Is hypertension a mortality risk factor in dialysis?

We retrospectively studied 370 chronic uremic patients, 234 males and 136 females with a mean age of 53 +/- 15 years, to determine the number of mortalities due to hypertension. With hypertension defined as blood pressure values > 150/90, a total of 168 patients were found to be normotensive and 202 as hypertensive. Blood pressure was also considered in association with some prognostic variables such as the patient's age, time of dialysis, renal diagnosis, and dialytic treatment (hemodialysis or peritoneal dialysis). No significant difference in survival was found between normotensive and hypertensive patients. Patients with diabetic nephopathy had a significantly poorer survival experience with respect to other nephropathies, independently of blood pressure values after beginning dialysis treatment. The Cox proportional hazard analysis showed an increased risk of death from aging and peritoneal dialysis, while the chi 2 test showed the role of hypertension as a mortality risk factor only in patients less than 50 years old (18% of deaths among normotensives vs. 31% of deaths among hypertensives, P < 0.05). We conclude that hypertension does not seem to represent the primary risk factor for overall survival in dialysis therapy.

Treatment of ectopic calcification in uremia.

Nine uremic patients on maintenance hemodialysis who showed wide arterial and/or stable periarticular calcifications in spite of a well controlled hyperphosphatemia were treated with the diphosphonate disodium ethane-1-hydroxy-1,1-diphosphonate (EHDP) in doses of 7.5 to 10 mg/kg of body wt/per day for 5 to 9 months. No clinical or biochemical side-effects were noted. A significant reduction of the extent of periarticular calcifications was observed in five patients: two of them had a complete regression of soft-tissue calcifications, and one patient showed a reduction of arterial calcification. EHDP (7.5 to 10 mg/kg of body wt/per day) induced a significant increase of the osteoid volume and osteoid surface without significant modification of the calcification front. No evident effect on bone resorption and on the mineral content of the radius has been observed.

Low-dose leukocyte interferon-alpha therapy in dialysed patients with chronic hepatitis C.

Kidney failure is a contraindication to interferon therapy, and active chronic hepatitis is incompatible with kidney transplantation. Our study was aimed at investigating the activity and tolerability of leukocyte interferon-alpha in patients undergoing pre-transplant dialysis and suffering from chronic active hepatitis due to Hepatitis C virus infection. Ten patients, with persistently high ALT levels, were treated with leukocyte interferon-alpha, at a dose of 1 MU three times weekly for one year. Viraemia, ALT levels and other blood and urine tests, hepatitis stage and drug tolerance were all monitored throughout the study and the six-month follow-up period. After six months of treatment, two patients had continuing normalisation of ALT, negative HCV-RNA tests and normalisation of histological features ('long-term responders'). Four patients relapsed; three did not respond to treatment; and one patient discontinued it because of intolerance. The four relapsing patients received a second cycle with the same interferon, at a dose of 3 MU three times weekly, with attainment, in one patient, of complete remittance after six months of follow-up. Leukocyte interferon-alpha yielded an overall 30% therapeutic response in dialysed patients with chronic hepatitis C. Its use is helpful in enabling dialysed patients to undergo transplantation.

Ethylene-oxide and steam-sterilised polysulfone membrane in dialysis patients with eosinophilia.

Eosinophilia and some acute dialysis side-effects, such as itching, flushing and bronchospasm, are often associated with the presence of ethylene oxide (ETO) as dialyzer sterilizing agent. This study evaluated the effects of two different polysulfone (PS) hollow-fiber dialysers sterilized with ETO and steam in 31 chronic dialysis patients with eosinophilia. Clinical symptoms, metabolic and biochemical parameters, complement (C3a and C5a) activation and production were evaluated in each patient dialysed for two months at a time with Cuprophan dialyser, ETO-PS dialyser and steam-PS dialyser. The steam-sterilizer agent does not alter the purifying capacity of the PS membrane which maintains its superiority over Cuprophan in terms of biocompatibility. Using steam-PS, intradialytic eosinophil kinetics seems to improve. In some patients with high serum levels of ETO-specific IgE these levels tend to diminish. Generic intradialytic symptoms do not differ between the two sterilization methods, although some hypersensitivity symptoms during the first dialysis hour are considerably lower in some patients when steam-sterilized PS is used.

Serum B2 microglobulin (B2M) in CAPD.

Twenty-six chronic uremic pts (8F and 18M, mean age 64 yrs) on CAPD for 15 months on the average, were studied as regards the levels of B2M measured by radioimmunoassay in fasting serum samples. Considering residual renal function, 2 pts groups were identified: 11 pts with a diuresis greater than or equal to 500 cc/day and 15 pts with a diuresis less than 500 cc/day. Serum B2M was significantly decreased in the first group (24.8 +/- 8.1 vs 34.7 +/- 7.1 mg/l; p less than 0.02). Considering the incidence of peritonitis episodes, 12 pts without and 14 pts with one or more peritonitis episodes were noted. The group with no peritonitis showed significantly decreased serum B2M values (25.1 +/- 7.6 vs 35.03 +/- 4.8 mg/l; p less than 0.005). No relationship was found as regards primary renal diseases, sex and age of pts. We conclude that residual renal function and peritonitis episodes modify serum B2M levels in CAPD. The long term follow up of pts could be of interest for better defining the role of these factors as regards the incidence of pathologic lesions associated with B2M deposition.

[Systolic ejection murmur in the differential diagnosis of isolated aortic insufficiency and its association with stenosis]. / Il soffio sistolico da eiezione nella diagnosi differenziale tra insufficienza aortica isolata e associata a stenosi.

As assessment of the value of systolic ejection murmur in the differentiation of valvular insufficiency with and without stenosis was carried out by means of ECG, polycardiography and M-mode echocardiography in 60 patients with aortic valve disease divided into 35 subjects with and 25 without stenosis. Attention was directed to the configuration of the murmur, with particular reference to the proto-, meso- or telesystolic location of its acme and the Q-acme distance. It was found that the acme was meso or telesystolic in all cases where stenosis was present, whereas it was proto- or very initially mesosystolic in its absence.

[Hemorrhagic complications during therapy with carbenicillin in 2 cases of acute renal insufficiency]. / Complicanze emorragiche in corso di terapia con carbenicillina in due casi di insufficienza renale acuta

During the treatment of two patients with acute renal insufficiency with carbenicillin for Pseudomonas aeruginosa sepsis haematemesis, melaena and omnipresent petechiae were observed. Suspension was followed by rapid regression and the normalisation of clotting. Attention is drawn to haemorrhage as clotting. Attention is drawn to haemorrhage as a possible complication of carbenicillin management in patients with acute renal insufficiency.

[Mitral valve prolapse. Age and sex incidence, echocardiographic diagnosis and clinical and electrocardiographic correlations]. / Prolasso della mitrale. Incidenza per età e sesso, diagnosi ecocardiografica e correlazioni cliniche ed elettrocardiografiche.

The paper reports an electrocardiographic and M and B-mode echocardiographical study in 3682 non-selected patients among which a total of 241 were identified with mitral valve prolapse. In males the highest frequency was found during the second decade of life with a tendency to decrease with increasing age. In females, who were found to be the most severely affected (2:1 in relation to males), two peaks of incidence were observed during the third and fifth decade, with a greater frequency in the latter and a marked absence of cases in the fourth decade. Many echocardiographically diagnosed mitral prolapses were both clinically and electrocardiographically silent; moreover it was observed that the risks of this complication increased in parallel to the thinness and redundance of the mitralic flap affected by prolapse and the dilation of the valvular ring.

[Clinical experience in HFR with a new resin-only sorbent cartridge]. / Sperimentazione clinica in HFR di una cartuccia rigenerante priva di carbone.

Adsorbent therapies have become increasingly popular over the last several years as they permit an additional method to selectively or non-selectively remove toxins. Adsorbents offer a unique removal strategy as they have an extremely high adsorption capacity due to their great surface area. This paper describes experiments that utilized a synthetic divinylbenzene styrenic resin cartridge to remove uremic toxins from chronic renal failure patients. The resin-only cartridge was tested as an alternative after a small number of patients (primarily taking ACE inhibitors) experienced gastrointestinal problems using hemodiafiltration with on-line regeneration (HFR). Subsequent laboratory evidence suggested that the particular carbon used in the cartridge was able to activate contact phase activation. This could potentially cause problems in patients taking ACE inhibitors, as they are unable to degrade bradykinin efficiently. The resin-only cartridge was tested in at 6 centers throughout Italy and included patients that had experienced previous reactions to the carbon-resin cartridge. At the conclusion of the study, no adverse reactions were reported and the cartridge exhibited excellent removal of b2 microglobulin and angiogenin.

Study of inhibitor and nucleator activities in calcium stone formers.

In 30 calcium stone formers urinary citrate, magnesium, calcium, phosphorus, uric acid and oxalate excretion were compared with the activity product ratios and formation product ratios of oxalate, brushite and monosodium urate. A positive correlation was found between calcium and phosphorus excretions and APRox and APRbr; no correlation was found between oxalate, uric acid, citrate and magnesium excretion and APR or FPR. Thus calcium and phosphorus contribute significantly to the increments of urine saturation; citrate and magnesium do not modify the inhibitor urinary activity, and oxalate and uric acid do not influence inhibition and saturation activities of urine.

Hemodialysis leukopenia and complement function with different dialyzers.

The relationship between leukopenia and the complement system during hemodialysis was re-examined by studying not only the in vivo effects of four different dialyzer membranes (cellulose hydrate, cuprophan, cellulose acetate, and polyacrilonitrile) on leukocyte counts and complement levels, but especially by investigating the effects of these membranes on complement function in vitro. Whereas from in vivo studies no definite conclusions could be drawn, in vitro investigations provided clear-cut information. When more sophisticated technical approaches were undertaken, it became evident that hemodialysis leukopenia has to be thought of in terms of chemotactic factor generation. In fact, a strict correlation was demonstrated between the degree of leukopenia induced by the dialyzers tested and the ability of the relative membrane to generate chemotactic activity in vitro. Moreover, the previously observed ability of polyacrilonitrile membrane to induce a decrement in complement function was due to the ability of polyacrilonitrile to adsorb complement activity and did not correspond to effective complement consumption. This finding explained why polyacrilonitrile dialysis is not accompanied by a decrease in circulating granulocytes. Taken together, our data strongly point to a pivotal role of complement system in the pathogenesis of hemodialysis leukopenia.

Lymphocyte hyporesponsiveness during edema, proteinuria and hypertension (EPH) gestosis.

In vitro immunological tests showed that patients with pre-eclampsia are characterized by a greater degree of lymphocyte hyporesponsiveness to mitogens during pregnancy than normotensive controls. Thus, a relationship has been hypothesized between the hypoimmune lymphocyte response and the pathogenesis of the disease. We studied 20 non-pregnant healthy volunteers (group a), 11 women with a normal pregnancy (group b) and 13 women with EPH gestosis (group c). In all patients we determined the number of lymphocytes and the lymphocyte function (PHA, Con A, PWM responsiveness) in autologous and homologous plasma during pregnancy and 5 to 30 days after delivery. The mean values of the number of EAC and E rosettes in the three groups studied were similar. The mean values of the mitogenic response to PHA in autologous plasma were significantly reduced in both groups b and c in comparison with group a, but there was no statistical difference between groups b and c. The PHA lymphocyte responsiveness returned to normal in both homologous and autologous plasma after delivery. Our data demonstrate that no difference exists between pregnant women with and without pre-eclampsia as regards impaired cell-mediated lymphocyte response in vitro. Moreover, the diminished lymphocyte responsiveness to mitogens during pregnancy seems to be due to humoral circulating factor(s).

Cell mediated immunity in idiopathic glomerulonephritis.

Various recent reports have suggested the presence of a functional defect of lymphocyte subpopulations in minimal-change nephropathy during the active phase. A probable role of inhibitory humoral factor(s) has been hypothesized. However, other authors have been unable to detect a significant difference between plasma from patients with nephrotic syndrome due to minimal-change nephropathy and plasma from other glomerulonephritis in the degree of inhibition of mitogen-induced lymphocyte transformation. In our study, T cell function, as measured by the response to PHA in autologous plasma, was depressed only in patients with minimal-change nephrotic syndrome and in patients with membranoproliferative glomerulonephritis. The lymphocyte function returned to normal when lymphocytes were cultured in homologous plasma. The lymphocyte responsiveness of patients with other glomerulonephritis with or without nephrotic syndrome was normal in both autologous and homologous plasma. Moreover, only plasma from patients with minimal-change nephropathy in the active phase and with membranoproliferative glomerulonephritis were able to induce inhibition of mitogenesis of lymphocytes from healthy donors. These data seem to confirm the presence of specific humoral inhibitory factor(s) in the plasma of these patients. Finally, preliminary findings seem to demonstrate an increase of the number of TG cells in patients with minimal-change nephropathy in remission who relapse early in the subsequent follow-up.

Long-term comparison between captopril and nifedipine in the progression of renal insufficiency.

To verify the hypothesis that angiotensin-converting enzyme (ACE) inhibitors possess a unique renoprotective effect in progressive chronic renal disease, we decided to compare the effects of an ACE inhibitor and a calcium antagonist on both hypertension and the progression of non-diabetic renal insufficiency in a long-term study. A four-year, multicenter, prospective, randomized trial was conducted on 142 hypertensive patients (pts) with established chronic renal failure from six Italian nephrology departments. They were on standard antihypertensive therapy with a low-protein diet and underwent twice-monthly surveillance for a one year pre-randomization period. After that year, 121 pts were randomly allocated to captopril or slow-release nifedipine therapies for a three-year study period. The progression of renal insufficiency was monitored every two months. Blood pressure control was significantly better after randomization than during the year of standard antihypertensive therapy. The progression rate before randomization (BR) was definitely higher before than after randomization (AR): Creatinine clearance (CCr) change BR = -0.46 +/- 0.45 ml/min/month, creatinine clearance change AR = -0.23 +/- 0.43 ml/min/month (P less than 0.01). After randomization, the mean blood pressure values were virtually the same throughout the three year period of the study in the two groups treated by captopril (group I), or nifedipine (group II).(ABSTRACT TRUNCATED AT 250 WORDS)