Decreased antigen-specific T-cell proliferation by moDC among hepatitis B vaccine non-responders on haemodialysis.

Patients with end-stage kidney disease, whether or not on renal replacement therapy, have an impaired immune system. This is clinically manifested by a large percentage of patients unresponsive to the standard vaccination procedure for hepatitis B virus (HBV). In this study, the immune response to HBV vaccination is related to the in vitro function of monocyte-derived dendritic cells (moDC). We demonstrate that mature moDC from nonresponders to HBV vaccination have a less mature phenotype, compared to responders and healthy volunteers, although this did not affect their allostimulatory capacity. However, proliferation of autologous T cells in the presence of tetanus toxoid and candida antigen was decreased in non-responders. Also, HLA-matched CD4+ hsp65-specific human T-cell clones showed markedly decreased proliferation in the group of non-responders. Our results indicate that impairment of moDC to stimulate antigen-specific T cells provides an explanation for the clinical immunodeficiency of patients with end-stage kidney disease.

Immunosuppression should be stopped in patients with renal allograft failure.

Patients returning to haemodialysis or peritoneal dialysis after a failed kidney transplantation sometimes have a renal allograft left in situ for some urine production. Low-dose immunosuppressive medication is often continued in such patients. To evaluate the morbidity and mortality between patients in time periods with (group A) or without (group B) low-dose maintenance immunosuppression, the present study was initiated. In a multi-centre cohort study we analysed data from patient files, which showed failure after at least 3 months graft function between 10 August 1972 and 4 April 1996, including 197 kidney transplantations. A total of 1.7 versus 0.51 infections per patient year was found in groups A and B, respectively (odds ratio [OR]: 3.4, 95% confidence interval [CI]: 2.5-4.5). There was an increased mortality in group A compared to group B (OR 3.4, 95% CI: 1.8-6.3), both from infectious disease (OR 2.8, 95% CI: 1.1-7.0), and cardiovascular disease (OR 4.9, 95% CI: 1.8-13.5). Continuation of immunosuppressive medication did not lead to fewer rejections (defined as a painful, tender graft and/or haematuria and/or low-grade non-infectious fever). Transplantectomy-related morbidity and mortality were acceptable. The increase in morbidity and mortality associated with low-dose maintenance immunosuppression argues in favour of stopping these medicaments when failed renal allograft patients return to dialysis.

Spontaneous hypoglycaemia in chronic renal failure.

Spontaneous hypoglycaemia in renal failure occurs more frequently than is considered generally. The pathogenesis is complex. Understanding the underlying mechanisms is of interest to all practitioners attending patients with renal failure. A case report is presented describing a patient with 'spontaneous' hypoglycaemia, without any illness other than renal failure. The various mechanisms contributing to or causing hypoglycaemia are reviewed.

Pharmacokinetics of epoetin in haemodialysis patients after subcutaneous administration: influence of chronic treatment.

The purpose of this study was to investigate whether chronic subcutaneous administration of epoetin has an influence on its pharmacokinetics in patients with chronic renal failure and anaemia. 14 Patients were included in the study. The data of 8 patients could be evaluated at the end of the study. All patients were on maintenance haemodialysis. The pharmacokinetic profile of epoetin was studied directly after the first subcutaneous administration of 60 U/kg body weight. Patients were further treated with epoetin to maintain haemoglobin concentration between 6.0 and 6.5 mmol/l. After about one year of treatment the pharmacokinetic profile was studied again, using the same dosage. Between both profiles no significant differences (paired Student's t-test) were found in the pharmacokinetic parameters studied: absorption half-life, time to maximum concentration, maximum concentration, elimination half-life, area under the curve and mean residence time. However, in individual patients large differences may be found.

Oxalosis in chronic renal failure.

The incidence and severity of oxalate deposition as a complication of chronic renal failure in a retrospective study of 73 patients is presented. The reason for this study was the occurrence of a syndrome characterised by multiple shunt-complications, muscle weakness and peripheral ulceration in three haemodialysis patients. This syndrome seems to be caused by an obliterative vasculitis due to oxalate deposition in the media of peripheral vessels (Figure 1).