Long-term follow-up of tacrolimus treatment in immune posterior uveitis.

PURPOSE: To study the efficacy of tacrolimus in immune posterior uveitis. METHODS: Twenty-one eyes of 11 patients with immune posterior uveitis under tacrolimus treatment were prospectively followed for 1 to 5 years. Tacrolimus dosage was adjusted to maintain blood levels in the range of 7 to 10 ng/mL. Systemic and ophthalmic evaluations were performed at baseline and during follow-up. RESULTS: After a mean follow-up of 45 months, no treatment other than tacrolimus was necessary to control the inflammation in 6 cases (54.5%). The number of annual recurrences decreased from 3.2 to 1.29 during tacrolimus treatment (p=0.021). In four patients, tacrolimus was suspended after a treatment period of 27+/-3.5 months and a follow-up period of 12 months free of uveitis relapses. All four were free from relapses following tacrolimus withdrawal. Visual acuity remained unchanged in 16/21 (76%) eyes, deteriorated in 4/21 (19%), and improved in 1/21 (5%). Renal function transiently deteriorated in four patients from basal serum creatinine levels of 0.84, 1.1, 0.88, and 0.78 mg/dL to maximum levels of 1.33, 2.48, 1.38, and 1.39 mg/dL, respectively. This deterioration was directly related with elevated tacrolimus serum levels, returning to normal when doses were reduced. During the overall controlled evolution period, a slight increase of serum creatinine from a basal value of 0.89+/-0.2 mg/dL to a final of 1+/-0.19 mg/dL was detected, which was not statistically significant. All secondary effects were mild, transient, and did not require interruption of long-term treatment to be controlled. CONCLUSIONS: Tacrolimus was well tolerated and useful in controlling posterior immune uveitis. Tacrolimus could be considered a real alternative to cyclosporine, and not only in cases of cyclosporine resistance or toxicity.

[Extra-hospital nephrology: a challenge for our near future]. / Nefrología extrahospitalaria: un reto para nuestro futuro inmediato.

The Spanish nephrology is one of the medical specialties that have experienced a greater development in the last years. Defined initially as an activity in the hospital and consolidated in this sense, at the present time the "Libro Blanco of the Spanish Nephrology" makes a call of attention on the necessity of a change of welfare direction. The attention was called on the little development of the prevention activities and the delay in the arrival of the patient to the Service of Nephrology, which causes a worsening of his pathology. In order to approach us this reality it is necessary to give priority to the attendance of the patient out of the hospital and to guarantee a logical continuity between welfare levels. The welfare initiatives that have been carried out in the Spanish territory are scarce and still insufficient. The progressive increase in the incidence and prevalence of the ERD associated with a bad evolution and elevated costs is converting ERD in an important problem of public health, that requires specific plans of detection and prevention. The improvement of the coordination between general practioners and nephrologists is necessary. Multiple papers show a delayed reference of the patients with renal disease to the nephrologists. The initiatives of coordination between both levels should be centered in studies epidemiologists that clarify the real meaning of the renal pathology and in educating the GP on the early reference to the nephrologist of the patients with renal failure.

Incidence and prognosis of acute renal failure in older patients.

Few studies have assessed the prevalence and outcome of acute renal failure (ARF) in the elderly. Among 437 ARF cases prospectively studied during a nine-year period in a nephrology department, 152 (35%) occurred in patients over 70 years of age (Group 1). Patients over 70 account for only 10.5% of all hospital admissions in our country, and prevalence of ARF was 3.5 times higher in these patients than in younger people. Acute tubular necrosis (ATN) was diagnosed in 40% of Group 1 and 52% of the younger patients (Group 2) (P less than .05), whereas prerenal ARF was found in 47% and 32%, respectively (P less than .001). Dehydration was the most frequent cause of prerenal ARF in the elderly (51%). The etiological distribution of ATN was similar in both groups, being of multifactorial origin in most cases. Oliguria was present in 49% of ATN in Group 1 and in 66% of Group 2 (P less than .05). There were no significant differences in dialysis needs. Mortality was higher in the elderly in all types of ARF, although differences did not reach statistical significance. Need for dialysis, mechanical respiration, decreased level of consciousness, and hypotension were associated with poor prognosis in both groups. Total recovery from ARF in older persons was less frequent and slower than in younger patients. It may be concluded that patients over 70 years of age are at high risk for developing ARF; nevertheless, age should not be used as a discriminating factor in therapeutic decisions concerning ARF.

Malignant pheochromocytoma, still a therapeutic challenge.

For cases of malignant pheochromocytoma the prognosis is poor and experience with its treatment remains limited. We present a case of a hypertensive 16 year old woman with malignant pheochromocytoma and a good treatment response. Bone metastases appeared 6 months after the first resection. Local excision of the thoracic vertebrae metastases and palliative radiation therapy were performed, after which she received twelve cycles of cyclophosphamide, vincristine, and dacarbazine. Sixteen months later the patient remains asymptomatic without biochemical catecholamine activity.

Fibroblast growth factor protects the kidney against ischemia-reperfusion injury.

Ischemia-reperfusion injury, a common source of renal dysfunction in adults, is associated with tubular epithelial cell damage. Since fibroblast growth factors (FGF) attenuated tissue injury after transient myocardial ischemia, we hypothesized that acidic fibroblast growth factor (aFGF; FGF-1) would attenuate renal ischemia-reperfusion injury. We studied the effects of FGF-1 in a rat model of acute renal failure induced by bilateral renal ischemia (60 min) and 1, 2 or 7 days reperfusion. After FGF-1 administration at the onset of renal reperfusion, there was less functional impairment of the kidneys. The histological changes were not as severe as in controls. Increases in serum creatinine and blood urea nitrogen 24 h after reperfusion were attenuated by 35% (p< 0.01) and by 53% (p< 0.001), respectively, in FGF-1-treated animals compared to vehicle-treated rats. The ischemia/reperfusion-induced increase in tissue myeloperoxidase, a marker of neutrophil infiltration, was mitigated (67% reduction, p< 0.05) with FGF-1 treatment. As shown by histology, neutrophil infiltration and tubular cell necrosis in medulla were less pronounced (p< 0.0001 and p< 0.05, respectively) in animals receiving FGF-1. Furthermore, ischemia-induced apoptosis, prevalent in tubular cells of the cortex, was also attenuated by FGF-1-treatment (83% reduction, p< 0.0001). Pretreatment of animals with Nw-nitro-L-arginine (L-NNA), an inhibitor of nitric oxide synthase, abolished the attenuating effects of FGF-1 on neutrophil infiltration, suggesting that nitric oxide might participate in the anti-inflammatory effects of FGF-1 in this experimental design. Our data support a role for FGF-1 in attenuation of renal damage or failure after ischemia-reperfusion injury of the kidney, in part at least by inhibition of neutrophil infiltration.

[Selective IgA deficiency in systemic lupus erythematosus (author's transl)]. / Deficiencia selectiva de IgA en el lupus eritematoso sistémico.

The case of a 23 year-old female with a diagnosis of systemic lupus erythematosus associated to selective IgA deficiency is reported. The patient persistently had serum IgA levels below 0.05 mg/dl, while the remaining serum immunoglobulins were normal. No salivary IgA was detected, and the karyotype disclosed no abnormalities of the chromosome 18. In the in vitro immunological study a normal number of B and T lymphocytes was found, and decreased production of all surface immunoglobulins was observed.

Causes of graft bruits other than of renal arterial stenosis.

Hypertension and bruit over the graft are commonly associated to renal arterial stenosis in transplant patients. However, these findings can have other origins, too. In the present work we report on two patients in whom remote arteriovenous fistulas were the cause of a spurious bruit heard over the kidney allograft.

[Upper urinary tract fistulas in renal transplantation]. / Fístulas del tramo urinario superior en el trasplante renal.

237 kidney transplants were performed in our department in a period running from November 1979 to October 1986. Out of this total number of transplants we analyzed the incidence of fistulas of the upper urinary tract, which in our series is 3.3%. Following a study protocol of these patients referring to multiple parameters, we conclude that in our series fistulas of the upper urinary tract appear precociously (less than 45 days post-transplant) and in connection with acute rejection episodes (high doses of steroids). On the basis of anatomopathological criteria we establish that its treatment has to be surgical and a meticulous surgical extraction technique is essential for its prevention.

[Pre-transplantation evaluation with echo-Doppler of the receptor's vascular risk factors]. / Evaluación pretrasplante mediante eco-Doppler de los factores de riesgo vascular del receptor.

A total of 51 potential recipients of a renal transplant (RT) have been evaluated with an Eco-Doppler study of the posterior femoral, popliteal and posterior tibial corteries. Acceleration (AC), mean rate (MR), maximum systolic rate (MXSR) and minimal diastolic rate (MNDR), as well as pulsatility (PI) and resistance index (RI) were measured. Arterial high blood pressure (HBP), smoking, time in haemodialysis (HD) and cholesterol and triglycerides levels, were evaluated as vascular risk factors. RI and PI were maximal, and MXSR, MR and AC minimal at the popliteal artery level. Smoking (number of cigarettes/day) (R = 0.77), systolic blood pressure (BP) (R = 0.43), time of HBP evolution (R = 0.044), cholesterol level (R = 0.43) and time in HD (R = 0.35) correlate with Eco-Doppler parameters. Fifteen of these 51 patients underwent transplantation, and increased RR and PR with decreased MR and MXSR were seen post-RT in the ipsilateral popliteal and posterior tibial arteries. Eco-Doppler is a useful technique to evaluate the vascular risk of potential RT recipients.