Andres Purroy

Loss of renal graft due to recurrent IgA nephropathy with rapidly progressive course: an unusual clinical evolution.

Recurrence of IgA nephropathy following renal transplantation has been described in 40-50% of patients, and it usually has a good outcome. We present the case of a 54-year-old man with IgA nephropathy who developed terminal renal failure in 1985, 3 years after the onset of the disease. In March 1986 he received a cadaveric renal allograft following treatment with ciclosporin and steroids. Eight months later he developed microhaematuria and proteinuria and 10 months later he developed acute nephritic syndrome and rapidly progressive renal failure. Renal biopsy disclosed an IgA nephropathy with epithelial crescents in 60% of glomeruli. Treatment with plasma exchange and cyclophosphamide was unsuccessful and the patient lost his graft and returned to regular haemodialysis 15 months after renal transplantation.

Verapamil Deleterious Effects in Chronic Renal Failure

Three hypertensive patients with chronic renal failure treated with slow-release verapamil at the recommended doses for high blood pressure experienced acute deleterious effects shortly after treatment (6 h to 3 days). Patients developed slow cardiac rhythms (junctional bradycardia or atrial fibrillation), hypotension and hyperkalemia. Consequently they also had oliguria and worsening of the renal function. Inotropic support, fluid therapy and potassium-lowering measures were able to restore the renal function and sinus rhythm after 10-12 h. Only 7 similar cases have been described so far. It is suggested that slow-release formulations of verapamil must be used with caution in hypertensive patients with impaired renal function.

Assessment of Haemostatic Risk Factors in Patients with Acute Renal Failure Associated with Severe Systemic Inflammatory Response Syndrome

Background/Aim: The prognosis of acute renal failure (ARF) in the Intensive Care Unit (ICU) is variable and depends mainly on the underlying disease. Consequently, the outcome prediction is difficult. The majority of the prognostic measures used include clinical parameters and routine laboratory tests but not no study has considered the prognostic value of haemostatic disturbances. These disturbances play a key role in the evolution of multiple organ dysfunction syndrome (MODS) in patients with ARF, which occurs as part of systemic inflammatory response syndrome (SIRS). The aim of the present study was to search for early significant predictive factors among a group of haemostatic parameters in these patients. Methods: Forty patients (age: 60.1 ± 14.1 years) with ARF (requiring renal replacement therapy) associated with SIRS and haemodynamic instability (systolic blood pressure <90 mm Hg and/or vasopressor drugs) were included. The plasmatic levels of the following haemostatic factors were measured within the first 6 h of the SIRS evolution: von Willebrand Factor (vWF), thrombomodulin, plasminogen activity inhibitor type 1 (PAI-1 antigen), tissue type plasminogen activator (t-PA antigen), prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin complexes (TAT) and D-dimer. Age, sex, medical or surgical disease, septic status or not, type of ARF (prerenal or acute tubular necrosis, oliguric or nonoliguric), and requirement for inotropics and mechanical ventilation were also considered. Univariate and multivariate logistic regressions were used to identify the risk factors for death and to develop a possible mortality prediction model on this basis. Results: By univariate analysis, high levels of PAI-1 antigen (≧60 ng/ml) and F1 + 2 (>2.5 nmol/l) at early phases of ARF-severe SIRS were found to be independent risk factors for death (odds ratio (OR) = 6.37, p = 0.0181 and OR = 5.49, p = 0.0238, respectively). Age over 61 years and requirement of mechanical ventilation were independent death risk factors (OR = 4.33, p = 0.0251 and OR = 2.4, p = 0.0078, respectively). A possible mortality prediction model was obtained including the age and the PAI-1 antigen and F1 + 2 variables. Conclusion: In patients with ARF associated with severe SIRS, the independent risk factors from the early phases of the process are not only the known variables such as advanced age, but also high levels of PAI-1 antigen and F1 + 2. In the future, the individual probability of death could be calculated by a prediction model which includes these variables.

ACE Inhibitors for Scleroderma Renal Crisis

To the Editors: We read with great interest the review by Steen and colleagues (1) on the outcome of scleroderma renal crisis before and after the availability of angiotensin converting enzyme (ACE...

Red cell distribution width: a method that improves detection of iron deficiency in chronic hemodialysis patients.

Rafael Díaz-Tejeiro, MD, Department of Nephrology, University Clinic, School of Medicine, University of Navarra, E-31080 Pamplona (Spain) Dear Sir, The pathogenesis of anemia of maintenance hemodialysis patients is multifactorial. Superimposed iron deficiency because of the repetitive blood losses associated with dialyzer use and bleeding secondary to uremic gastroenteritis and platelet dysfunction is a common feature [1]· The sensitivity of various iron measurements varies with the severity of iron lack. On this basis iron deficiency is commonly divided into three stages: storage iron depletion, iron-deficient erythropoiesis and iron deficiency anemia [2]. Red cell indices, such as mean corpuscular volumen (MCV), mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration, are sensitive only in the second and the third stages [2]. Moreover, several reports have shown that the serum iron and trans-ferrin saturation are of little value in identifying iron deficiency in these patients [3]. Serial measurements of serum ferritin levels provide an acceptable alternative for monitoring iron balance in chronic hemodialysis patients [4]. The majority of studies have suggested that iron deficiency is associated with serum ferritin values of less than 55 ng/dl [5]. The use of a new red blood cell parameter, the red blood cell distribution width (RDW), which is offered as a routine parameter on automated blood count, in combination with MCV improves the classification of anemias and the early detection of iron deficiency [6, 7]. It has been demonstrated that RDW values greater than 14.6% are associated with decreased iron stores [6]. To evaluate the usefulness of the RDW in detecting iron deficiency we examinated blood samples from 27 patients in maintenance hemodialysis. Patients with morphologically identified red cell abnormalities and patients with MCV values greater than 100 fl were excluded because these abnormalities may also cause RDW elevation. All patients were treated with phosphate binders Table 1. Relation of MCV and MC V/ RDW with serum ferritin in 27 patients in chronic hemodialysis

Effects of Xipamide on Transmembranary Potassium Movements and Prostacyclin Production

Several observations suggest a possible interaction between ion transport mechanisms and the arachidonic acid cascade in the natriuretic and in the antihypertensive effects of diuretics(1). Moreover, several studies have established that some diuretic drugs may act on the arachidonic acid cascade(2). In fact, it has been recently reported that the modification of K+ transmembrane gradient by some diuretic drugs may stimulate the generation of prostacyclin, PGI2,(3), Xipamide, X, is a sulfonamide type drug with diuretic and antihypertensive effects but whose mechanism of action remains unknown(4). We, thus, have investigated whether X does modify transmembranary K+ movements and PGI2 production.