James A. Hasbargen

Role of Aldosterone in the Sodium Retention of Patients with Nephrotic Syndrome

The role of aldosterone in the abnormal sodium retention in patients with nephrotic syndrome has been debated. In fact, studies using a converting enzyme inhibitor to lower plasma aldosterone have rejected such a role. We therefore studied 5 nephrotic patients and 6 control subjects by using the more specific aldosterone antagonist, spironolactone. After withdrawal of diuretics 5 days prior to the study, the nephrotic patients and control subjects were placed on a high-sodium diet (285 +/- 6 mEq/day) for 8 days. After 4 days, spironolactone 200 mg p.o., b.i.d., was given for the remaining 4 days. Plasma renin activity and plasma aldosterone levels were similar in both nephrotic patients and control subjects before the study, after sodium loading and after spironolactone had been given. After 4 days of high sodium intake control subjects were in sodium balance, but the nephrotic patients were in a positive sodium balance (approx. 80 mEq/day; p less than 0.01). On days 3 and 4 of spironolactone, the nephrotic patients exhibited an increase in urinary sodium excretion (205 +/- 20 vs. 312 +/- 13 mEq/day; p less than 0.005) but not the control subjects (279 +/- 16 vs. 286 +/- 13 mEq/day; NS). It is therefore concluded that aldosterone is a significant contributor to the sodium retention in patients with nephrotic syndrome.

Increased Norepinephrine Secretion in Patients with the Nephrotic Syndrome and Normal Glomerular Filtration Rates: Evidence for Primary Sympathetic Activation

Considerable controversy exists in regard to the state of arterial circulatory integrity in patients with the nephrotic syndrome. Increased sympathetic nervous system activity, along with activation of the renin-angiotensin-aldosterone system and the nonosmotic release of vasopressin, is seen in other states of arterial underfilling. Thus, in the present study, sympathetic nervous system activity was assessed by determining plasma norepinephrine secretion and clearance rates using a whole-body steady-state radionuclide tracer method in 6 edematous patients with the nephrotic syndrome of various parenchymal etiologies and 6 normal control subjects in the supine position. Patients were withdrawn from all medications 7 days prior to study. Mean creatinine clearances and serum creatinine concentrations were normal in both the nephrotic syndrome patients and controls (99 +/- 13 vs. 112 +/- 15 ml/min, p = NS, 1.1 +/- 0.1 vs. 0.8 +/- 0.0 mg/dl, p = 0.03, respectively). However, the nephrotic syndrome patients exhibited significant hypoalbuminemia (2.0 +/- 0.4 vs. 3.8 +/- 0.1 g/dl, p < 0.01). The supine plasma norepinephrine level was elevated in the patients with the nephrotic syndrome as compared with controls (240 +/- 58 vs. 119 +/- 22 pg/ml, p = 0.07). More significantly, the secretion rate of norepinephrine was markedly increased in nephrotic patients (0.30 +/- 0.07 vs. 0.13 +/- 0.02 micrograms/m2/min, p < 0.05), whereas the clearance rate of norepinephrine was similar in the two groups (2.60 +/- 0.29 vs. 2.26 +/- 0.27 l/min, p = NS). Plasma renin activity and plasma aldosterone, arginine vasopressin and atrial natriuretic peptide concentrations were not different in nephrotic syndrome patients compared with controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Prostatic Involvement in Wegener's Granulomatosis

Two cases of Wegeners granulomatosis presenting with prostatic involvement are described and compiled with the five previously detailed cases. Each of these patients presented with obstructive symptoms, proteinuria, leukocyturia, and hematuria. The urinary sediment normalized with treatment of the underlying granulomatous vasculitis. Wegeners granulomatosis is a rare cause of prostatic obstructive symptoms, but should be considered whenever the relatively unusual entity of granulomatous prostatitis is diagnosed. One patient was initially treated exclusively with trimethoprim-sulfamethoxazole (TMP-SMX). He responded, but noted recurrence during the 15th month of treatment. We also report on this patients antineutrophil cytoplasmic antibody (ANCA) titers, which correlated with clinical assessment and predicted recurrence 2 months before elevation of the Westergren sedimentation rate (WSR) and clinical diagnosis.

Successful Treatment of Aspergillus Peritonitis Complicating Peritoneal Dialysis

Fungal peritonitis is an uncommon complication of peritoneal dialysis. There have been four reported cases of dialysis-related Aspergillus peritonitis. Only one patient survived and none have continued peritoneal dialysis. This report describes the first case of dialysis-related Aspergillus peritonitis that was able to continue peritoneal dialysis and reviews the previous cases. Dialysis catheter removal and intravenous amphotericin appear to be the most beneficial therapy.

Hypogammaglobulinemia in a Renal Transplant Recipient With Antiglomerular Basement Membrane Disease

A thirty-six-year-old woman developed antiglomerular basement membrane disease, necessitating bilateral nephrectomies. Subsequent to cadaveric renal transplant and 8 years of immunosuppressive treatment with prednisone and azathioprine, the patient developed multiple life-threatening infections. Quantitative immunoglobulins revealed IgG = 9, IgA less than 6.7, and IgM = 33. Lymphocyte population studies revealed absence of B-lymphocytes. It is suspected that prednisone or azathioprine may have caused a defect in B cell differentiation. In patients who are taking immunosuppressive medications and develop multiple infections, it is indicated to evaluate immunoglobulin and/or B lymphocyte status.

Utility of Skin Biopsy in the Diagnosis of IgA Nephropathy

Thirty-seven patients with the diagnosis of IgA nephropathy were evaluated with punch skin biopsies of non-sun exposed skin. Biopsies were performed regardless of clinical activity. Biopsies were positive for IgA immunofluorescence in two patients. In an effort to enhance positivity of biopsies, patients were pretreated with 0.1 mL of histamine and then repeat biopsies were performed on 14 patients with previously negative skin biopsies. All 14 patients had negative repeat skin biopsies for IgA immunofluorescence. A review of the literature revealed 76 positive skin biopsies in a total of 138 patients with IgA nephropathy. Positive skin biopsies were also reported in 169 of 510 patients with other renal diseases. We conclude that a 4 mm punch skin biopsy with or without histamine is an insensitive and non-specific test for diagnosing IgA nephropathy.