Hypertension in chronic renal failure and ESRD: prevalence, pathophysiology, and outcomes.

Hypertension and cardiovascular disease were detected to be major problems in end-stage renal disease patients soon after the application of chronic dialysis to treat uremia. Nearly 40 years later, and despite awesome technological and pharmacological advances, cardiovascular diseases remain the number one cause of death in all categories of renal patients, ie, chronic renal insufficiency, end-stage renal disease on dialysis and the renal transplant recipient. This is quite likely related to the massive clinical burden of cardiovascular risk factors: hypertension, cardiac fibrosis and hypertrophy, abnormal lipid profiles, smoking, dietary factors, and enhanced sympathetic activity. For example, left ventricular hypertrophy and abnormal echocardiograms are present in up to 75% to 80% of incident dialysis patients related to the interactions of these cardiovascular risks. It is important to understand how hypertension and the other cardiovascular disease risk factors interact in these patients. Based on the latest national data from the USRDS, the prevalence of underlying cardiac disease is increasing during the period of chronic renal failure. A proper understanding of the pathophysiology and prevalence of hypertension and its consequences in renal patients may lead to more rational therapies and clinical trials. At this time, the nephrologists are dealing with an epidemic of cardiovascular diseases in their patients.

Minimal change nephropathy associated with sclerosing mesenteritis.

A 65-year-old man with sclerosing mesenteritis developed the nephrotic syndrome. Percutaneous renal biopsy revealed classical histologic findings of minimal change nephropathy with a mild interstitial nephritis. Immunomodulation with prednisone led to a rapid and complete remission of the proteinuria but did not alter the course of the underlying sclerosing mesenteritis. The association of lymphomatous and nonlymphomatous neoplasms with minimal change nephropathy has been well-described. Our review of the literature indicates a parallel association of malignant lymphoma with sclerosing mesenteritis and a variety of disorders that constitute a spectrum of disease. The occurrence of this histopathologic form of renal injury and therapeutic response in the setting of a known lymphoreticular disorder suggests a role for a generalized alteration in cell-mediated immunity and not a tumor-induced elaboration of a factor(s) that directly damages the glomerular filtration barrier.

Death by withdrawal from dialysis: a 20-year clinical experience.

The reasons for withdrawal from dialysis are not well understood. The goals of this study were to determine the risk of dying by withdrawal from dialysis over time and to elucidate pertinent clinical correlates in 716 long-term dialysis patients. These patients were monitored from the initiation of dialysis through the time of death, transplant or transfer to another program during a 20-yr period from 1970 through 1989. The causes of death in the 340 deceased patients were analyzed. Clinical correlates and associated risk factors were evaluated in the patients who died from withdrawal from dialysis. Withdrawal from dialysis was defined as: "Death with manifestations of uremia because of withdrawal from dialysis. Underlying medical conditions should not have been active, leading to rapid deterioration with imminent death." Withdrawal from dialysis and cardiac events were the second leading cause of death, each accounting for 18.5% of the deaths. Patients stopping dialysis were older at the start of dialysis than were patients dying of other causes (P < 0.0006; Kruskal-Wallis test), with 65.1% of these patients 61 yr of age and older. Cancer, malnutrition, catabolism, and "dissatisfaction with life" were important associations with the decision to withdraw. More than 50% of patients withdrawing from dialysis had either diabetic nephropathy or atherosclerotic renal vascular disease. Withdrawal from dialysis was a common cause of death in these dialysis patients especially if they were over 61 and had systemic diseases such as diabetes mellitus and renal vascular disease. The reasons for a higher incidence of withdrawal in certain programs deserve further study.

Urinary lactate dehydrogenase isoenzyme analysis in adult population.

This investigation was a systemic study on an adult population of urinary lactate dehydrogenase (LDH) isoenzyme analysis for the distinction between upper and lower urinary tract infections. The study included 160 urine samples from patients and healthy individuals. On the basis of clinical symptoms, urinary bacterial colony counts, renal function tests and radiologic findings, the adults were divided into pyelonephritis group, cystitis group, pelvic lesion group, and control group. This technique correctly identified 23 of 26 patients with pyelonephritis by the presence of elevated LDH-V (over 10 percent) and all of 12 patients with cystitis by the presence of elevated LDH-I (over 60 relative units) but low LDH-V (below 10 percent or lower than LDH-I). In the pelvic group, the results of eight patients were consistent with cystitis and four with pyelonephritis. Our study confirms the sensitivity and specificity of the LDH isoenzyme technique for the differential diagnosis of urinary tract infection on adult patients and is consistent with previous studies on pediatric patients. However, one should be cautious to interpret the results of LDH isoenzymogram before extra-urinary tract lesions are excluded.

Kappa-chain nephropathy associated with plasma cell leukemia.

A 45-year-old-woman had plasma cell leukemia (PCL) and mild renal insufficiency. Renal biopsy findings were compatible with kappa-chain nephropathy. Our case adds PCL to the list of plasma cell dyscrasias associated with kappa- and/or lambda-chain nephropathy.

Does treatment of hypertension prevent renal failure?

The association between malignant hypertension and renal insufficiency is now well established. The previous adage of not treating this entity for fear of precipitating renal failure has now been replaced by one of aggressive medical therapy as a means to prevent further renal damage. Even when treatment appears to cause renal insufficiency, continued aggressive therapy is indicated as the majority of these people will either stabilize or even improve their renal function. The association of renal failure and benign hypertension is less clear. We feel that if long-term controlled studies could be performed, benefit would be evident. However, even without this evidence, the ability to prevent the malignant hypertensive lesion is sufficient reason to aggressively treat this group.

Ultrasonic guidance for renal biopsy.

B-mode ultrasonic guidance was used to perform 76 percutaneous renal biopsies. Renal tissue was obtained from 73 (96.1%) subjects with adequate tissue for interpretation or diagnosis in 72 instances. Major bleeding complications occurred in four (5.3%) patients. Ultrasound has proved to be a safe and effective means of guiding physicians performing renal biopsies. In addition, it has many advantages over other techniques.