IgA vasculitis with nephritis (Henoch-Schönlein purpura) after COVID-19: A case series and review of the literature.

COVID-19 most related glomerular disease to date seems to be collapsing glomerulopathy, mostly in young Afroamerican patients with APOL1 gene risk alleles. However, in our population, predominant in elderly Caucasian patients, most biopsied pathology since the beginning of the pandemic has been IgA nephritis or Schönlein-Henoch purpura. Since the description of the first case of this entity after SARS-CoV-2 infection by our research group, three more cases have arisen, which are described in the following article. In contrast to the rest of IgA vasculitis cases reported, our patients presented more renal function deterioration and all of them required immunosupresive therapy. Moreover, some showed incomplete recovery of renal function. This case series strengthens the hypothesis that SARS-CoV-2 infection may be another trigger of this pathology.

Vasculitis IgA con nefritis (púrpura de Schönlein-Henoch) tras COVID-19: una serie de casos y revisión de la literatura / IgA vasculitis with nephritis (Henoch-Schönlein purpura) after COVID-19: A case series and review of the literature

La patología glomerular más relacionada con enfermedad COVID-19 hasta la fecha parece ser la glomerulopatía colapsante, principalmente en pacientes de raza afroamericana y con alelos de riesgo para el gen APOL1. No obstante, en nuestra población, conformada por pacientes adultos mayores de raza caucásica, la patología más biopsiada desde el inicio de la pandemia ha sido la nefritis IgA o púrpura de Schönlein-Henoch.Desde la descripción del primer caso de esta entidad tras infección por SARS-CoV-2 por nuestro grupo de investigación hemos objetivado otros tres, los cuales se describen a continuación. En contraste con el resto de los casos publicados de vasculitis IgA, nuestros pacientes presentaban mayor deterioro de función renal y todos requirieron tratamiento inmunosupresor. Además, algunos presentaron recuperación incompleta de función renal. Esta serie de casos afianza la posibilidad de que la infección por SARS-CoV-2 sea un desencadenante más de esta patología. (AU)

COVID-19 most related glomerular disease to date seems to be collapsing glomerulopathy, mostly in young Afroamerican patients with APOL1 gene risk alleles. However, in our population, predominant in elderly Caucasian patients, most biopsied pathology since the beginning of the pandemic has been IgA nephritis or Schönlein-Henoch purpura.Since the description of the first case of this entity after SARS-CoV-2 infection by our research group, three more cases have arisen, which are described in the following article. In contrast to the rest of IgA vasculitis cases reported, our patients presented more renal function deterioration and all of them required immunosupresive therapy. Moreover, some showed incomplete recovery of renal function.This case series strengthens the hypothesis that SARS-CoV-2 infection may be another trigger of this pathology. (AU)

[IgA vasculitis with nephritis (Henoch-Schönlein purpura) after COVID-19: A case series and review of the literature]. / Vasculitis IgA con nefritis (púrpura de Schönlein-Henoch) tras COVID-19: una serie de casos y revisión de la literatura.

COVID-19 most related glomerular disease to date seems to be collapsing glomerulopathy, mostly in young Afroamerican patients with APOL1 gene risk alleles. However, in our population, predominant in elderly Caucasian patients, most biopsied pathology since the beginning of the pandemic has been IgA nephritis or Schönlein-Henoch purpura.Since the description of the first case of this entity after SARS-CoV-2 infection by our research group, three more cases have arisen, which are described in the following article. In contrast to the rest of IgA vasculitis cases reported, our patients presented more renal function deterioration and all of them required immunosupresive therapy. Moreover, some showed incomplete recovery of renal function.This case series strengthens the hypothesis that SARS-CoV-2 infection may be another trigger of this pathology.

Phenotypic characterization of X-linked hypophosphatemia in pediatric Spanish population.

BACKGROUND: X-linked hypophosphatemia (XLH) is a hereditary rare disease caused by loss-of-function mutations in PHEX gene leading tohypophosphatemia and high renal loss of phosphate. Rickets and growth retardation are the major manifestations of XLH in children, but there is a broad phenotypic variability. Few publications have reported large series of patients. Current data on the clinical spectrum of the disease, the correlation with the underlying gene mutations, and the long-term outcome of patients on conventional treatment are needed, particularly because of the recent availability of new specific medications to treat XLH. RESULTS: The RenalTube database was used to retrospectively analyze 48 Spanish patients (15 men) from 39 different families, ranging from 3 months to 8 years and 2 months of age at the time of diagnosis (median age of 2.0 years), and with XLH confirmed by genetic analysis. Bone deformities, radiological signs of active rickets and growth retardation were the most common findings at diagnosis. Mean (± SEM) height was - 1.89 ± 0.19 SDS and 55% (22/40) of patients had height SDS below-2. All cases had hypophosphatemia, serum phosphate being - 2.81 ± 0.11 SDS. Clinical manifestations and severity of the disease were similar in both genders. No genotype-phenotype correlation was found. Conventional treatment did not attenuate growth retardation after a median follow up of 7.42 years (IQR = 11.26; n = 26 patients) and failed to normalize serum concentrations of phosphate. Eleven patients had mild hyperparathyroidism and 8 patients nephrocalcinosis. CONCLUSIONS: This study shows that growth retardation and rickets were the most prevalent clinical manifestations at diagnosis in a large series of Spanish pediatric patients with XLH confirmed by mutations in the PHEX gene. Traditional treatment with phosphate and vitamin D supplements did not improve height or corrected hypophosphatemia and was associated with a risk of hyperparathyroidism and nephrocalcinosis. The severity of the disease was similar in males and females.

Duration of Treatment with Corticosteroids and Recovery of Kidney Function in Acute Interstitial Nephritis.

BACKGROUND AND OBJECTIVES: Drug-induced acute interstitial nephritis represents an emerging cause of acute kidney disease, especially among polymedicated elderly patients. Although corticosteroids are frequently used, controversy exists about the timing of initiation, efficacy, safety, and duration of treatment. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We performed a retrospective study of 182 patients with biopsy-proven drug-induced acute interstitial nephritis from 13 Spanish centers. Exposure was defined as the length of corticosteroid treatment. The main outcome was the level of serum creatinine at month 6, with respect to baseline values. RESULTS: The most common offending agents were nonsteroidal anti-inflammatory drugs (27%). In 30% of patients, the offending drug could not be identified. The median time to suspected drug withdrawal was 11 days (interquartile range, 5-22). All patients presented with acute kidney disease and were treated with corticosteroids. The mean initial dose of prednisone was 0.8±0.2 mg/kg per day. High-dose corticosteroid treatment was maintained for 2 weeks (interquartile range, 1-4). After 6 months, the mean recovered GFR was 34±26 ml/min per 1.73 m2 and ten patients required maintenance dialysis. Use of high-dose corticosteroids for 3 weeks or treatment duration >8 weeks were not associated with better recovery of kidney function. In the multivariable analysis, delayed onset of steroid treatment (odds ratio, 1.02; 95% confidence interval, 1.0 to 1.04) and the presence of interstitial fibrosis of >50% on the kidney biopsy specimen (odds ratio, 8.7; 95% confidence interval, 2.7 to 27.4) were both associated with serum creatinine level at month 6 of >75%, with respect to baseline values. CONCLUSIONS: High-dose corticosteroid treatment for 3 weeks or prolonged treatment for >8 weeks were not associated with greater kidney function recovery in drug-induced acute interstitial nephritis. A delay in the initiation of corticosteroids resulted in worse recovery of kidney function.

Echocardiographic findings in haemodialysis patients according to their state of hydration / Hallazgos ecocardiográficos en pacientes en hemodiálisis según su estado de hidratación

Background: Chronic fluid overload is frequent in hemodialysis patients (P) and it associates with hypertension, left ventricular hypertrophy (LVH) and higher mortality. Moreover, echocardiographic data assessing fluid overload is limited. Our aim was to evaluate the relationship between fluid overload measured by bioimpedance spectroscopy (BIS) and different echocardiographic parameters. Methods: Cross-sectional observational study including 76 stable patients. Dry weight was clinically assessed. BIS and echocardiography were performed. Weekly time-averaged fluid overload (TAFO) and relative fluid overload (FO/ECW) were calculated using BIS measurements. Results: Based on TAFO three groups were defined: A- dehydrated, TAFO <-0.25 L 32 P (42%); B- normohydrated, TAFO between -0.25 and 1.5 l: 26 (34%); C- overhydrated, TAFO>1.5 l: 18 (24%). We found significant correlation between TAFO and left atrial volume index (LAVI) (r: 0.29; p=0.013) but not with FO/ECW (r 0.06; p=0.61). TAFO, but not FO/ECW kept a significant relationship with LAVI (p=0.03) using One-Way ANOVA test and linear regression methods. LVH was present in 73.7% (concentric 63.2%, eccentric in 10.5%). No differences between groups in the presence of LVH or left ventricular mass index were found. Conclusions: We found that left atrial volume index determined by echocardiographic Area-length method, but not left ventricle hypertrophy or dimensions of cavities, are related on hydration status based on bioimpedance measured time-averaged fluid overload (TAFO), and not with FO/ECW (AU)

Introducción: La sobrehidratación es frecuente en pacientes en hemodiálisis (P) y se asocia con hipertensión, hipertrofia ventricular izquierda (LVH) y mayor mortalidad. Los datos ecocardiográficos evaluando sobrecarga hídrica son escasos. Nuestro objetivo fue evaluar la relación entre sobrehidratación medida por Bioimpedancia multifrecuencia (BIS) y parámetros ecocardiográficos. Métodos: Estudio transversal observacional, con 76 P estables; El peso seco fue determinado clínicamente; se realizaron ecocardiograma, BIS y analítica sanguínea. Se calcularon la sobrehidratación promedio semanal (TAFO) y sobrehidratación relativa (FO/ECW). Resultados: 3 grupos: A- deshidratados, TAFO <-0.25 L: 32 P (42,1%); B- normohidratado, TAFO -0.25 - 1.5 L: 26 P (34,2%); C- sobrehidratados TAFO > 1.5 L: 18 P (23,7%). Encontramos correlación significativa entre TAFO e índice de volumen auricular izquierdo (LVAI) (r: 0.29; p=0.013) y no con FO/ECW (rho 0,06; p = 0,61). TAFO, pero no FO/ ECW, mantuvo una relación significativa con LVAI (p = 0,03) utilizando test de ANOVA y regresión lineal. LVH estuvo presente en 73,7% de P (concéntrica 63,2%, excéntrica 10,5%). No encontramos diferencias entre grupos en cuanto a la presencia de LVH, ni del índice de masa ventricular izquierda. Conclusiones: Nosotros observamos que el índice de volumen auricular izquierdo determinado por longitud de área medida por ecocardiograma y no la hipertrofia ventricular izquierda o dimensión de cavidades se relaciona con el estado de hidratación medido por sobrehidatación semanal y no con FO/ECW (AU)

Echocardiographic findings in haemodialysis patients according to their state of hydration.

BACKGROUND: Chronic fluid overload is frequent in hemodialysis patients (P) and it associates with hypertension, left ventricular hypertrophy (LVH) and higher mortality. Moreover, echocardiographic data assessing fluid overload is limited. Our aim was to evaluate the relationship between fluid overload measured by bioimpedance spectroscopy (BIS) and different echocardiographic parameters. METHODS: Cross-sectional observational study including 76 stable patients. Dry weight was clinically assessed. BIS and echocardiography were performed. Weekly time-averaged fluid overload (TAFO) and relative fluid overload (FO/ECW) were calculated using BIS measurements. RESULTS: Based on TAFO three groups were defined: A- dehydrated, TAFO <-0.25 L 32 P (42%); B- normohydrated, TAFO between -0.25 and 1.5 l: 26 (34%); C- overhydrated, TAFO>1.5 l: 18 (24%). We found significant correlation between TAFO and left atrial volume index (LAVI) (r: 0.29; p=0.013) but not with FO/ECW (r 0.06; p=0.61). TAFO, but not FO/ECW kept a significant relationship with LAVI (p=0.03) using One-Way ANOVA test and linear regression methods. LVH was present in 73.7% (concentric 63.2%, eccentric in 10.5%). No differences between groups in the presence of LVH or left ventricular mass index were found. CONCLUSIONS: We found that left atrial volume index determined by echocardiographic Area-length method, but not left ventricle hypertrophy or dimensions of cavities, are related on hydration status based on bioimpedance measured time-averaged fluid overload (TAFO), and not with FO/ECW.

Glomerulonephritis and cryoglobulinemia: first manifestation of visceral leishmaniasis.

Visceral leishmaniasis due to Leishmania Infantum is an endemic parasitic infection in the Mediterranean area. Since 2009, Europe's largest outbreak of Leishmaniasis has been reported in the region of Madrid (Spain). Renal involvement is an unusual complication. Different forms of renal disease have been described: interstitial, glomerular, and vascular damage. Direct invasion of renal parenchyma by the parasite has been described as a mechanism of kidney damage, especially in the immunocompromised. Immune complex deposition and T cells adhesion molecules activation have demonstrated that a pathogenic role in glomerulonephritis related to visceral leishmaniasis. The association between mixed cryoglobulinemia and visceral leishmaniasis has been previously reported in six patients. Renal involvement is only described in one of them. From July 2009 to October 2012, 4 patients with membranoproliferative glomerulonephritis and mixed cryoglobulinemia with negative serology for hepatitis B and C were diagnosed in our hospital. Serology of Leishmania in serum bank samples was performed; it was positive in 3 patients. Leishmania parasite was confirmed by other tests. We present 3 patients with mixed cryoglobulinemia and membranoproliferative glomerulonephritis as first clinical manifestation of visceral leishmaniasis.

Haplotype analysis of CLDN19 single nucleotide polymorphisms in Spanish patients with familial hypomagnesemia with hypercalciuria and nephrocalcinosis.

BACKGROUND: Familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC) is an autosomal recessive tubular disease caused by mutations in the CLDN16 or CLDN19 gene. Previous studies using microsatellite markers flanking the CLDN19 locus estimated that p.G20D (c.59G>A), a recurrent mutation in Spanish families, is a founder mutation. In the present study, we assessed the haplotype of Spanish patients using single nucleotide polymorphisms (SNPs). METHODS: Twenty-seven FHHNC patients were included in this study. We analyzed four SNPs located in CLDN19 introns 3 and 4 by polymerase chain reaction amplification and DNA sequencing. RESULTS: Three new patients with homozygous p.G20D were identified. The SNP genotyping analysis showed that alleles carrying this mutation shared a common SNP haplotype. CONCLUSIONS: Our findings suggest the existence of a founder effect responsible for FHHNC in our cohort. Testing for the presence of mutation p.G20D should be the first genetic screening in Spanish patients.

Predictors of response and relapse in patients with idiopathic membranous nephropathy treated with tacrolimus.

BACKGROUND: Although tacrolimus is recommended by KDIGO Clinical Practice Guideline for Glomerulonephritis for the treatment of idiopathic membranous nephropathy (MN), little is known about factors that influence response and relapse of the disease after tacrolimus therapy. METHODS: Multicentre study that collected 122 MN patients with nephrotic syndrome and stable renal function treated with tacrolimus. Duration of treatment was 17.6 ± 7.2 months, including a full-dose and a tapering period. RESULTS: The percentage of remission was 60, 78 and 84% after 6, 12 and 18 months of treatment, respectively. The amount of proteinuria at baseline significantly predicted remission, the lower the baseline proteinuria the higher the probability of remission. Only 10 patients (8%) received concomitantly corticosteroids, and their rate of remission was similar (80% at 18 months). Among responders, 42% achieved complete remission (CR) and 58% partial remission (PR). Almost half (44%) of the responder patients relapsed. The amount of proteinuria at the onset of tacrolimus tapering was significantly higher in relapsing patients. By multivariable analysis, the presence of a PR versus CR at the onset of tacrolimus tapering and a shorter duration of the tapering period significantly predicted relapses. Tolerance was good and the number of adverse events low. CONCLUSIONS: Tacrolimus monotherapy is an effective and safe option for the treatment of MN with stable renal function. Relapses are frequent in patients with PR and can be partially prevented by a longer tapering period.

Lower plasma sodium is associated with a microinflammatory state among patients with advanced chronic kidney disease.

BACKGROUND/AIMS: Lower serum sodium levels have been associated with increased mortality among patients with chronic kidney disease (CKD). Our aim was to analyze the independent factors associated with lower sodium levels among nondialysis patients with advanced CKD and to evaluate the evolution of these patients in comparison to those with higher plasma sodium over a 1-year period. METHODS: We included 72 patients with CKD stages 4 and 5 without clinically evident cardiopathy or liver disease. Bioelectrical impedance and echocardiography were performed to analyze the possible relation between plasma sodium and volume status and subclinical left ventricular (LV) dysfunction. During follow-up, we compared the evolution of patients with lower baseline plasma sodium (low quartile: <138 mEq/l) with that of patients with higher levels over a 1-year period. RESULTS: At baseline, the independent predictors of lower plasma sodium were C-reactive protein (CRP; OR 0.96; 95% CI 0.91-0.99) and body mass index (OR 0.89; 95% CI 0.78-0.99). An inverse correlation between plasma sodium and CRP was observed (r = -0.32; p = 0.01). Plasma sodium did not correlate with extracellular water and was not different between patients with or without echocardiographic data of LV dysfunction (p = 0.7). During follow-up, patients with lower sodium at baseline showed persistently lower sodium values (p = 0.04), higher CRP (p = 0.05), lower serum albumin (p < 0.01) and higher erythropoietin-stimulating agent resistance index (p = 0.05). CONCLUSIONS: Our results suggest an association between lower plasma sodium and a microinflammatory state among patients with advanced CKD. Inflammation could be an underlying confounding factor explaining the increased mortality in these patients.

Geriatric assessment for therapeutic decision-making regarding renal replacement in elderly patients with advanced chronic kidney disease.

UNLABELLED: In patients older than 75 years with advanced chronic kidney disease (CKD), the decision between treatment with dialysis [intention to treat with dialysis (ITD)] or conservative care (CC) is a challenge. Geriatric assessment can be helpful. The aim was to identify which factors had had an influence on decision-making. METHODS: We recruited 56 patients. At baseline we analyzed age, frailty (defined following the criteria of Fried et al. [J Gerontol A Biol Sci Med Sci 2001;56:146-156]), dependence for activities of daily living (ADL), cognitive impairment, depression, comorbidity, cardiovascular disease, and diabetes. After full information about prognosis and treatment options, the preferences of the patients and families were taken into consideration as determinants in the decision-making process. During the follow-up, we evaluated clinical and laboratory parameters, hospitalization, mortality and reevaluated frailty. RESULTS: Twenty patients opted for CC, and 36 patients opted for ITD. On univariate analysis, the predictive factors of the election of CC were age, prefrailty, cognitive impairment, and dependence for ADL. In the multivariate analysis, age and prefrailty remained as predictors for the choice of CC. Hospitalizations were more frequent in CC. Survival was similar in both groups (p = 0.098). CONCLUSIONS: Frailty assessment could be useful for decision-making about the treatment in elderly patients with CKD. CC may be a good treatment option.

Mycophenolate in refractory and relapsing lupus nephritis.

BACKGROUND: Mycophenolate (MF) is effective as induction and maintenance treatment in patients with lupus nephritis (LN). This study evaluates the efficacy and safety of MF in patients with refractory and relapsing LN. METHODS: Data were retrospectively obtained for 85 patients (35 refractory and 50 relapsing) from 11 nephrology departments in Spain. The primary endpoints were the incidence and cumulative number of renal responses and relapses and their relationship with baseline clinical and analytical data. The secondary endpoint was the appearance of side effects. RESULTS: The main clinical and analytical variables were similar both in refractory and relapsing LN. Most of the patients had received cyclophosphamide, and all of them switched to MF. 74 patients (87%) achieved a response (69% partial, 31% complete). Age at starting MF, gender, pathological classification, body mass index, blood pressure, baseline renal function, and proteinuria were not associated with achieving response. After stopping MF, 3 of 19 patients (15.7%) relapsed, all at 6 months of follow-up. No differences were found between clinical and analytical variables and number of relapses. Side effects were unremarkable, except for 1 patient, who died of thrombocytopenia and ovarian hemorrhage. CONCLUSIONS: Switching to MF from other immunosuppressive treatments is effective and safe in refractory and relapsing LN.

Cystatin C as a predictor of mortality and cardiovascular events in a population with chronic kidney disease.

Background. We examine whether cystatin C, a surrogate marker of renal function, could identify patients with chronic kidney disease (CKD) with an increased risk of renal disease progression, death, or cardiovascular events. Methods. Data were obtained for 180 patients, with a diagnosis of chronic renal failure based on serum creatinine estimated glomerular filtration rate (eGFRcreat) <90 mL/min/1.73 m(2). This population was grouped in tertiles according to cystatin C and creatinine values at baseline. Cardiovascular events and overall mortality were estimated for each tertile. Predictors of overall mortality and for the development of renal disease progression were analyzed. Results. The median age was 75 years (interquartile range 69-82) and the median eGFRcreat 38 mL/min m(2) (interquartile range 33-49). Overall mortality was lower on the first and on the second tertiles of cystatin C than on the third one (HR = 0.060; 95% CI: 0.008-0.447 and HR = 0.094; 95% CI: 0.022-0.406, resp.). Deaths related to the creatinine tertiles followed the same pattern, but differences were not as large. Cardiovascular mortality was lower on the second than on the third cystatin C tertile (HR = 0.198; 95% CI: 0.040-0.987), but it did not show differences on the first and the second creatinine tertiles compared with the third one (HR = 0.126; 95% CI: 0.013-1.265 and HR = 0.403; 95% CI: 0.093-1.740). The only independent predictors of mortality during followup were baseline cystatin C (OR = 0.100; 95% CI: 0.021-0.463) and baseline uric acid (OR = 1.377; 95% CI: 1.070-1.773). Conclusion. Cystatin C may be an alternative to creatinine for detecting a high risk of death and cardiovascular events in a population with CKD.

Lack of influence of serum magnesium levels on overall mortality and cardiovascular outcomes in patients with advanced chronic kidney disease.

Background. Low serum magnesium has been associated with an increased cardiovascular risk in the general population and in dialysis patients. Our aim was to analyze the influence of serum magnesium on overall mortality and cardiovascular outcomes in patients with advanced CKD not yet on dialysis. Methods. Seventy patients with CKD stages 4 and 5 were included. After a single measurement of s-magnesium, patients were followed a mean of 11 months. Primary end-point was death of any cause, and secondary end-point was the occurrence of fatal or nonfatal CV events. Results. Basal s-magnesium was within normal range (2.1 ± 0.3 mg/dL), was lower in men (P = 0.008) and in diabetic patients (P = 0.02), and was not different (P = 0.2) between patients with and without cardiopathy. Magnesium did not correlate with PTH, calcium, phosphate, albumin, inflammatory parameters (CRP), and cardiac (NT-proBNP) biomarkers but correlated inversely (r = -0.23; P = 0.052) with the daily dose of loop diuretics. In univariate and multivariate Cox proportional hazard models, magnesium was not an independent predictor for overall mortality or CV events. Conclusions. Our results do not support that serum magnesium can be an independent predictor for overall mortality or future cardiovascular events among patients with advanced CKD not yet on dialysis.

Serum alkaline phosphatase levels and left ventricular diastolic dysfunction in patients with advanced chronic kidney disease.

BACKGROUND: High levels of alkaline phosphatase (ALP) have been associated with increased mortality in patients with advanced chronic kidney disease (CKD). We hypothesize that elevated ALP could be partly explained by subclinical liver congestion related to left ventricular diastolic dysfunction. METHODS: Doppler echocardiography was performed in 68 patients with advanced CKD followed up for a median of 2.1 years. Time-averaged levels of ALP and γ-glutamyl transferase (GGT) were compared between patients with and without diastolic dysfunction. We also evaluated the effect of intensifying diuretic treatment on ALP levels in a small group of 16 patients with high ALP and signs of volume overload. RESULTS: ALP correlated significantly (p < 0.001) with GGT but not with parathyroid hormone (p = 0.09). Patients with diastolic dysfunction showed higher ALP (p = 0.01), higher GGT (p = 0.03) and lower albumin (p = 0.04). The highest values of ALP were observed in patients with diastolic dysfunction plus pulmonary hypertension (p = 0.01). Intensifying diuretic therapy in a subgroup of patients with signs of fluid overload induced a significant reduction in body weight, GGT (p < 0.001) and ALP levels (p < 0.001). CONCLUSIONS: Elevated ALP in patients with advanced CKD could be partly explained by subclinical liver congestion related to left ventricular diastolic dysfunction, hypervolemia or both. The worse prognosis of these patients could be explained by their myocardial damage.

Spontaneous remission of nephrotic syndrome in idiopathic membranous nephropathy.

Spontaneous remission is a well known characteristic of idiopathic membranous nephropathy, but contemporary studies describing predictors of remission and long-term outcomes are lacking. We conducted a retrospective, multicenter cohort study of 328 patients with nephrotic syndrome resulting from idiopathic membranous nephropathy that initially received conservative therapy. Spontaneous remission occurred in 104 (32%) patients: proteinuria progressively declined after diagnosis until remission of disease at 14.7 +/- 11.4 months. Although spontaneous remission was more frequent with lower levels of baseline proteinuria, it also frequently occurred in patients with massive proteinuria: 26% among those with baseline proteinuria 8 to 12 g/24 h and 22% among those with proteinuria >12 g/24 h. Baseline serum creatinine and proteinuria, treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists, and a >50% decline of proteinuria from baseline during the first year of follow-up were significant independent predictors for spontaneous remission. Only six patients (5.7%) experienced a relapse of nephrotic syndrome. The incidence of death and ESRD were significantly lower among patients with spontaneous remission. In conclusion, spontaneous remission is common among patients with nephrotic syndrome resulting from membranous nephropathy and carries a favorable long-term outcome with a low incidence of relapse. A decrease in proteinuria >50% from baseline during the first year predicts spontaneous remission.

Strict volume control and longitudinal changes in cardiac biomarker levels in hemodialysis patients.

BACKGROUND: Our aim was to analyze the longitudinal changes in cardiac biomarker levels in hemodialysis patients with high comorbidity treated in our special hospital unit. We hypothesize that strict volume control strategy (salt-restricted diet, extended dialysis sessions and dry weight clinical assessment and reassessment in every session) could prevent progression of left-ventricular damage and, therefore, progressive increment in cardiac biomarker levels over time. METHODS: This is a longitudinal cohort study including 46 dialysis patients in which a strategy of strict volume control has been adopted. N-terminal pro-B-type natriuretic peptide (NT-proBNP), troponin T and C-reactive protein (CRP) levels were measured at baseline and prospectively at 4, 8 and 12 months. The possible association between volume control and cardiac biomarker levels was analyzed. RESULTS: Dry weight could be reduced (p < 0.01) over time. A reduction in systolic BP (p < 0.05) and in CRP levels (p < 0.05) was observed, whereas NT-proBNP and troponin T values remained stable. However, patients in the high quartile of NT-proBNP at baseline showed a reduction (p = 0.02) in troponin T over time with no significant trend (p = 0.08) to progressive reduction in NT-proBNP values. CONCLUSIONS: Strict volume control in dialysis patients may prevent progressive increment in cardiac biomarker levels over time. The impact seems to be higher among patients with higher levels at baseline in whom strict volume control can even reduce cardiac biomarker levels on follow-up.

Two-year experience with telemedicine in the follow-up of patients in home peritoneal dialysis.

We evaluated the use of telemedicine in the long-term control of stable patients undergoing peritoneal dialysis at home. From September 2003 to August 2005, patients were randomly selected from current cases and invited to join study group A, in which they had telemedicine support. Patients not selected for this group, or who refused the invitation, were placed in study group B, and used for comparison. There were 25 patients in group A and 32 patients in group B. Videoconferencing equipment was installed in each patient's home, connected to a videoconferencing unit at the hospital by three ISDN lines. Patients in group A were followed for a mean of 8 months (range 3-24) with alternate months of teleconsultations and hospital visits. A total of 172 teleconsultations were conducted. A mean of 22 min (SD 9) were spent on each teleconsultation, significantly less than in hospital consultations, which took a mean of 33 min (SD 8) (P<0.01). In 148 teleconsultations (89%) medical treatment was modified. In 4 cases (2%) patients needed a hospital visit. In all instances (100%) the condition of the catheter exit site and the presence of oedema could be evaluated. In group A, the estimated cost of telemedicine was euro198 and that of a hospital visit was euro177. The mean hospitalization rate was 2.2 days/patient/year in group A and 5.7 days/patient/year in group B (P<0.05). Home telemedicine appears to be clinically useful in the long-term follow-up of stable patients undergoing peritoneal dialysis, and the costs and savings also seem to be encouraging.