[Gastrointestinal stromal tumors]

Gastrointestinal stromal tumours (GISTs) are the most common group of mesenchymal tumours affecting the gastrointestinal tract. Despite this, GISTs are relatively rare, since all mesenchymal tumours constitute just 1 percent of all primary GI cancers. Most often, GISTs affect the stomach and proximal small intestine but can be found in any section of the alimentary tract, including, occasionally, the omentum, mesentery and peritoneum. Virtually all GISTs (especially those larger than 1 cm) have malignant potential. Malignant potential of a tumour increases with its size and its mitotic rate, and it also depends on its anatomic location: intestinal GISTs are more aggressive than gastric tumours. Treatment of GISTs was revolutionized when it was discovered that mutational activation of KIT or PDGFRA stimulates the growth of these cancer cells. Mutational activation of KIT or PDGFRA led to abnormal activation of receptor tyrosine kinase and uncontrolled oncogenic signalling. This uncontrolled oncogenic signalling can be specifically targeted therapeutically with small molecule inhibitors of the receptor tyrosine kinase (imatinib, sunitinib). All GISTs > or = 2 cm in size should be resected. To reduce disease recurrence, adjuvant imatinib therapy is recommended for all high-risk patients after resection. Neoadjuvant therapy is recommended for primarily unresectable tumours or a limited amount of potentially resectable metastatic disease. The goal of treatment is to reduce tumour size, thus facilitating complete surgical resection and increasing the likelihood of organ preservation.

Long-term outcome of patients with idiopathic membranous nephropathy

Although idiopathic membranous nephropathy (iMN) is a common glomerular disease, its therapy still remains controversial. The aim of our study was to analyse the outcome of patients with iMN diagnosed and treated in our center. We retrospectively studied 82 patients with iMN that were diagnosed between January 1991 and June 2002. The group consisted of 57 males (69.5%) and 25 females (30.5%) with a mean age of 53 years. The mean follow-up was 56 +/- 38 months. Remission was achieved in 59.2% of patients treated with chlorambucil, 71.4% treated with cyclophosphamide, 85.7% treated with cyclosporine and in 71.4% of those who were left untreated intentionally. However, the proportion of patients in the different treatment subgroups differed significantly (60% vs. 8.5% vs. 8.5% vs. 23%, respectively). The relapse rate was 31.3%. The second-line treatment was effective in a majority of the patients. At the end of follow-up, almost 70% of the patients were in remission with the parameters of nephrotic syndrome significantly improved and renal function unchanged. The renal survival was 100%. Immunosuppressive therapy is effective in iMN, but spontaneous remissions occur as well. Although relapses are frequent, almost 70% of the patients were in remission at the end of follow-up. The renal survival in our group of iMN patients was very good, probably due to preserved renal function at diagnosis.

[An unusual cause of acute anuric renal failure]

We present a case of a 79-years old woman with acute anuric renal failure due to biopsy confirmed immunotactoid glomerulonephritis. Despite biclonal gammopathy IgG lambda, no hematologic or any other underlying malignancy was found. A possible association with viral hepatitis, cryoglobulinemia or autoimmune disease was also excluded. The patient was treated with pulse i.v. dexamethasone with very good results. Diuresis resumed and renal function gradually normalized. Our patient is one of the oldest patients with immunotactoid glomerulonephritis described. The presentation by acute renal failure with an improvement of renal function after therapy has not been previously published.

Daily oral versus pulse intravenous cyclophosphamide in the therapy of ANCA-associated vasculitis--preliminary single center experience

The aim of the multicentric randomized trial CYCLOPS is to optimize the treatment of induction of remission in patients with generalized, but not immediately life-threatening ANCA (antineutrophil cytoplasmic antibodies) -associated vasculitis. This will be achieved by reducing the dose of cyclophosphamide by administering it as intermittent pulses. The lower cumulative dose will be very probably accompanied with lower toxicity, whereas the effectivity should be comparable. We have enrolled 28 patients to the study. At present, 18 of them are suitable for evaluation. Our preliminary results show that pulse intermittent administration of cyclophosphamide is safer from the point of morbidity and mortality due to infectious complications. In our hands, this treatment modality does not seem to be less effective than the conventional daily oral cyclophosphamide. However, unambiguous results and treatment recommendations will not be available until the final evaluation of all patients enrolled in the trial.

[Renal infiltration in lymphoma--diagnosis in renal biopsy (case report)]

A case story of a patient with renal biopsy (RB) proven infiltration with lymphoma is given. RB in patient with known malignancy and onset of renal failure was indicated with regard to an atypical picture of kidney involvement (non-enlarged kidneys, without any structural changes typical for tumour mass presence). Though spread of the primary tumour to the kidney is not uncommon, involvement severe enough to impair renal function is unusual and occurs primarily with rapidly growing haematologic malignancies; diagnosis is being established by renal biopsy only rarely.

[Bartter syndrome or renal tubular acidosis?]

In normotensive patients (pts) with apparently inherited electrolyte disorder characterized by hypokalemia and with metabolic alkalosis the suspicion is usually pronounced on the diagnosis of Bartter syndrome or Gitelman syndrome. During the last two years three pts were admitted to our nephrologic unit of the 1st Internal Department of the 1st Medical School who presented with hypokalemia, metabolic alkalosis and alkalic urine and were followed previously under working diagnosis of (incomplete) renal tubular acidosis. In the article we give the description of the clinical picture in the three pts diagnosed as Bartter/Gitelman syndrome. In conclusion--the problems of differential diagnosis in pts with such a complex disorder of acidobase balance are discussed and new diagnostic approach with mutational studies is suggested.

[Fibrillary glomerulonephritis]

An overview of fibrillary glomerulonephritis (GN) is given as well as the description of clinical course in four patients diagnosed and treated in our department. Fibrillary GN and immunotactoid glomerulopathy are entities, characterized by fibrillar and microtubular deposits in mesangium and the glomerular capillary loops. Decisive for diagnosis of fibrillary GN (resp. immunotactoid GN) remains the electron microscopy (EM) of the renal biopsy (RB) specimen. At the nephrologic division of 1st Internal Department of 1st Medical School of Charles University four cases of patients with fibrillary GN were diagnosed from the mid seventies (when both entities were newly described) by the end of the year 2001. In all patients the diagnosis was proven by EM. RB was indicated mainly for proteinuria, hematuria and decrease of renal function. On conclusion: though fibrillary GN/immunotactoid GN are relatively rare disorders, they represent entities, which should not be omitted in the differential diagnosis of nephrotic syndrome/renal insufficiency and which deserve further study.

Transjugular renal biopsy. Our experience with 67 cases

BACKGROUND

Transjugular renal biopsy (TJRB) is still a novel technique of renal tissue sampling exploiting the transjugular route. TJRB should be performed particularly in situations when the percutaneous route is precluded, i.e. especially in patients with clotting disorders. In the past, only a few papers reported the experience with larger numbers of patients. The goal of this paper is to analyze our experience with TJRB.

METHODS AND RESULTS

From 1993 to 1999, 67 patients, mean age 49.8 years (SD +/- 10.2), male/female ratio 40/27, underwent TJRB. Fifty-two patients (78%) suffered from renal insufficiency and 19 of them (28%) were on dialysis treatment at the time of TJRB. Arterial hypertension was recorded in 42%. The combined kidney and liver biopsy (46%) and clotting disorders (39%) were the most frequent indications for performing TJRB. Renal tissue was yielded in 53 patients (79%) but a sample sufficient for histological diagnosis was taken in 49 (73%), reaching on average 10.8 glomeruli. Altogether 19 different histological entities were disclosed and out of them, vascular nephrosclerosis (12%), necrotizing and crescentic glomerulonephritis, IgA nephropathy (IgAN) and amyloidosis (three latter per 10%) represented the most frequent diagnoses. TJRB was combined with liver biopsy in 31 patients (46%) and/or hepatic vein catheterization in 22 patients (33%) confirming portal hypertension in 8. The clinically significant liver histology was found in 20 patients, of them cirrhosis/fibrosis in 8, chronic hepatitis in 4 and steatosis in 5. Among those 20 patients, IgAN was disclosed as the most common renal diagnosis (6). Clinically symptomatic complications were recorded in 12 cases (18%) but 9 of them suffered from clotting disorders. Complications included development of subcapsular hematoma in 6 cases, macroscopic hematuria in 4 cases, and hypovolemic hemorrhagic shock in 2. One patient had to undergo surgical treatment. Dividing the patients into a subgroup with or without clotting disorders, the complication rate was 34 vs. 7%.

CONCLUSIONS

TJRB is a new diagnostic method, which, looking at its indications, facilitates the diagnosis of glomerulopathies in patients who could not be considered for percutaneous renal biopsy, particularly due to clotting disorders. The technical aspect of this procedure plays a fundamental role in the final risk/benefit ratio but if done correctly it involves acceptable risk and is well tolerated.

[Kidney involvement in light-chain deposition disease]

An overview concerning different types of kidney involvement associated with monoclonal gammapathy (MG) is given, focused on light-chain deposition disease (LCDD). Pathophysiologic basis of LCDD remains in the light-chain tissue deposition (resp. in tissue deposition of immunoglobulin's stable domain). This mechanism is typical for monoclonal immunoglobulin's overproduction as found in MG. Clinical picture of LCDD reflects multiorgan character of disorder, while renal lesions rank among the most frequent, serious and best documented ones. Clinical data referring to a group of six patients, treated in our nephrologic department are presented. Diagnosis of LCDD was established on basis of the renal biopsy finding. Renal functions were decreased at the time of diagnosis in all patients, whereas haemodialysis treatment was started in one patient. On conclusion therapeutic possibilities of LCDD are discussed, in which number symptomatic therapy of renal failure is combined with corticosteroids therapy and cytostatic therapy; prognosis of most patients remains serious.

The localisation of TPPS4 in some organs and its possible nephrotoxicity in rats

Photodynamic therapy (PDT) is now being used more frequently in carefully selected cases of malignancies. The drugs used for PDT are mostly derivatives of haematoporphyrine (HPD) and its active component photofrine II. Another compound prepared by total synthesis is meso-tetra-(4-sulfonatophenyl)-porphine (TPPS4) but its application in human medicine was rejected because of its neurotoxicity. Our TPPS4 was prepared by the method of Busby et al. in the modification of Jirsa and Kakac (1987). This product is purer and without neurotoxic effects. In this study, we concentrated our attention on the effect of TPPS4 on nephrotoxicity and its accumulation in some organs. As the parameters of toxic kidney damage we used urine levels of N-acetyl-beta-D-glucosaminidase (NAG), serum creatinine levels, glomerular filtration rate (GFR) and proteinuria. TPPS4 was administered i.v. in a dose of 25 mg/kg b.w. The animals were observed for 21 days after drug application. Urine and blood samples were collected over 24-hour periods on days 0, 5 and 21. The serum creatinine level was significantly higher only on day 5 (65.0+/-1.46 micromol/l vs 56.5+/-2.69 micromol/l on day 0, p<0.05). There were no significant changes in GFR, proteinuria or NAG activity in the urine during the experiment. AST serum activity was increased. We determined the concentration of TPPS4 (pmol/mg w.w.) in rat organs on the 21st day after the injection. The concentration of TPPS4 was high in kidneys (30.8+/-5.5), liver (13.5+/-2.0), lungs (11.7+/-4.6) and spleen (9.7+/-1.5), while the concentration in heart and brain was low. We conclude that TPPS4 has the highest concentration in the kidney 21 days after its administration and does not exert any nephrotoxic effects during this period.

Influence of plasma exchange on serum levels of cytokines and adhesion molecules in ANCA-positive renal vasculitis

BACKGROUND

Increased serum levels of proinflammatory cytokines may contribute to the organ damage in active antineutrophil cytoplasmic antigen (ANCA)-positive renal vasculitis. Plasma exchange (PE) may influence the activity of vasculitis not only by removing pathogenic autoantibodies, but also by lowering the serum levels of circulating cytokines.

METHODS

Serum levels of IL-1beta, IL-1ra, IL-6, IL-8, ICAM-1 and VCAM-1 were measured using ELISA in 10 patients with active ANCA-positive renal vasculitis (5 patients with Wegener's granulomatosis, WG, and 5 patients with microscopic polyangiitis, MPA) during the course of therapeutic PE. Cytokines and adhesion molecules were measured in samples of serum obtained at the beginning and at the end of the 1st, 3rd and 5th PE and in samples of filtrate obtained during the same PE.

RESULTS

In comparison with controls, patients with ANCA had higher serum levels of IL-1ra, IL-8, ICAM-1 and VCAM-1 before the 1st PE. Serum levels of IL-6, IL-8, ICAM-1 and VCAM-1 were increased in patients with MPA, and the serum levels of all the cytokines and adhesion molecules measured in patients with WG were increased. At the end of the PE course there were decreases in the serum levels of IL-1ra and VCAM-1 in ANCA patients and IL-1ra and ICAM-1 in WG patients. Single PE in ANCA patients led only to a decrease in serum levels of ICAM-1 and VCAM-1. On the other hand, there was no change in serum levels of IL-1beta and IL-8, and the serum levels of IL-1ra and IL-6 even increased at the end of a single PE, in spite of high levels of all cytokines and adhesion molecules in the plasma filtrate.

CONCLUSION

Serum levels of soluble adhesion molecules decrease after PE, but serum levels of proinflammatory cytokines are not reduced even by a PE course. Removal of these substances by PE is obviously counteracted by their increased production, possibly further stimulated by the contact of blood with the synthetic membrane. The insufficient influence of PE on the elimination of proinflammatory cytokines may partially explain its limited effect in some patients with ANCA-positive renal vasculitis.

Long term treatment of IgA nephropathy with cyclosporine A

20-50% of patients with IgA nephropathy (IgAN) reach end-stage renal failure. Yet a standard treatment for those with progressive course and/or great proteinuria is lacking. We treated 6 patients with biopsy proven IgAN, proteinuria over 3.5 g/24 h and S-creatinine less than 200 micromol/L non-responding to corticosteroids administered for 3 months. They were given cyclosporine A (CsA) 5 mg/kg bw/day then titrated aiming at a serum concentration of 70-150 ng/mL for one year tapered to discontinuation in 9 months. Prednisone 5-10 mg on alternate days was given with CsA. Proteinuria (g/day) decreased from 4.66 +/- 0.43 to 1.38 +/- 0.29 (p < 0.01) after 1 month and to 0.59 +/- 0.14 (p < 0.001) after 1 year of treatment and remained lower than baseline 2 years from the beginning (1.44 +/- 0.27, p < 0.001). GFR (creatinine clearance) did not change during the first month (1.25 +/- 0.21 mL/s vs 1.38 +/- 0.29 mL/s), but decreased after 1 year (1.05 +/- 0.14 mL/s, p < 0.05). After two years it increased to 1.17 +/- 0.16, NS from baseline. We also calculated the ratio of proteinuria to the GFR (mg/L) to assess the role of hemodynamic changes in the decrease of proteinuria. This ratio was 53.80 + 6.47 before therapy, it decreased after 1 month (11.56 +/- 1.7, p < 0.05) and further after 1 year (6.78 + 1.45, p < 0.01). Three months after discontinuation it was still 14.32 +/- 1.00, p < 0.05 from baseline. In conclusion, CsA significantly lowered moderate to high proteinuria in 6 patients with IgAN. Significant decrease of the proteinuria/GFR ratio suggests some non-hemodynamic mechanism of CsA action. The therapy was well tolerated and side-effects were not so severe as to require CsA withdrawal.

[Plasma leptin levels in patients with kidney diseases of various etiologies]

BACKGROUND

Leptin is a new hormone influencing food intake, energy expenditure and body weight. This protein is produced by adipocytes, exerts its effects on brain, endocrine pancreas and other organs by activating transmembrane receptors and is cleared from plasma mainly by the kidneys. The aim of our study was to compare plasma concentrations of leptin in our nephrological out-patients and controls.

METHODS AND RESULTS

We examined 36 diabetic patients with various stages of nephropathy, 12 males with nephrotic syndrome due to membranous nephropathy, 15 dialysis patients and 11 controls. Leptin was assessed in plasma by ELISA. There was a significant difference between plasma levels of leptin in males and females (7.7 +/- 11.4 vs 17.6 +/- 17.3, p < 0.001) and in dialysis and non-dialysis patients (19.6 +/- 16.5 vs 10.7 +/- 14.5, p < 0.05). There was also a difference between dialysed and non-dialysed men (15.1 +/- 16.2 vs 5.9 +/- 9.2, p < 0.05). We found no difference between men with and without nephrotic syndrome and between BMI or age. There was a positive correlation of leptin with diabetic and non-diabetic women. There was positive correlation of P-leptin with serum creatinine in non-dialysed women (r = 0.68, p < 0.001) and a negative correlation with S-albumin in nephrotic men (r = -0.65, p < 0.05).

CONCLUSIONS

Women have higher plasma leptin concentrations than men and dialysis patients have higher concentrations than non-dialysed patients. Apart from the positive correlation with S-creatinine in non-dialysed women. There was positive correlation with S-albumin in nephrotic men there were no correlations with renal function, BMI, age, S-cholesterol, S-triglycerides and S-albumin.

[Relation between plasma levels of IGF-I, leptin and TNF-alpha in diabetics]

BACKGROUND

TNF-alpha, IGF-I and leptin are agents which influence insulin resistance, they play probably a part in the pathogenesis of diabetic nephropathy and influence mutually their production. The objective of the submitted investigation was to assess whether there exist relations between their concentrations in the plasma of diabetic patients.

METHODS AND RESULTS

The authors examined 37 patients aged 18-67 years from a diabetic clinic, 10 with normal albuminuria and normal renal function, 12 with microalbuminuria and 15 with macroalbuminuria and/or reduced renal function. TNF alpha, IGF-I and leptin were assessed in plasma, using commercial kits, by the ELISA method. IgF-I in plasma correlated inversely with glycated haemoglobin (r = -0.20, p < 0.05). In women a correlation was found between IGF-I and TNF-alpha concentrations (r = 0.65, p < 0.01). No other mutual correlations were found between concentrations of the investigated substances and between cytokine concentrations and serum creatinine, glycated haemoglobin, the blood glucose level and body mass index.

CONCLUSIONS

IGF-I plasma levels correlate inversely with glycated haemoglobin and in women with the TNF-alpha level. No other correlations were found between IGF-I. TNF-alpha and leptin plasma levels. The levels do not correlate with age, renal function and compensation of diabetes.

Cytokines and adhesion molecules in renal vasculitis and lupus nephritis

BACKGROUND

Plasma levels of some pro-inflammatory cytokines and soluble adhesion molecules have been suggested to be useful parameters to assess the activity of antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis and lupus nephritis. We hypothesized that the renal activity of these diseases is better reflected by the urinary excretion and fractional excretion of these molecules.

METHODS

Plasma levels and urinary excretion of tumour necrosis factor-alpha (TNF-alpha), interleukin (IL)-6, IL-8, and the soluble cell adhesion molecules sICAM-1 and sVCAM-1 were measured by enzyme-linked immunosorbent assay (ELISA) in 14 patients with ANCA-positive renal vasculitis (eight active, ANCA-A; six in remission, ANCA-R), six patients with active lupus nephritis (LN), 15 patients with IgA nephropathy (IgAN) and nine healthy subjects. Fractional excretion of selected cytokines and adhesion molecules was also calculated.

RESULTS

Patients with ANCA-A had increased urinary excretion and fractional excretion of TNF-alpha (9.27 +/- 3.19% vs 0.58 +/- 0.02%, P < 0.01), IL-6 (120.79 +/- 65.83% vs 1.89 +/- 0.34%, P < 0.01) and increased fractional excretion of IL-8 (23.34 +/- 6.38% vs 2.56 +/- 1.07%, P < 0.01) and sVCAM-1 (0.81 +/- 0.33% vs 0.03 +/- 0.02%, P < 0.01) compared with controls. Urinary excretion of TNF-alpha and IL-6 and fractional excretion of TNFalpha, IL-6 and IL-8 were higher in ANCA-A than in ANCA-R. Patients with LN had increased plasma TNF-alpha (20.52 +/- 2.01 pg/ml vs 12.33 +/- 0.23 pg/ml, P < 0.05) and sVCAM-1 (1537.88 +/- 276.36 ng/ml vs 692.26 +/- 44.42 ng/ml, P < 0.05) and increased urinary excretion of TNF-alpha (2.81 +/- 0.51 microg/mol creat vs 0.98 +/- 0.05 microg/mol creat, P < 0.01), IL-8 (35.78 +/- 14.03 microg/mol creat vs 12.46 +/- 5.19 microg/mol creat, P < 0.05) and sVCAM-1 (48.98 +/- 20.20 microg/mol creat vs 2.92 +/- 1.35 microg/mol creat, P < 0.01) compared with controls. Patients with IgAN had, in comparison with controls only increased plasma TNF-alpha (18.10 +/- 0.57 pg/ml vs 12.33 +/- 0.23 pg/ml, P < 0.05).

CONCLUSIONS

Urinary excretion and fractional excretion, but not plasma levels, of selected pro-inflammatory cytokines (TNF-alpha, IL-6 and IL-8) were increased in patients with active ANCA-positive renal vasculitis, but not in ANCA positive vasculitis in remission. These parameters may be useful to monitor the activity of this disease.

[Soluble cytokinin receptors in renal vasculitis and lupus nephritis]

BACKGROUND

Activation of various cytokines, e.g. TNF alpha, IL-1 and/or IL-6 may play important role in the pathogenesis of renal vasculitis and lupus nephritis (LN). Systemic effects of these cytokines may be modulated by their circulating soluble receptors. Plasma levels of cytokine receptors may thus be also markers of the activation of these cytokines.

METHODS AND RESULTS

Plasma levels of TNF alpha, its soluble receptor p75 (sTNF-RII), IL-6 and soluble IL-6 receptor (sIL-6R) were measured using ELISA in 17 pts with ANCA-positive renal vasculitis (12 active-ANCA-A, 7 in remission ANCA-R), 9 pts with active lupus nephritis (LN) and 5 healthy subjects. Pts with LN had in comparison with controls increased plasma levels of TNF alpha, sTNF-RII, IL-6 and sIL-6R. Pts with ANCA-A had also in comparison with controls increased plasma levels of TNF alpha, sTNF-RII and sIL-6R, but plasma levels of IL-6 were not significantly increased dut to great standard deviation. Pts with ANCA-R had in comparison with controls increased plasma levels of sTNF-RII, but plasma levels of TNF alpha were in ANCA-R significantly lower than in ANCA-A. While the ratio TNF alpha/sTNF-RII was significantly lower in all groups of pts than in controls, the ratio IL-6R/sIL-6R was in comparison with controls significantly increased only in LN.

CONCLUSIONS

While increased plasma levels of TNF alpha may be nonspecific marker of the activity of ANCA-positive renal vasculitis and LN, plasma levels of sTNF-RII are increased also in pts with ANCA-positive renal vasculitis in remission. Increased plasma levels of sTNF-RII may interfere with systemic effects of TNF alpha, but may also prolong the lifetime of its active form. Plasma levels of sIL-6R are increased both in ANCA-A and in LN, but their increase is, however, much less pronounced than that of sTNF-RII and cannot effectively block systemic effects of IL-6.

Effect of 1 year cyclosporine A treatment on the activity and renal involvement of systemic lupus erythematosus: a pilot study

Our objective was to determine the effect of 1 year low-dose cyclosporine A (CSA) treatment on disease activity and renal involvement in systemic lupus erythematosus (SLE). Patients included in the pilot study had an active form of the disease as defined by the SLE Disease Activity Index (SLEDAI). Main organ involvement was represented by lupus nephritis classified in repeated renal biopsies. Eleven patients with SLE were enrolled in the study. In eight of them, previous therapy with cyclophosphamide or azathioprine had to be interrupted due to serious adverse reaction or low efficacy. Nine patients experienced clinical nephrotic syndrome, and two the nephritic syndrome. After 12 months of CSA treatment, the mean SLEDAI score had decreased significantly from 26.18 to 4.00 (P < 0.01). Similarly, the titre of antinuclear and anti-dsDNA antibodies had dropped significantly (P < 0.01). Proteinuria decreased rapidly from 9.10 to 1.70 g/24 h (P < 0.001). According to the WHO classification of renal biopsies, three patients had their class altered from IV to III in response to CSA treatment and five patients had changed the status from the high severity grade to the mild. The adverse reactions included hypertension (45%), gingival hyperplasia (18%) and hirsutism (9%). No significant increase in serum creatinine or any CSA related toxic changes were found in renal biopsies. The favourable response observed in patients with active SLE and with major renal involvement strongly suggests that low-dose CSA is a potent drug as much for the reduction of the disease activity as for lupus nephropathy treatment.

[Laboratory findings and serum levels of amyloid A and soluble interleukin-2 receptors in patients with renal amyloidosis]

BACKGROUND

Renal amyloid involvement results either from primary or secondary amyloidosis. Extent of amyloid tissue deposition in kidneys and clinical course depends not only on the type of basic process but reflects also time of diagnosis and possibility to influence the basic process.

METHODS AND RESULTS

We analyzed laboratory and clinical data of patients with bioptically proven renal amyloidosis. We found renal amyloidosis in 27 patients from an overall number of 750 renal biopsies (RB) performed in our department (i.e. 3.6%). AA amyloidosis was diagnosed in 16 pts, AL amyloidosis in 11 pts. About 50% of patients had laboratory signs of nephrotic syndrome, all patients had various degree of proteinuria. Impaired renal function were found in more than 50% of patients, in 6 of them we had to start renal replacement therapy. 8 pts died. Complications of severe nephrotic syndrome were the causes of death in majority of cases. We have started investigation of some amyloid precursors and cytokines in patients with AA and AL amyloidosis. We compared the results with group of patients with vasculitis. We investigated plasma and urinary levels of SAA (serum AA) and soluble receptor for interleukin 2 (sIL-2R).

CONCLUSIONS

Clinical features and laboratory findings in our patients with renal amyloidosis approximately are in accordance with literary data. Plasmatic level of SAA was increased not only in the group of patients with AA amyloidosis, but also in the group of vasculitis. Urinary sIL-2R was significantly increased in patients with AA amyloidosis in comparison with healthy controls.

[Clinical problems in kidney disorders associated with myeloma and other paraproteinemias]

An overview of constantly enlarging spectrum of renal lesions in monoclonal gammapathies and new insights in possible pathogenesis of renal disturbances is given. Between the different types of renal affections a predominant role is played by the "myeloma kidney", induced by the presence of casts, primary amyloidosis with light chains deposition and tubular dysfunctions. Case stories of 3 patients, affected by myeloma kidney (with acute and chronic renal failure) and primary amyloidosis (with pronounced nephrotic syndrome) in context of monoclonal gammapathy are presented. Clinical problems of patients necessitating intensive hematologic and nephrologic care are highlighted, as well as need of early diagnosis and complex care.

[The effect of plasmapheresis on cytokine serum levels and adhesion molecules in ANCA-positive renal vasculitis]

BACKGROUND

Increased serum levels of proinflammatory cytokines may contribute to the organ damage in active ANCA-positive renal vasculitis (ANCA-A). Plasma exchange (PE) may influence the activity of vasculitis not only by removal of pathogenic autoantibodies, but also by lowering of serum levels of circulating cytokines.

METHODS AND RESULTS

Serum levels of IL-1, IL. 1ra, IL-6, IL-8, ICAM-1 and VCAM-1 were measured using ELISA in 10 pts with active ANCA-positive renal vasculitis (5 pts with Wegener's granulomatosis-WG, 5 pts with microscopic polyangiitis-MPA) during the course of therapeutic PE. Cytokines and adhesion molecules were measured in samples of serum obtained in the beginning and at the end of the 1st, 3rd and 5th PE and in the samples of filtrate obtained during the same PE. Pts with ANCA had before the 1st PE in comparison with controls higher serum levels of IL-1ra, IL-8, ICAM-1 and VCAM-1. There were increased serum levels of IL-6, IL-8, ICAM-1 and VCAM-1 in pts with MPA and increased serum levels of all measured cytokines and adhesion molecules in pts with WG. At the end of the course of PE there was the decrease of serum levels of IL-ira and VCAM-1 in pts with ANCA and IL-1ra and ICAM-1 in WG. Single PE led in pts with ANCA only to the decrease of serum levels of ICAM-1 and VCAM-1. On the other hand, there was no change of serum levels of IL-1 and IL-8 serum levels of IL-1ra and IL-6 even increased at the end of single PE, in spite of high levels of all cytokines and adhesion molecules in plasmafiltrate.

CONCLUSIONS

Serum levels of soluble adhesion molecules decrease after PE, but serum levels of proinflammatory cytokines are not reduced even by the course of PE. Removal of these substances by PE is obviously counteracted by their increased production, possibly further stimulated by the contact of blood with synthetic membrane. Insufficient influence of PE on the elimination of proinflammatory cytokines may partially explain its limited effect in some patients with ANCA-positive renal vasculitis.

[Cytokines and adhesion molecules in renal vasculitis and lupus nephritis]

BACKGROUND

Plasma levels and urinary excretion of proinflammatory cytokines and soluble adhesion molecules may be useful parameters of the activity of ANCA-positive renal vasculitis and lupus nephritis.

METHODS AND RESULTS

Plasma levels and urinary excretion of TNF alpha, IL-6, IL-8, ICAM-1 and VCAM-1 were measured by ELISA in 14 patients (pts) with ANCA-positive renal vasculitis (8 active-ANCA-A, 6 in remission ANCA-R), 6 pts with active lupus nephritis (L.N), 15 pts with IgA nephropathy (IgAN) 10 pts with autosomal dominant polycystic kidney disease and 9 healthy subjects (Co). Fractional excretion (FE) of selected cytokines and adhesion molecules was also calculated. Pts with LN had in comparison with controls increased plasma levels of ICAM-1, VCAM-1, IL-6, IL-8 and TNF alpha, increased urinary excretion of VCAM-1, IL-8 and TNF alpha and increased fractional excretion of VCAM-1 and IL-8. Patients with ANCA-A had in comparison with controls increased plasma concentrations of ICAM-1 and VCAM-1, increased urinary excretion of VCAM-1, IL-6 and TNF alpha and increased fractional excretion of VCAM-1, IL-6, IL-8 and TNF alpha. Patients with ANCA-R had in comparison with controls higher plasma levels of ICAM-1, VCAM-1, IL-6 and TNF alpha, increased urinary excretion of VCAM-1 and TNF alpha and increased fractional excretion of VCAM-1, IL-6 and TNF alpha.

CONCLUSIONS

Patients with ANCA-positive renal vasculitis had in contradistinction to pts with active LN increased fractional excretion of IL-6 and TNF alpha. Both cytokines are probably produced in renal vasculitis locally in the kidney. Increased plasma levels of soluble adhesion molecules and increased plasma levels and fractional excretion of proinflammatory cytokines in patients with ANCA-positive renal vasculitis in clinical remission may explain the strong propensity of these patients to develop relapses of the diseases on withdrawal of immunosuppressive treatment.

[Clinical spectrum of the antiphospholipid syndrome]

Antiphospholipid syndrome (APS) is characterized by multiple arterial and venous thromboses, repeated spontaneous abortions and thrombocytopenia, together with the presence of antiphospholipid antibodies in serum. We present three patients, two men and a woman, at the age of 43, 24 and 23 years respectively. The younger man and the woman had secondary APS and systemic lupus erythematosus, the older man had primary APS. The symptoms and course of the disease were different. The older man lives 17 years after the onset of first symptoms with multiple neurologic disorders, the younger man is symptomless. The woman died several months after the acute onset of the disease.

Cytokine profile in autosomal dominant polycystic kidney disease

To elucidate the pathogenetic mechanism of renal parenchymal injury in autosomal dominant polycystic kidney disease (ADPKD) patients, typically characterized by renal cystic changes paralleled by interstitial inflammation and gradual fibrotic changes, the role of selected inflammatory mediators was evaluated in a group of ADPKD patients with normal glomerular filtration rate. The plasma concentrations of IL-6, IL-8, ICAM-1 and VCAM-1 (which may reflect systemic response to inflammation/infection) were increased in the ADPKD patient group. Coupled with decreased urinary excretion of the IL-1 receptor antagonist (which exerts an anti-inflammatory role), these results suggest that even in overt infection free status, the proinflammatory system is more activated and anti-inflammatory defence system weakened in ADPKD subjects. Our data support the current view that cytokines are candidate contributors to pathogenesis of ADPKD.

[Long-term administration of cyclosporine A in patients with IgA nephropathy]

BACKGROUND

IgA nephropathy is the most common glomerulonephritis all over the world and a considerable proportion of the patients reaches end-stage renal failure. Yet the standard treatment for the patients with progressive course and/or great proteinuria is currently lacking. All suggested treatment protocols, including short-term treatment with cyclosporine A had equivocal results. Therefore we decided to try long-term cyclosporine treatment.

METHODS AND RESULTS

We treated 6 patients (4 males, 2 females, age 21-31 years) with bioptically proven IgA nephropathy and proteinuria over 3.5 g/24 hrs with or without nephrotic syndrome non responding to corticosteroid therapy administered for at least 3 months. Patients with serum creatinine greater than 200 mumol/l and/or glomerulosclerosis in more than 50% of glomeruli in renal biopsy were excluded. Pts were given cyclosporine A in initial dose 5 mg/kg bw/day then titrated aiming to the serum concentration of 70-150 ng/ml. Prednisone 5-10 mg on alternate days was given with cyclosporine. Proteinuria decreased during first month of therapy from 4.66 +/- 0.43 g/day to 1.38 +/- 0.29 g/day (p < 0.01) and remained low after one year of treatment (0.59 +/- 0.14 g/day, p < 0.001). Glomerular filtration rate (creatinine clearance) did not change during first month of therapy (1.25 +/- 0.21 ml/s vs. 1.38 +/- 0.29 ml/s), but slightly decreased after one year of treatment (1.05 +/- 0.14 ml/s, p < 0.05). We also calculated ratio of proteinuria to glomerular filtration rate (g/l) to assess the role of hemodynamic changes in the decrease of proteinuria. This ratio was 53.80.10(-3) +/- 15.20.10(-3) before cyclosporin therapy, it decreased significantly after one month (11.56.10(-3) +/- 3.24.10(-3), p < 0.05) and achieved the lowest value after one year of therapy (6.78.10(-3) +/- 4.25 .10(-3) +/- 4.25.10(-3), p < 0.01). Serum cholesterol also significantly decreased after 12 months of therapy (6.21 +/- 0.62 vs. 5.41 +/- 0.45 mmol/l, p < 0.05).

CONCLUSIONS

CyA significantly lowered moderate to high proteinuria with much less decrease of glomerular filtration rate in 6 patients with IgA. Significant decrease of proteinuria/GFR ratio strongly suggests some non-hemodynamic mechanisms of cyclosporine action in these patients. Therapy was well tolerated and side-effects were not so severe to require cyclosporine withdrawal.

[Renal failure caused by rhabdomyolysis induced by hypokalemia in Conn's syndrome]

The authors submit a case-history of a patient who developed renal failure as a result of acute rhabdomyolysis induced by severe hypokalaemia in Conn's syndrome. The authors describe the diagnosis of the disease, its course and discuss the relationship of hypokalaemia, rhabdomyolysis and acute renal failure.

[Renal vasculitis and glomerulonephritis with anti-neutrophil cytoplasmic antibody positivity]

BACKGROUND

Anti-neutrophil cytoplasmic antibodies (ANCA) define pathogenetically related group of renal vasculitides and glomerulonephritides mostly with serious prognosis. If unrecognized, these life-threatening diseases may cause loss of independent renal function and other dangerous extrarenal complications (e. g. pulmonary haemorrhage). We concentrated on the diagnosis, treatment and log-term follow-up of these patients.

METHODS AND RESULTS

Renal biopsy was performed in 46 ANCA-positive patients. Age and sex distribution, type of ANCA, organ involvement, renal biopsy findings, renal function and effect of therapy were analyzed in these patients. Twenty three patients suffered from renal vasculitis, most commonly Wegener's granulomatosis (14 patients) and microscopic polyarthritis (7 patients). IgA nephropathy (7 patients) and idiopathic necrotizing/crescentic glomerulonephritis (8 patients) prevailed in patients with limited renal involvement. Renal morphology and function was most seriously impaired in patients with Wegener's granulomatosis. Immunosuppressive treatment was able to control the activity of the disease with the negativization of ANCA and improvement or stabilization of renal function in more than 90% of patients.CONCLUSIONS. ANCA-positive renal vasculitis and glomerulonephritis is relatively common. Clinical signs of extrarenal involvement are present in about 50% of patients with ANCA-positive glomerulonephritis. Rapidly introduced immunosuppressive treatment effectively controls renal and extrarenal manifestations of the disease.

[Diagnostic and pathogenic significance of antineutrophil cytoplasmic antibodies in vasculitides]

OBJECTIVES

The study represents a complex report on diagnostic and pathogenic significance of antineutrophil cytoplasmic autoantibodies (ANCA). Our report is founded on the results of our clinical and experimental studies.

METHODS

ANCA was examined by indirect immunofluorescence, or ELISA-anti MPO. The data for evaluation of diagnostic ANCA associations were gained by means of questionnaires. The experimental part involved examination of the impact of sera containing ANCA and monoclonal antibodies (MoAb) against proteinase 3 and control MoaB specific for neutrophils.

RESULTS

Within the course of 1 year we have examined 1010 samples, ANCA was found in 65 patients: 26 cases of systemic vasculitis, 12 cases of other autoimmune diseases, 9 cases of isolated glomerulonephritis, 7 cases of inflammatory intestinal diseases, 6 cases of ophthalmic inflammatory diseases, and 6 cases of other diseases. Vasculitis of small vessels found in our group of patients are concomitted by ANCA positivity in 90% (Wegener's granulomatosis 15/16, Churg--Strauss's syndrome 3/5, MPA 9/9), vasculitis of medium vessels 12% (classical polyarteritis nodosa 1/2, Kawasaki disease 0/2, Henoch--Schönlein's purpura 0/4, Takayasu's arteritis 1/4). The ANCA-containing sera inhibit the candidacidal activity by 65% in average. THe inhibitory impact is yielded by anti-proteinase MoAb, in contrast to the control MoAb.

CONCLUSION

c-ANCA in high concentration is specific for active form of Wegener's granulomatosis, other types of ANCA in low titres are not of diagnostic value for vasculitis. ANCA is concomitted especially by small vessels vasculitis. The proved inhibition of microbicidal PMN activity by ANCA can participate in some clinical signs of immunodeficiencies in vasculitis. (Tab. 5, Ref. 18.).

[Renal impairment in monoclonal gammapathies. Clinical study]

BACKGROUND

Renal involvement is an important and frequent complication in patient with monoclonal gammapathy (MG), especially in multiple myeloma (MM). Light chain proteinuria produces many renal manifestations, the most serious form is acute renal failure, which occurs in 5-10% of patients with MM. The frequency and form of renal involvement was determined in a group of patients with MG. The disturbances observed were correlated with the concentration and type of paraprotein in serum and urine.

METHODS AND RESULTS

We investigated 82 patients, 37 men and 45 women with an average age of 63.5 years. Apart from standard nephrologic tests the aminoaciduria/24 h and urine acidification capacity was determined. In some patients renal biopsy was performed. Proteinuria was observed in 66 cases (80.5%), in 54 of them of Bence-Jones type. Nephrotic syndrome developed in 4 patients, in all cases the renal amyloidosis was present. Renal insufficiency was diagnosed in 39 patients (47.5%), mostly in MM. In 14 cases was renal insufficiency reversible, in 14 remain stable and in 11 progressed during the course of disease. Irreversible progression developed in terminal phase of disease in most cases. Acute renal failure was observed in 6 patients, only in four of them further course of renal disease could be evaluated. In half of these 4 patients the renal failure was reversible.

CONCLUSIONS

Higher frequency of proteinuria and renal insufficiency was detected in patients with light chain paraprotein of lambda type, or biclonal kappa+lambda type. Aminoaciduria was diagnosed in 40% of patients, we did not observe complete Fanconi's syndrome. Incompleted form of renal tubular acidosis we diagnosed in 52% of cases without other signs of renal involvement.

[The spectrum of diseases associated with antineutrophil cytoplasmic antibodies]

BACKGROUND

Antineutrophil cytoplasmic antibodies (ANCA) are considered as a diagnostic marker of systemic vasculitis and rapidly progressing glomerulonephritis. They are frequently associated with other pathological conditions. The author's objective was to analyze a group of patients examined at the Department of Clinical Immunology of the First Medical Faculty Charles University in the course of one year and evaluation of the diagnostic asset of the ANCA examination.

METHODS AND RESULTS

ANCA was assessed in serum using the method of indirect immunofluorescence. In cases of p-ANCA the ELISA test was used to assess antimyeloperoxidase antibodies. Clinical data were evaluated on the basis of analysis of a questionnaire sent to doctors of patients where ANCA was detected. In 1992 1010 specimens were examined and in 115 ANCA was detected. This was the case in a group of 65 patients with the following diagnoses: systemic vasculitis 26x, systemic immunopathological diseases 12x, renal diseases 9x, inflammatory bowel diseases 7x, inflammatory eye diseases 6x, monoclonal paraproteinaemia 2x, other 4x. The patients had renal affections (45%), affections of the joints (20%), skin (18%), eyes (14%), lungs (12%), GIT (11%), ENT (9%), and nerves (9%). Type c in titres above 1:160 was always associated with the diagnosis of Wegener's granulomotosis, in other instances c- or x-types titres of 1:20 were involved. Antibodies against myeloperoxidase were detected in four instances.

CONCLUSIONS

The authors confirmed that c-ANCA in high concentrations are specific for the predominantly active form of Wegener's granulomatosis. The group of patients with p-ANCA is too small to generalize the diagnostic impact. Low ANCA concentrations are found in many other diseases. The importance of ANCA can be evaluated only in a clinical context and the importance of their presence must not be overestimated.

[Rapidly progressive glomerulonephritis in a solitary kidney positive for anti-glomerular basement membrane antibodies and antineutrophil cytoplasmic antibodies]

The authors describe the case-report of a 72-year-old female patient with acute failure of a solitary kidney with complete functional breakdown which developed within several days and was due to rapidly progressive glomerulonephritis (RPGN) with concurrent positivity of antineutrophil cytoplasmatic autoantibodies (ANCA) and anti-glomerular basement antibodies (AGBMA). Intensive combined immunosuppressive therapy with methyl prednisolone, cyclophosphamide and azathioprine and concurrent plasmaphereses led to negativity of both types of antibodies but were not able to restore sufficient renal function and regular dialysis treatment to be started. Subsequently AGBMA remained negative, while ANCA became again positive. Despite this partial restoration of renal function was manifested by an increased diuresis and the frequency of dialyses could be reduced. The case-report has several remarkable features. An uncommon RPGN of the antirenal type is involved, moreover in a solitary kidney with concurrent C-ANCA positivity. The concurrent presence of ANCA and AGBMA autoantibodies in RPGN has been described in the literature only in several tens of cases. So far it was not described in our country. Based on their experience the authors conclude: 1. a solitary kidney cannot be considered in case of suspected RPGN as a strict contraindicatio of renal biopsy, 2. RPGN with concurrent positivity of ANCA and AGBMA is indicated for long-term immunosuppressive therapy on account of a more favourable prognosis than simple antirenal RPGN, and also with regard to a possible suspected systematic vasculitis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Renal resistance to atrial natriuretic factor as a cause of the escape failure phenomenon in patients with non-ascitic liver cirrhosis]

BACKGROUND

Chronic administration of synthetic mineralocorticoids leads in healthy subjects only to temporary fluid retention with subsequent restoration of sodium balance, i.e. the so-called mineralocorticoid escape phenomenon. There is a failure of mineralocorticoid escape in patients with ascitic liver cirrhosis with progressive fluid retention. The aim of this study was to contribute to the elucidation of the mechanisms of the escape phenomenon in patients with preascitic liver cirrhosis.

METHODS AND RESULTS

Synthetic mineralocorticoid, fludrocortisone, was administered for 7 days to 8 patients with non-ascitic liver cirrhosis (LC) and 6 controls (CO) on a high sodium diet. CI seemed to have some central volume expansion before fludrocortisone administration, as assessed from a higher left atrial diameter and lower plasma aldosterone. Fludrocortisone administration in CI led to a comparable increase of ANF and suppression of plasma aldosterone as in CO with a higher diameter of the left atrium and lower PRA than in controls. Despite a comparable increase of ANF after fludrocortisone administration cGMP excretion was significantly higher in CO than in CI (434.5 + 247.1 vs. 824.6 + 317.3 pmol/min, p < 0.05). Natriuresis of CI seemed to depend on urinary cGMP excretion before fludrocortisone administration. The natriuretic response of these CI to a high sodium diet was exaggerated (290.0 + 53.9 vs. 160.0 + 18.3, p < 0.05), but they were unable to escape completely from the retaining effect of fludrocortisone.

CONCLUSIONS

Failure of mineralocorticoid escape in patients with preascitic liver cirrhosis may be due to the renal resistance to ANF with insufficient increase of urinary cGMP excretion.

Long-term control of hypertension and the predictive value of peripheral plasma renin activity after ablation of end stage kidneys with a new embolic agent

Embolization of end-stage kidneys using our own embolizing agent Vilanol (partially hydrolyzed polyvinyl acetate) was performed in 10 patients with hypertension refractory to conservative therapy. Native kidneys were embolized in 7 patients with chronic renal failure, nonfunctioning renal transplants in 2 patients, and a shrunken kidney in 1 patient. Five of the 10 patients had high (9.96-18.2 ng/ml/h) peripheral renin (PR) levels. The embolization was technically successful in 4 of these 5 patients and was immediately followed by a marked decrease in PR, and simultaneous improvement in blood pressure (BP). The other 5 patients had very low PR levels (0.07-0.65 ng/ml/h), and a reduction in BP was observed in 4 after embolization. One patient died following embolization from cardiac arrest due to hyperkalemia. Six patients (3 in each group) have been on follow-up for 2-5 years with sustained decrease in BP. We conclude that the new agent is effective for renal ablation and control of refractory hypertension.

[Rapidly progressing glomerulonephritis with antibodies against cytoplasm of neutrophilic leukocytes]

The authors describe the clinical, laboratory and morphological findings, the clinical course and response to treatment in three patients with rapidly progressing glomerulonephritis where positive antibodies against the cytoplasm of neutrophil granulocytes (ANCA) were found. The authors confront their own clinical experience with data in the literature. Examination of ANCA is not only a significant contribution towards a more accurate diagnosis of renal vasculitis, but also an indicator of the activity of the disease and thus of the effectiveness of immunosuppressive treatment.

[Hypertension in patients with polycystic kidneys--the effect of volume expansion]

Arterial hypertension is found in as many as 75% patients with autosomal dominant polycystic kidneys with normal renal function, its pathogenesis is however not quite clear so far. The authors examined 16 patients with polycystic kidneys with normal or only slightly reduced renal function (plasma creatinine lower than 140 umol/l), 8 of these patients were normotonic (N) and 8 hypertonic (H). In all examined subjects right-sided cardiac catheterization was performed with assessment of the minute cardiac volume by thermodilution. To all patients in the course of one hour 1500 ml saline per 70 kg body weight were administered and the haemodynamic examinations were repeated after termination of the infusion. In all subjects before and after expansion the plasma renin activity was assessed (PRA), as well as plasma aldosterone (PA), plasma catecholamines (PC) and the atrial natriuretic factor (ANF), the renal blood flow and glomerular filtration by means of clearance and extraction of PAH and inulin clearance. The authors did not find differences in plasma concentrations, cardiac output and splanchnic and renal ANF extraction in groups N and H, nor in PRA, PA and PC. Volume expansion led in both groups to a comparable rise of ANF and suppression of PRA and PA. Group H did not differ from group N in any of the investigated haemodynamic and renal parameters except for systemic vascular resistance. In hypertensive patients before expansion a close correlation was found between pressure in the pulmonary artery in a wedged position and diuresis (r = 0.935, p less than 0.01) and natriuresis (r = 0.895, p less than 0.01). The volume expansion was in both groups associated with a comparable rise of diuresis, the haemodynamic response of patients N and H was however quite different. While in patients of group N a decline of the systemic vascular resistance occurred as well as an increase of the minute volume without a change of the renal flow and glomerular filtration, in hypertonic patients the systemic vascular resistance and minute volume did not change but there was a significant rise of the renal flow and glomerular filtration. The relationship of diuresis and natriuresis of hypertensive patients with polycystic kidneys to volume parameters and the rise of the renal perfusion pressure during volume expansion indicates the importance of pressure natriuresis for ensuring the sodium and volume homeostasis in these patients.

Embolization of the kidney in secondary renal hypertension as an alternative to surgical nephrectomy. An experimental study

Embolization of the renal arterial bed with embolization agent Vilan 500 was performed in 13 dogs. Embolized kidneys shrink after the procedure and the functional parenchyma is extinguished. Peripheral PRA values were followed to find out whether renin production by the embolized kidney is extinguished (the non-embolized kidney was surgically removed). In nine of the thirteen dogs peripheral PRA decreased below 0.5 ng/ml/h; this renin activity can be considered extrarenal. Embolization of the kidneys with Vilan 500 can thus substitute surgical nephrectomy in patients with secondary renal hypertension.

Peripheral plasma renin activity (PRA) in recipients with allograft artery stenosis; its diagnostic value in acute stage hypertension

Peripheral PRA was examined in 11 patients with graft artery stenosis after the onset and throughout the course of hypertension. In the acute stage PRA was elevated in 9 patients and decreased to normal in the later stage of hypertension in all but 1 patient with malignant hypertension. The findings suggest that the determination of peripheral PRA is helpful in diagnosing graft artery stenosis only in the acute stage of hypertension, but it has no unequivocal value to the prognosis of hypertension or indication for operation.