Frederic B. Westervelt

Therapy of the idiopathic nephrotic syndrome with alternate day steroids

Eighty-one adult patients with the idiopathic nephrotic syndrome were treated with prednisone, 60 to 120 mg, on alternate days. Treatment was continued with diminishing drug doses for up to 10 years. Biopsy specimens were categorized as showing lipoid nephrosis 36 per cent, focal sclerosis 12 per cent, diffuse proliferative 22 per cent and membranous nephropathy 30 per cent. Patients with systemic causes of the nephrotic syndrome were excluded. Proteinuria decreased to normal or to less than or equal to 3 g with a greater than or equal to 50 per cent decrease from base line in 83 per cent of the patients with lipoid nephrosis, 30 per cent of the patients with focal sclerosis, 50 per cent of the patients with diffuse proliferative nephritis and 71 per cent of the patients with membranous nephropathy. Improvement occurred in those with focal sclerosis, diffuse proliferative nephritis and membranous nephropathy only after prolonged treatment (14 to 15 months). Stable or improved renal function occurred in 97 per cent of those with lipoid nephrosis, 50 per cent of those with focal sclerosis, 73 per cent of those with diffuse proliferative nephritis and in 83 per cent of those with membranous nephropathy. Death or dialysis occurred in 12 per cent of the patients, and complications coincident with treatment occurred once every 12 patient years. Compared to other series of patients with the idiopathic nephrotic syndrome, therapy of our patients with prolonged alternate day steroids resulted in (1) decreased protein excretion, (2) maintenance of good renal function and (3) decreased number of complications of therapy.

Ventriculojugular shunt nephritis with Corynebacterium bovis: Successful therapy with antibiotics☆

A patient with hydrocephalus and a ventriculojugular shunt presented with acute nephritis, nephrotic syndrome (proteinuria 10 g/24 hours), decreased complement levels, circulating immune complexes and diminished creatinine clearance (41 ml/min). Seven blood cultures grew Corynebacterium bovis. A renal biopsy specimen revealed mesangiocapillary glomerulonephritis by light microscopy, and thickened glomerular basement membranes with areas of increased granular density by electron microscopy. Immunofluorescent examination of the biopsy specimen demonstrated 2+ granular glomerular basement membrane deposits of immunoglobulin M (IgM), with trace third component of complement (C-3), fourth component of complement (C-4) and immunoglobulin G (IgG). Rabbits immunized with C. bovis produced a line of partial identity in agar with patient serum against a sonicate of C. bovis. Indirect fluorescein staining of the biopsy specimen with the rabbit antiserum demonstrated 1+ granular glomerular basement membrane deposits. Potassium thiocyanate microelution of sections prior to examination markedly diminished staining with antihuman antiserum, but did not affect staining with rabbit antiserum. Following initial therapy with intravenous penicillin for six weeks the bacteremia cleared, serum complement levels returned to normal, proteinuria decreased and creatinine clearance increased. A relapse occured four weeks later with decreased complement levels, increased proteinuria and decreased creatinine clearance. Blood cultures were again positive for C. bovis. Following therapy with erythromycin and rifampin, the bacteremia cleared and there was a sustained improvement of all parameters. To our knowledge, this is the first time an association has been noted between C. bovis ventriculojugular shunt infection and glomerulonephritis. These findings support the potential role of C. bovis as an etiologic agent in human renal disease and further define the immune complex nature of shunt nephritis.

Treatment of Hemodialysis Fistula Pseudoaneurysms with Detachable Balloons: Technique and Preliminary Results

Pseudoaneurysm formation is commonly encountered during the life of a dialysis fistula. When these become excessively large or numerous, surgical revision of the graft has been the only treatment option. The authors have treated seven patients by using percutaneous placement of a detachable balloon to occlude a pseudoaneurysm of an upper extremity graft. In four cases the balloon was directed into the pseudoaneurysm from a femoral artery approach. In three cases a direct puncture was made into the pseudoaneurysm for placement of the balloon. The patients were followed up from 1 week to 7 months. Initial technical success was achieved in all seven cases with no complications. Thrombosis of two grafts occurred during the first week after the procedure: one because of herniation of the balloon out of the pseudoaneurysm and one for unknown reasons. One balloon was inadvertently punctured and deflated during subsequent dialysis. Treatment in the other four cases was successful, as evidenced by no further enlargement of the pseudoaneurysms. Direct puncture of the pseudoaneurysm simplifies the procedure and probably decreases the likelihood of balloon herniation because of the orientation of the balloon.

Serum Amylases in Chronic and End-Stage Renal Failure: Effects of Mode of Therapy, Race, Diabetes and Peritonitis

Serum total amylase, pancreatic amylase and lipase activities were studied prospectively in 43 hemodialysis, 22 peritoneal dialysis and 22 chronic renal failure patients. None of the patients had symptoms of pancreatic disease at the time of study. Mean total amylase activities were similar and above the upper limit of normal in the 3 treatment groups. Total amylase was abnormal in 75% of the patients and exceeded twice the upper limit of normal in 24%. Blacks and nondiabetics had higher levels than whites and diabetic patients, respectively. Percentage pancreatic amylase exceeded the upper limits of normal in one third of the patients. Mean pancreatic amylase was above the upper normal limit in the 3 groups, and values were abnormal in 63% of all patients. Mean pancreatic amylase activity was significantly lower in peritoneal dialysis than in hemodialysis or chronic renal failure patients (p = 0.01). Pancreatic amylase activity was unaffected by race. The higher total amylase activity in blacks was due to increased salivary isoenzyme. Hemodialysis treatments did not change total amylase or pancreatic amylase activity. Mean lipase activity approximated the upper limit of normal in the 3 groups and values were abnormal in 42% of all patients. Serum total amylase and pancreatic amylase activity did not increase during episodes of peritonitis in the peritoneal dialysis group. Peritoneal dialysis, whether or not accompanied by peritonitis, was responsible for removal of only a small amount of amylase activity per day.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of Human T-Lymphotropic Virus Type III Antibodies Among Patients in Dialysis Programs at a University Hospital

Excerpt More than 13 000 cases of the acquired immunodeficiency syndrome (AIDS) have been reported. The identification of the human T-lymphotropic virus type III (HTLV-III) as the causative agent h...

Prophylactic antibiotic therapy with cefamandole and tobramycin for patients undergoing renal transplantation.

The incidence of infections among patients undergoing renal transplantation has been reported as high as 83% during the first post-transplant year. In an effort to reduce the occurrence of such infections, we evaluated the role of perioperative prophylactic antibiotics in these patients. Thirty-seven patients undergoing transplantation were assigned randomly to treatment groups (N = 20, cefamandole, 1 gm IM every 6 hrs for 8 doses/tobramycin 1 mg/kg IM for 1 dose, starting 2 hrs prior to surgery) and control groups (N = 17, no antibiotics). A uniform infection surveillance system was used. Eighty-one percent (30/37) of patients became infected; 70% (14/20) of treated patients and 94% (16/17) of controls (p = 0.14). Since antibiotic prophylaxis might be expected to exert the greatest influence in the immediate postoperative period, we examined patient outcome data for both the first seven posttransplant days and for the entire hospitalization. Of the 38% (14/37) of patients who developed infections during the first posttransplant week, a statistically greater proportion came from the control group than from the treated group (10/17 vs. 4/20, p = 0.04). These data suggest that this regimen is effective in reducing the occurrence of infections during the first week following renal transplantation.

Nephrotic Syndrome and Focal Glomerular Sclerosis in Aging Man

Focal glomerular sclerosis (FGS) with the nephrotic syndrome is a disecades. Less than 2% of reported patients are older than 60 years of age, and to our knowledge no patients over 70 years of age have been described. The present report documents with renal biopsies the occurrence of FGS and the nephrotic syndrome in 4 patients with an average age of 70 years, 3 being septuagenarians. We suggest that FGS in these patients may represent a disease of senescence, and that FGS in younger patients may result from accelerated glomerulotubular senescence.

Persistence of Candida Despite Seemingly Adequate Systemic and Intraperitoneal Amphotericin B Treatment in a Patient on CAPD

A case of Candida peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD) is presented. Despite 2 weeks of intravenous and 4 weeks of intraperitoneal amphotericin B, good clinical response, and repeatedly negative fungal cultures from the peritoneal dialysate, her Tenckhoff catheter upon removal grew the same Candida species. This case emphasizes the point that Candida may persist on the catheter despite seemingly adequate antifungal treatment and good clinical and microbiologic response.

Cohort study of human immunodeficiency virus (HIV) antibody testing among patients receiving long-term dialysis at a university hospital.

In a longitudinal study to determine the seroprevalence of antibody to the human immunodeficiency virus (HIV) and the natural history of a positive enzyme immunoassay (EIA) result we followed a cohort of 98 patients receiving long-term dialysis. Eight patients (8.2%) in the cohort had a positive EIA and a negative Western blot test result. The EIA-positive results of all patients seroconverted to negative during follow-up. No illness suggestive of HIV infection developed in any of the patients. Significantly associated with a false positive EIA were prior renal transplantation, transfusions during the months just before the positive EIA result, and a greater number of lifetime transfusions before the positive test result. We confirm that routine HIV screening of patients receiving long-term dialysis is associated with a high rate of false positive EIA results and conclude that such testing is unnecessary in the absence of established risk factors for HIV infection.

Transient Paralysis of Upper Extremity After Percutaneous Cannulation of the Subclavian Vein for Hemodialysis

Two cases of transient paralysis of upper extremity after percutaneous cannulation of the subclavian vein for hemodialysis are presented for the first time. Large amounts of lidocaine used, together with its deep and too lateral administration are responsible for development of this transient complication.