Cardiac magnetic resonance imaging in hemodialysis patients.

BACKGROUND: The anatomy of left ventricular hypertrophy (LVH) in dialysis patients was studied with magnetic resonance imaging (MRI). Potential benefits of spironolactone were examined in a subset of patients. METHODS: This was a prospective case series of 30 hemodialysis patients in whom cardiac MRI was performed. Repeat MRI was done in a subset of 13 patients after 9 months of daily oral spironolactone 25 mg. RESULTS: Subjects exhibited a characteristic cardiac morphology, distinct from both concentric LVH (cLVH) and eccentric LVH (eLVH). Compared with normal controls, LV mass index was increased, end-diastolic volume index was increased, and ejection fraction was reduced, but sphericity indices did not differ. No significant changes were seen after spironolactone. CONCLUSIONS: LVH in dialysis patients has a unique MRI appearance which is distinct from either cLVH or eLVH, with profound LV thickening and moderate dilation of the ventricular cavity. A 9-month course of spironolactone therapy did not affect morphology.

Necrotizing and crescentic lupus nephritis with antineutrophil cytoplasmic antibody seropositivity.

BACKGROUND AND OBJECTIVES: Lupus nephritis is a classic immune complex glomerulonephritis. In contrast, antineutrophil cytoplasmic antibodies are associated with necrotizing and crescentic glomerulonephritis, in the absence of significant immune deposits. Antineutrophil cytoplasmic antibodies are detected by indirect immunofluorescence in 20% of patients with systemic lupus erythematosus. We report 10 cases of necrotizing and crescentic lupus nephritis with antineutrophil cytoplasmic antibody seropositivity. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Ten patients with systemic lupus erythematosus, antineutrophil cytoplasmic antibody positivity, and renal biopsy findings of lupus nephritis and antineutrophil cytoplasmic antibody-associated glomerulonephritis were identified. The clinical features, pathologic findings, and outcomes are described. RESULTS: The cohort consisted of eight women and two men with a mean age of 48.4 yr. Perinuclear antineutrophil cytoplasmic antibody was detected by indirect immunofluorescence in nine patients. Four of the nine patients and the single remaining patient were found to have myeloperoxidase-antineutrophil cytoplasmic antibodies by enzyme-linked immunosorbent assay. Clinical presentation included proteinuria, hematuria, and acute renal insufficiency, with mean creatinine of 7.1 mg/dl. All biopsies exhibited prominent necrosis and crescents with absent or rare subendothelial deposits and were interpreted as lupus nephritis and antineutrophil cytoplasmic antibody-associated glomerulonephritis. All patients received cyclophosphamide and prednisone. Three patients died of infectious complications. Among the remaining seven patients, five achieved a complete or near-complete remission, one had a remission with subsequent relapse, and one had no response to therapy. CONCLUSION: Antineutrophil cytoplasmic antibody-associated necrotizing and crescentic glomerulonephritis may occur superimposed on lupus nephritis. In patients with lupus nephritis and biopsy findings of prominent necrosis and crescent formation in the absence of significant endocapillary proliferation or subendothelial deposits, antineutrophil cytoplasmic antibody testing by enzyme-linked immunosorbent assay is recommended.