Hyperreninemia, lysozymuria, and erythrocytosis in Fanconi syndrome with medullary cystic kidney

Adult onset Fanconi syndrome with medullary cystic kidney was diagnosed in a 30-year-old male with muscular weakness, hypokalemia, normal BP, hyperreninemia, and secondary aldosteronism. He also had non-specific aminoaciduria, lysozymuria, and beta 2-microglobulinuria. Urinary concentrating and acidifying capacity was impaired, and both sodium and potassium were lost into the urine. I.v. pyelography revealed medullary cystic kidney. Renal biopsy showed juxtaglomerular hyperplasia, heavy subintimal deposits and C3 and IgG in preglomerular arteriolar walls, and degenerative changes in the tubules, including loss of brush border and "macula densa-like" lesions. Polycythemia with elevated serum erythropoietin levels, and raised blood ACTH values with features of cortisolism were also present. Indomethacin therapy decreased plasma renin activity (PRA), plasma aldosterone, and urinary loss of potassium and sodium, while serum potassium approached normal levels. Metoprolol, a beta-adrenergic blocking agent, caused similar effects. Insensitivity to the pressor effect of angiotensin II was reversed by indomethacin treatment. Somatostatin infusion lowered PRA and aldosterone without affecting BP. Several biochemical aberrations of this patient resemble Bartter's syndrome, including the effect of indomethacin.

Fatal renal vasculitis and minimal change glomerulonephritis complicating treatment with penicillamine. Report on two cases

Two cases with different and not previously described fatal renal complications during treatment with penicillamine are reported. A man with seronegative rheumatoid arthritis with features of systemic lupus erythematosus was treated with penicillamine for six months and developed a mild membranous glomerulonephritis and a severe renal vasculitis leading to uremia and death. A woman with primary biliary cirrhosis was treated with penicillamine for nine months and developed a nephrotic syndrome, the renal biopsy showing minimal change glomerulonephritis. The nephrotic syndrome responded to prednisone but the patient died, probably from septicemia. Penicillamine may thus cause glomerular damage without deposition of immune complexes. A restricted use of the drug is recommended.

Long-term 1,25-dihydroxycholecalciferol treatment in renal failure

1,25-Dihydroxycholecalciferol (1,25-DHCC) was administered to four patients on maintenance hemodialysis and to four patients with renal failure not requiring hemodialysis. Secondary hyperparathyroidism was found in both groups of patients. Before initiation of 1,25-DHCC treatment both groups had serum 1,25-DHCC levels below the normal range (33.1 +/- 15.3 pg/ml). During the treatment period, serum 1,25-DHCC concentrations were normalized. Parathormone concentration in serum decreased in both groups during the observation period. Serum calcium concentration was normalized in patients with renal failure and within the upper normal range in patients on maintenance hemodialysis. Bone biopsy and densitometry, of the radius showed a trend towards normalization of bone during the treatment period, while X-ray studies showed no clear effect of 1,25-DHCC treatment. This study shows that changes in bone mineralization can be reversed by normalization of 1,25-DHCC.

In vivo measurements of lead in bone at four anatomical sites: long term occupational and consequent endogenous exposure

Measurements of bone lead concentrations in the tibia, wrist, sternum, and calcaneus were performed in vivo by x ray fluorescence on active and retired lead workers from two acid battery factories, office personnel in the two factories under study, and control subjects. Altogether 171 persons were included. Lead concentrations in the tibia and ulna (representative of cortical bone) appeared to behave similarly with respect to time but the ulnar measurement was much less precise. In an analogous fashion, lead in the calcaneus and sternum (representative of trabecular bone) behaved in the same way, but sternal measurement was less precise. Groups occupationally exposed to lead were well separated from the office workers and the controls on the basis of calculated skeletal lead burdens, whereas the differences in blood lead concentrations were not as great, suggesting that the use of concentrations of lead in blood might seriously underestimate lead body burden. The exposures encountered in the study were modest, however. The mean blood lead value among active lead workers was 1.45 mumol l-1 and the mean tibial lead concentration 21.1 micrograms (g bone mineral)-1. The kinetics of lead in the tibia appeared to be noticeably different from that in the calcaneus. Tibial lead concentration increased consistently both as a function of intensity of exposure and of duration of exposure. Calcaneal lead concentration, by contrast, was strongly dependent on the intensity rather than duration of exposure. This indicated that the biological half life of lead in calcaneus was less than the seven to eight year periods into which the duration of exposure was split. Findings for retired workers clearly showed that endogenous exposure to lead arising from skeletal burdens accumulated over a working lifetime can easily produce the dominant contribution to systemic lead concentrations once occupational exposure has ceased.

Glucocorticosteroids in renal transplantation. II. Impact of high- versus low-dose postoperative methylprednisolone administration on graft survival and on the frequency and type of complications

In a previous clinical trial we demonstrated that, by increasing the postoperative administration of methylprednisolone from 1.0 to 3.5 mg/kg/day, the onset of the first inflammatory rejection episode was significantly delayed and the size of the inflammation was reduced. The 'high initial' steroid treatment specifically depleted blast cells and macrophages from the in situ inflammatory infiltrate. In this trial we demonstrate that the 'high initial' glucocorticosteroid administration significantly improves 1-year cadaver allograft survival from 44% to 68% (P = 0.003) without increasing the number of complications. Although the 'high initial' steroid administration only partially overcomes the impact of HLA-AB incompatibility, it seems to overcome entirely the impact of absence of blood transfusions. The 'high initial' steroid administration also makes the first episodes of inflammation easier to overcome: less steroids are needed to counteract the first rejection, and, as a consequence, only 30% more steroids were used in the 'high initial' versus the 'low initial' steroid programme.

Ultrasonic scanning after percutaneous renal biopsy

Renal ultrasonic scanning was performed before and after 57 consecutive kidney biopsies in order to assess the value of this method in the diagnosis of complications. One large and six small perirenal haematomas were found, corresponding to an incidence of 13%. This figure is considerably larger than the incidence found with conventional diagnostic methods, but smaller than with computed tomography. One hydronephrosis and a blood clot in the urinary bladder were also diagnosed. No clinically significant complications were missed. We recommend ultrasonography as the first diagnostic procedure when biopsy complications are suspected.

Striated muscle capillaries in uremic patients and in renal transplant recipients

With the use of light and electron microscopic and morphometric methods, we studied the gastrocnemius muscle capillaries in nine uremic patients and eight renal transplant recipients. Observations of intramuscular microangiopathy, eg, thickening and remnants of the capillary basement membrane (BM) and vacuolation of endothelial cells, were prominent in both patient groups. In morphometric analysis, the mean BM fraction of the total capillary area was larger, and the capillary lumen was smaller, in the uremic patients and in the renal transplant recipients than in the normal control subjects. The capillary-to-fiber ratio was higher in the patients with transplants than in the uremic patients or in the normal control subjects.

Kidney transplantation and tumours

During the period 1964--1978 700 renal transplants were given to 602 patients. Eight patients had a history of tumour before transplantation. After transplantation six cases with a de novo tumour were found. The treatment of the pretransplant tumours was completed on average 3 years before transplantation. The average interval from transplantation to discovery of de novo tumour was 2 years. The pretransplant tumours appeared 5 to 9 years before last control (Jan. 79) (mean 8 years). Two of the transplanted patients with previous tumours died later of their tumours. The others are still alive. Two of the patients with de novo tumour died of vascular accidents and one of tumour. The other three are alive. It seems that transplantation can be successful in patients with previous tumours. This study does not support previous reports of increased risk of de novo tumours in transplanted patients.

Urography and isotope renography following renal transplantation

The clinical yield from routine urography following renal transplantation was compared with that from isotope renography. In 50 recipients of renal transplants, 59 urograms and 55 renograms were studied. The most common pathologic finding at urography was renal papillary necrosis (in 6 patients). This condition had no obvious correlation with the further fate of the transplant. There were no other significant pathologic changes. It is concluded that isotope renography can be regarded as sufficient for routine follow-up. One baseline urogram is useful, but additional urographies should be carried out only when clinically indicated.

Early venous filling in transplanted kidneys

Early venous filling in patients with renal transplants was found in the presence of ischaemic injury, acute rejection, and chronic rejection; thus it cannot be used in differential diagnosis. Early venous filling was present only when the cortical circulation was scored as adequate although when observed in acute or chronic rejection the prognosis for the graft was poor.

Renal artery stenosis in hypertensive renal transplant recipients

Reconstruction of a stenotic renal artery was done on 5 hypertensive renal transplant recipients, all of whom had deterioration of renal function when the stenosis was detected. After reconstruction renal function improved in 4 of the patients. The blood pressure was easier to control in all 5 patients, with 3 becoming normotensive. A high preoperative plasma renin activity returned to normal postoperatively in 4 patients. No recurrences were observed after a followup of more than a year.

Microangiography of rejected human kidney transplants

A microangiographic study of 17 rejected and surgically removed human kidney transplants, three transplants removed for other reasons and two adequately perfused and preserved but not transplanted cadaver kidneys was performed. Transplants rejected with acute clinical course showed poor or variable glomerular filling and tapering cortical arteries with no impairment of medullary perfusion, more extensively in those transplants showing poor initial function. Chronic rejection, independent of other parameters showed lack of cortical perfusion, and glomerular filling; impaired perfusion of whole segments, arterial wall narrowing and changes secondary to kidney shrinkage. The radiographic patterns of chronic and acute rejection were distinguishable from each other and from nonrejected specimens.

Kidney function and compensatory growth of the kidney in living kidney donors

Pre- and postoperative kidney size and kidney function were studied in 46 living kidney donors aged 20-74 years. Kidney size was measured by planimetry and by estimation of a renal index. Kidney function was assessed by endogenous creatinine clearance and serum creatinine. Planimetry was superior to the renal index for expressing changes in renal size. Compensatory renal hypertrophy took place in donors up to the age of 74, but the greatest changes in renal size were observed in donors of under 40. Total renal function decreased postoperatively to about 77% of the initial level; this change in renal function was inversely correlated with age, but in all subjects studied the function remained within normal limits.

Subclinical neuropathy at "safe" levels of lead exposure

Electrophysiological methods revealed subclinical neuropathy in 26 workers, exposed from 1 to 17 years to lead and whose blood lead (PbB) values had never exceeded 70mu/100ml, as ascertained by checking the monitor reports of the factory and by careful exposure history. The PbB determinations had been tested repeatedly and had been found valid. The main findings were slowing of the maximal motor conduction velocities of the median and ulnar nerves and particularly the conduction velocity of the slower fibers of the ulnar nerve. Electromyographical abnormalities comprised fibrillations, diminution of the number of motor units on maximal contraction, and an abnormally long duration of the units. Earlier similar measurements from heavily exposed workers had been even more abnormal. Thus, a dose-response relationship exists on a group basis. Since the regular monitoring of PbBs in most workers during their entire period of exposure excludes the possibility of a body burden out of proportion to the PbB slight neurological damage is produced at exposures hitherto regarded as quite safe.

Plasma renin activity in the evaluation of hypertension in renal transplant recipients

Plasma renin activity (PRA) was measured in nine renal transplant recipients, seven of which had transplant renal artery stenosis. Surgical correction of the stenosed renal transplant artery was performed in six patients. After corrective surgery of the stenosed artery hypertension (mean arterial pressure before operation 156 mmHg) improved (mean arterial pressure postoperatively 110 mmHg) in four patients with high peripheral PRA (17.3+/-3.9 ng/ml. hr). Two patients, one hypertensive, the other normotensive with low PRA (1.5+/-0.05 ng/ml. hr) had no change in their blood pressure after corrective surgery. In three hypertensive renal transplant recipients the PRA of the venous effluent of the own kidneys and the renal transplant were studied selectively. Selective PRA determinations revealed the source of inappropriate renin secretion offering a basis for surgical management of the assocaited hypertension.