Urine cytologic profile in renal allograft recipients determined by monoclonal antibodies. Diagnosis of allograft rejection.

Controversy exists as to the type of cells present in the urine during renal allograft rejection. In order to resolve this controversy as well as to evaluate the value of urine sediment examination as a means of detecting AR, we quantitated the different cells present in urine during AR using an immunoperoxidase technique and monoclonal antibodies reactive with lymphocytes, monocytes, granulocytes, glomerular epithelial, tubular, and urothelial cells. Urine sediment (n = 176) was examined serially over 3 months in 15 transplant recipients. There were 12 episodes of early posttransplant acute tubular necrosis and 21 episodes of AR. It was possible to detect AR as well as to distinguish AR from ATN. Lymphocyte and tubular cell excretions were increased significantly during AR. Excretion of urothelial cells was also significantly increased during most episodes of AR suggesting that rejection of ureters occurs concomitantly with rejection of the kidneys.

Immunocytologic dissection of the urine sediment using monoclonal antibodies.

A method to identify nucleated nonsquamous cells in urine using monoclonal antibodies and immunoperoxidase stain is described. Cells from washed deposits of midstream urine samples were transferred to gelatinized slides in a cytocentrifuge, air-dried, acetone fixed, and subjected to microwave irradiation. Slide preparations were then treated with monoclonal antibodies with the use of a four-layer peroxidase-antiperoxidase technique. It was possible to identify granulocytes, monocytes, lymphocytes, and renal epithelial and urothelial cells. This method was found to be helpful in determining the profiles of cells in urine in acute tubular necrosis, drug-related acute interstitial nephritis, and crescentic glomerulonephritis.

Monoclonal antibodies: use in urine sediment examination.

Accurate identification of nucleated cells in urine can be difficult with conventional methods of microscopic urinalysis. Monoclonal antibodies were used with an immunoperoxidase technique to identify nucleated cells in urine. This new development in urinalysis is in its early stages, but it has helped to circumvent the difficulties associated with standard microscopy. The monoclonal antibody technique allowed for the identification of granulocytes, monocytes, lymphocytes, glomerular epithelial, proximal tubular, loop of Henle, distal tubule/collecting duct, and urothelial cells in urine, and by quantifying these cells it was possible to determine the urine cell profiles in various renal diseases as well as in allograft rejection and early post-transplant acute tubular necrosis in renal allograft recipients. The cell profiles are useful in aiding the diagnosis of these conditions.

Immunoperoxidase identification of nucleated cells in urine in glomerular and acute tubular disorders.

Nucleated nonsquamous cells in urine of patients with crescentic glomerulonephritis (CN), noncrescentic glomerulonephritis (NCN), acute tubular necrosis (ATN) and drug related acute interstitial nephritis (AIN) were identified using monoclonal antibodies and immunoperoxidase stain. Cell viability was determined by trypan blue permeability. CN was distinguishable from NCN by total cell numbers exceeding 30,000/ml (p less than 0.001) and counts of granulocytes exceeding 10,000/ml (p less than 0.05), monocytes exceeding 3,000/ml (p less than 0.001), T4 lymphocytes exceeding 1,500/ml (p less than 0.001), T8 lymphocytes exceeding 1,500/ml (p less than 0.001), glomerular epithelial cells exceeding 4,000/ml (p less than 0.001), proximal tubular cells exceeding 8,000/ml (p less than 0.001), loop of Henle cells exceeding 1,500/ml (p less than 0.01) and urothelial cells exceeding 1,500/ml (p less than 0.05). AIN was distinguishable from ATN by total cell numbers exceeding 75,000/ml (p less than 0.001) and counts of granulocytes exceeding 150,000/ml (p less than 0.001), monocytes exceeding 5000/ml (p less than 0.001), T4 lymphocytes exceeding 3,000/ml (p less than 0.01), T8 lymphocytes exceeding 2,500/ml (p less than 0.01) and cell viability exceeding 60% (p less than 0.05). Proximal tubular, loop of Henle, distal tubular/collecting duct and urothelial cells were present in high numbers in CN, ATN and AIN. CN can be distinguished from NCN, and ATN can be distinguished from AIN by identifying and quantifying the nucleated cells present in the urine.

Idiopathic membranous glomerulonephritis: long-term follow-up in 139 cases.

The clinical course of 139 patients (77 male, 62 female) with idiopathic membranous glomerulonephritis is reviewed. The median duration of follow-up was 52 months; 45% and 25% were followed for more than 5 and 10 years respectively. The median age at presentation was 36. Fifty-four percent of patients had the nephrotic syndrome at presentation. Half of the patients were treated at some stage with cyclophosphamide or corticosteroids. During the course of follow-up some deterioration in renal function occurred in only 20% of patients. The patients who suffered deterioration in renal function were mainly male and had significantly worse renal function and a higher incidence of the nephrotic syndrome than the other patients at presentation. Only 7 male patients (5%) developed terminal renal failure during follow-up and one female presented in terminal renal failure. Survival was 88% and 81% at 5 and 10 years. The median predicted (or actual) time for development of terminal renal failure in patients with progressive deterioration was 7.3 years. These data are in accord with other recently published series which have described a relatively benign prognosis for idiopathic membranous glomerulonephritis.

Histological features of IgA glomerulonephritis as predictors of pregnancy outcome.

116 pregnancies undertaken by 70 women with IgA glomerulonephritis and their diagnostic renal biopsies have been reviewed. An IgA diffuse mesangial proliferative lesion with superimposed focal and segmental proliferative lesions (IgA FSP) on diagnostic renal biopsy was associated with a greater incidence of maternal complications than IgA diffuse mesangial proliferative glomerulonephritis with no superimposed lesions (IgA DMP) and IgA diffuse mesangial proliferative glomerulonephritis with superimposed focal and segmental hyalinosis and sclerosis (IgA FSHS) (p less than 0.025). Patients with severe vessel lesions had a significantly greater incidence of fetal loss than those with only mild to moderate lesions (p less than 0.025).

IgA glomerulonephritis and pregnancy.

One hundred and sixteen pregnancies in 70 women with a biopsy-proven diagnosis of IgA glomerulonephritis have been analysed. Thirty percent (35) of the fetuses died, 22% (26) were premature and 44% (52) were full term. Maternal renal function declined during pregnancy in 26% (30) and in 2% (2) this was irreversible post-partum. Hypertension developed in 52% (61) of the pregnancies and in 13% (15) this was irreversible. Increased proteinuria was recorded in 62% (74) of the pregnancies. Fetal loss in pregnancies taking place after biopsy diagnosis was lower (16%) than those in which biopsy was performed either during or following the pregnancy (36%).

Membranous glomerulonephritis and pregnancy.

The clinical courses of 33 pregnancies in 24 patients with biopsy proven membranous glomerulonephritis have been analyzed. Twenty-four percent (8) of pregnancies resulted in fetal loss, 43% (14) in premature delivery and 33% (11) in a live birth after 36 weeks gestation. Maternal renal function declined during pregnancy in 9% (3) of the pregnancies and in 46% (15) hypertension developed. In 55% (18) proteinuria increased significantly during pregnancy. In 30% (10) nephrotic range proteinuria was recorded in the first trimester. Presence of nephrotic range proteinuria during the first trimester correlated with both poor fetal and poor maternal outcome (p less than 0.0004 and p less than 0.0002, respectively). It is concluded that pregnancy in patients with membranous glomerulonephritis is associated with increased fetal loss and, in some instances, a worsening in maternal renal function. The literature on this topic is reviewed in relation to these findings.

Triamterene-induced crystalluria and cylinduria: clinical and experimental studies.

We examined the occurrence of crystals and casts in the urine of healthy subjects after administration of triamterene and the site of crystal formation in experimental animals. Twenty out of twenty healthy subjects had abundant triamterene crystals and casts in acid urine after receiving a single 100 mg dose. Casts were present in the urine from 2-11 hours after administration of the diuretic. Cast formation occurred in acidic urine and was prevented by alkalinization of the urine with potassium citrate. Animal studies showed that crystallization and cast formation occurred in the medullary and papillary collecting ducts of the rat kidney. These findings provide a possible explanation for the reported nephrotoxicity of triamterene, particularly when given to patients who are receiving non-steroidal anti-inflammatory agents.

Randomized controlled trial of cyclophosphamide, warfarin and dipyridamole in idiopathic membranous glomerulonephritis.

40 patients with idiopathic membranous glomerulonephritis were randomized to receive either no treatment or a regime of cyclophosphamide for 6 months, and warfarin and dipyridamole for two years. During the two years of the trial there was no significant deterioration in renal function in either group. A significantly greater improvement in urinary protein excretion was, however, observed at all time points in the treatment group. Plasma albumin was also significantly higher in the treatment group at 18 and 24 months. As progressive deterioration in renal function in membranous glomerulonephritis is associated with persistent heavy proteinuria these results suggest a beneficial effect of treatment.

Loin pain as a presenting symptom in idiopathic glomerulonephritis.

Loin pain may be a major presenting symptom in patients with glomerulonephritis. Most of these patients show an underlying focal and segmental proliferative glomeruloneyphritis and there may be associated deposits of IgA and Igg in the mesangium. In this group of patients, vascular lesions are often prominent in the absence of hypertension. Episodes of recurrent macroscopic hematuria also occur, but the pain cannot be attributed to colic due to blood clots in the ureter.

Pregnancy in women with diffuse mesangial proliferative glomerulonephritis.

The clinical course of 168 pregnancies in 91 women with non-IgA diffuse mesangial proliferative glomerulonephritis has been analyzed. Twenty percent (33) of pregnancies resulted in fetal loss, 18% (31) in premature delivery and 62% (105) in a term infant. Maternal renal function declined, reversibly, in 3% (5) of pregnancies and in 48% (80) hypertension developed. In 53% (89) a significant increase in proteinuria occurred in pregnancy. Fetal and maternal complications of pregnancy occurred more frequently in patients with pre-existing hypertension although differences failed to reach statistical significance (p greater than 0.01). The presence of severe vessel lesions on the diagnostic renal biopsy was associated with a significantly higher fetal loss and prematurity rate (p less than 0.0005 and p less than 0.005, respectively).

Pregnancy in women with primary focal and segmental hyalinosis and sclerosis.

Thirty-one pregnancies and post partum clinical course of 21 women with a diagnosis of primary focal and segmental hyalinosis and sclerosis have been analyzed. Forty-five percent (14) of pregnancies resulted in fetal loss, 39% (12) in premature delivery and 16% (5) in a term infant. Of 17 fetuses for whom birthweight was recorded, 29% (5) were small for gestational age. Maternal renal function deteriorated in 49% (15) of pregnancies, in 13% (4) irreversibly. Three of these patients (15%) subsequently progressed to end-stage renal failure, and one to progressive chronic renal impairment, by the end of follow-up (median 4 years, range 1-25 years). In 74% (23) of pregnancies hypertension was recorded and this frequently developed early (61%) and was severe (45%). Nephrotic range proteinuria developed in 42% (13) of pregnancies. Increased proteinuria was recorded in 22 (17%) pregnancies. It is concluded that pregnancy in women with primary focal and segmental hyalinosis and sclerosis is associated with increased fetal loss and maternal complications.

A prospective study of cortical scarring in acute febrile pyelonephritis in adults: clinical and bacteriological characteristics.

Previous reports have demonstrated lesions on computerized axial tomography (CT), and nuclear scintigraphy (DMSA) in acute pyelonephritis (PN). We undertook a prospective study of all patients presenting to our hospital with PN over 40 months. Patients who fulfilled diagnostic criteria, were treated with intravenous antibiotics. Excluding two who were pregnant, all patients had imaging by intravenous urography (IVU), CT and DMSA during their admission. Urine samples were collected prior to treatment. Patients without IVU evidence of cortical scarring but with parenchymal defects on CT and/or DMSA underwent a repeat DMSA three or more months after the acute episode. Of the 164 patients, 142 were female. E. coli was found in 116 patients. Forty-six patients had an abnormality on IVU. Of the 106 patients without IVU evidence of cortical scarring, 59 had a defect on CT and/or DMSA. Late DMSA scans in 35 of these 59 patients showed a persistent abnormality in 77%. E. coli characteristics such as P-fimbriae and Type 1 fimbriae were not predictive of acute imaging abnormalities. Inhibition of E. coli growth by the addition of EDTA was highly predictive of acute CT and DMSA abnormalities with a sensitivity of 83.3% and a specificity of 82.8%. Acute pyelonephritis is often associated with acute CT and/or DMSA abnormalities which may evolve into renal cortical scars. Acute scan abnormalities can be predicted by the presence of E. coli which were susceptible to EDTA in culture. Late scarring could not be predicted by clinical features, response to treatment or antibiotic used.

Urinary erythrocyte morphology in the diagnosis of glomerular hematuria.

Urine samples from 141 consecutive patients referred for investigation of microscopic hematuria were examined by phase-contrast microscopy to determine the probable site of bleeding into the urinary tract. Dysmorphic (i.e. morphologically variable) erythrocytes, suggestive of glomerular bleeding, were present in 86 of 87 patients with significant hematuria who were later shown to have glomerulonephritis. In contrast, all of 30 patients with non-glomerular lesions had isomorphic (i.e. morphologically uniform) erythrocytes in the urine. Ten patients yielded a mixed morphologic pattern suggestive of dual pathology which was confirmed in four patients. Urine erythrocyte counts from 376 healthy individuals showed that 95% yielded less than 8,000 cells/ml and in each case erythrocytes exhibited a dysmorphic pattern suggesting that erythrocytes enter the urine of healthy subjects via the glomerulus. Electron microscopy of urinary erythrocytes from 36 patients with glomerulonephritis demonstrated the range of dysmorphic changes characteristic of glomerular bleeding, presumably resulting from environmental changes suffered by the erythrocytes within renal tubules.

The significance of focal and segmental hyalinosis and sclerosis (FSHS) and nephrotic range proteinuria in IgA nephropathy.

Between 1971 and 1991, 845 patients were diagnosed as having IgA glomerulonephritis on renal biopsy performed. These patients were followed for a mean period of 53 months post biopsy (range 0-336 months). By the end of follow up 147 (17%) of patients have developed chronic renal failure (Cr > 0.2 mmol/l) or end-stage renal failure. Presenting creatinine > 0.12 mmol/l, hypertension, nephrotic range, age > 40 years and male gender, all correlated strongly on univariate analysis with the development of chronic renal failure or kidney disease (all p < 0.0001). However, a number of patients developing chronic renal failure or end-stage renal failure already had renal impairment (creatinine > 0.12 mmol/l at presentation). A separate comparison was performed of patients presenting with creatinine < 0.12 mmol/l and either developing chronic failure or end-stage renal failure within 5 years of biopsy (n = 18) and those with creatinine still < 0.12 mmol/l after 5 years follow up (n = 186). Of the 18 patients who deteriorated 6 (35%) were nephrotic at presentation and 9 (56%) had focal hyalinosis and sclerosis on renal biopsy. This compared with 5 (3%) patients with nephrotic range proteinuria and 16 (10%) patients with focal hyalinosis and sclerosis among the 186 patients who did not deteriorate (p < 0.0001). The sensitivity and specificity of the presence of either or both factors in predicting deterioration was calculated at 65% and 87% respectively. Thus in patients with normal renal function at presentation the presence of nephrotic range or focal hyalinosis and sclerosis are strong predictors of adverse clinical outcome.