Dialysis staff encouragement and fluid control adherence in patients on hemodialysis.

BACKGROUND: Fluid control in patients on dialysis is an important predictor of outcome but is a difficult restriction to achieve. The authors examined the association between dialysis staff encouragement and fluid control adherence in patients on hemodialysis. METHODS: This cross-sectional study used the dialysis staff encouragement subscale (DSE). The outcome measure was intradialytic weight loss (IWL) of dry weight (DW), with nonadherence defined as IWL/DW greater than 5.7%. Predictors of nonadherence were identified using logistic regression. Odds ratio (OR) was for the occurrence of nonadherence as it correlated with a one standard deviation (SD) decrease in scale score. RESULTS: Seventy-two patients on hemodialysis participated, 45 men (62.5%) and 27 women. The crude OR in DSE score was 1.75 (95% confidence interval [CI]: 1.02 to 3.0) and adjusted odds ratio was 2.51 (95% CI: 0.99 to 6.34). CONCLUSION: Dialysis staff encouragement is important in improving fluid control adherence.

[Membranoproliferative glomerulonephritis].

MPGN is characterized by its peculiar histological findings; lobular appearance, cellular and mesangial matrix proliferation and double contoured capillary loops. Based on histomorphalogical pattern, three types are subdivided. MPGN may be primary (in most children) or secondary (in most adults) to chronic infections, cryoglobulinemia or systemic autoimmune disorders. Clinical manifestation of typical MPGN is nephrotic range proteinuria associated with microscopic hematuria, showing slowly progressive course. Treatment strategy is composed of exclusion of pathogen, especially in HCV positive MPGN, and intervention to autoimmune mechanism such as alternative-day steroid regimen.

Cohort study of advanced IgA nephropathy: efficacy and limitations of corticosteroids with tonsillectomy.

BACKGROUND: Elevated serum creatinine is associated with poor outcome in IgA nephropathy (IgAN). The efficacy and limitations of corticosteroids in advanced IgAN (Cr >or=1.5 mg/dl), however, remains controversial. METHODS: We retrospectively investigated 70 patients with advanced IgAN (Cr >or=1.5 mg/dl) classified into three groups according to their treatment regimens, that is, steroid pulse with tonsillectomy, conventional steroid, and supportive therapy. We evaluated the three groups to elucidate predictors for the endpoints ESRF and doubled serum creatinine from baseline. RESULTS: Steroid pulse with tonsillectomy, conventional steroid and supportive therapy were performed in 30, 25 and 15 patients, respectively. During the mean follow-up period of 70.3 (12-137) months, 41.4% of patients reached ESRF (13.3 vs. 56.0 vs. 73.3%, p < 0.001) and 45.7% doubled serum creatinine from baseline (16.7 vs. 64.0 vs. 73.3%, p < 0.001). The incidence of ESRF in the patients treated by steroid pulse with tonsillectomy was significantly lower than the incidences in the patients treated by conventional steroid and supportive therapy at a baseline creatinine level of 1.5-2 mg/dl, but no statistical difference was observed at a level of >2 mg/dl. The Kaplan-Meier estimated probability of renal survival without ESRF was 89.2, 74.1 and 72.2% at 5 years and 82.8, 51.0 and 45.1% at 8 years, respectively (p = 0.017). The predictors for ESRF, identified in a Cox proportional hazards model, were baseline serum creatinine (p < 0.001) and interstitial infiltrate (p = 0.003). Steroid pulse with tonsillectomy also had a protective effect on the risk of reaching ESRF (p = 0.013). By target cross-stratification, the patients with baseline creatinine of 1.5-2 mg/dl who underwent steroid pulse with tonsillectomy showed a better renal survival rate than the others (p < 0.001). CONCLUSION: Steroid pulse therapy combined with tonsillectomy may be more effective than conventional steroid therapy in patients with a baseline creatinine level of

Decreased CD4 lymphocyte count as a marker predicting high mortality rate in managing ANCA related rapidly progressive glomerulonephritis.

As antineutrophil cytoplasmic antibody positive rapidly progressive glomerulonephritis (ANCA-RPGN) has a high risk of end stage renal failure and is a potentially life threatening disease, early aggressive therapy is recommended. However, aggressive immunosuppressive therapy may lead to immunodeficiency and subsequent mortality in the patients with this disease. Therefore, we need the index of immunodeficiency to cure the disease. To evaluate any risk factors, including therapies, on mortality in ANCA-RPGN, we conducted a retrospective investigation on patient survival in 32 patients with ANCA-RPGN by Kaplan-Meier analysis and the Cox regression model. Fourteen patients were treated with leucocytapheresis (LAP group) and the 18 patients were treated by steroid pulse therapy (steroid pulse group) as initial treatment. The patients were chosen for the different therapies at random. Two patients in the LAP group, and eight patients in the steroid pulse group had died within 6 months. The lymphocyte counts and CD4 cell counts after complete course of therapy were lower in the patients who died than in those who survived in the steroid pulse group. Patient survival was higher in the LAP group than in the steroid pulse group, but did not reach statistical significance. Multivariate Cox regression analysis showed that the factors influencing patient survival were initial serum creatinine, LAP therapy, CD4 cell counts, and lymphocytes at the end of treatment. Age, titer of MPO-ANCA, and percent of glomerular crescents were not found to have an effect on the patient survival. We recommend: that early diagnosis should be established, and immunosuppressive therapy may be done with monitoring of the lymphocyte and CD4 cell count.

Regression of IgA nephropathy: a repeat biopsy study.

Histological cure of immunoglobulin A (IgA) nephropathy has been reported only rarely in adults. To elucidate the reversibility of established IgA nephropathy, we performed a repeat biopsy study. A second biopsy was performed in 35 patients with IgA nephropathy in whom hematuria, an essential finding of IgA nephropathy, had disappeared (proteinuria also had disappeared in 23 patients) after a treatment protocol involving high doses of methylprednisolone and tonsillectomy. The interval between the first and second biopsy was 18 to 138 months (mean, 77.1 months). Mean serum creatinine level was 1.11 +/- 0.35 (SD) mg/dL (range, 0.6 to 1.9 mg/dL) at the time of the first biopsy and 0.96 +/- 0.24 mg/dL at the time of the second biopsy. Mesangial proliferation was significantly reduced in second-biopsy specimens (mesangial proliferation score: first-biopsy specimens, 2.49 +/- 0.74; second-biopsy specimens, 0.91 +/- 0.89; P < 0.001). Acute inflammatory glomerular lesions, such as endocapillary proliferations, glomerular tuft necrosis, and cellular crescents, were present in 32 patients in first-biopsy specimens, whereas these were no longer present in any of the second-biopsy specimens. Although no significant difference in percentage of globally sclerotic glomeruli was observed between the first and second biopsy specimens, the percentage of segmentally sclerotic glomeruli was significantly lower in second-biopsy specimens (P < 0.001). Interstitial mononuclear cell infiltration was markedly reduced in second-biopsy specimens (P < 0.001). The area of renal cortex affected by interstitial fibrosis and/or edema was significantly reduced in second-biopsy specimens (first-biopsy specimens, 21.4% +/- 20.3%; second-biopsy specimens, 9.6% +/- 11.7%; P < 0.01). The distribution of IgA mesangial deposits had diminished in most patients, and no IgA deposits were seen in second-biopsy specimens from 8 patients. These findings indicate that mesangial proliferation and interstitial changes in IgA nephropathy are reversible to a considerable extent. A histological cure may be obtainable in a considerable proportion of patients, especially if treatment is initiated at a relatively early stage.

High prevalence and adverse effect of hepatitis C virus infection in type II diabetic-related nephropathy.

Over a 4-yr period in the northeast region of Japan (Tohoku), 3643 patients for whom a renal biopsy was available were screened. In addition, 2370 biopsied patients for whom hepatitis C virus (HCV) serology was available were evaluated. The prevalence of HCV infection was investigated in the 2370 biopsied patients. The highest prevalence of HCV infection was found in type II diabetic-related glomerulosclerosis (II-DGS) (24 of 123; 19.5%). At renal biopsy, clinical and laboratory findings and histologic parameters were comparable between the HCV-positive and -negative II-DGS groups. After renal biopsy, the decline of renal function reflected by the slope of reciprocal serum creatinine (1/S(Cr)) was significantly greater in the HCV-positive group than in the HCV-negative group (P = 0.001). The log-rank test performed on the renal survival curves showed a significant difference in the two groups (P = 0.019). According to a multiple linear regression analysis adjusted for the effect of age, gender, BP, HbA1c, urinary protein excretion, and histologic parameters as covariates, urinary protein excretion (P = 0.011), severe arteriolar hyalinosis (P = 0.006), and HCV infection (P < 0.001) were significantly associated with 1/S(Cr) slope. Finally, HCV infection was randomly examined in 545 outpatients and inpatients with type II diabetes mellitus who did not undergo renal biopsy. Of these, 56 patients were positive for HCV antibody (10.3%), and their proteinuria was heavier than in 489 HCV-negative patients (P = 0.001). This study reveals that HCV infection is present at a high rate in type II diabetic-related nephropathy and may have an adverse effect on the progression of the disease.