 13%, and the a-wave amplitude (dominated by rods) diminished by 21%. The flicker amplitude (dominated by cones) decreased by 20%. All of the latter four changes were significant (P < 0.02). Damage to the retina in HIV infection cannot solely be explained by visible changes in HIV retinopathy.