Kenneth F. Fairley

Renal biopsy: indications and complications in pregnancy

Summary. A series of 111 renal biopsies performed in 104 pregnant women during the past 20 years at The Royal Melbourne Hospital and Royal Womens Hospital, Melbourne were reviewed. The indications for biopsy and the histological findings are detailed. The complication rate was very low (4.5%). It is concluded that the procedure is safe and that renal biopsy during pregnancy yields a definitive histological diagnosis in almost all cases. The indications for renal biopsy in pregnancy are discussed.

Renal biopsy as an outpatient procedure

We evaluated the safety and efficacy of outpatient renal biopsy by prospectively comparing outpatient and inpatient renal biopsies in which patients were given the choice between having the procedure as an inpatient or an outpatient. Three hundred fifty renal biopsies were performed between January 1992 and August 1994; 118 patients had the procedure as an outpatient and 232 patients had the procedure with discharge planned for the following day. There was no difference between the two groups in terms of patient age, sex, or renal function. The complication rate for the two groups was not significantly different, with two inpatients having loin pain and one having macroscopic hematuria compared with one outpatient having loin pain and one having macroscopic hematuria. The biopsies provided samples of comparable size. We conclude that outpatient renal biopsy is a safe procedure and provides adequate tissue samples.

Mesangiocapillary Glomerulonephritis Type II (Dense-Deposit Disease): Clinical Features of Progressive Disease

Twenty-seven patients presenting to the Royal Melbourne Hospital between 1968 and 1988 with mesangiocapillary glomerulonephritis type II with intramembranous dense deposits (dense-deposit disease, DDD) are analyzed. Patients were divided into two groups on the basis of whether renal function deteriorated (14 patients) or remained stable (13 patients). At presentation or during the course of the disease, heavy proteinuria, macroscopic hematuria, and high quantitative urinary red cell or white cell counts characterized patients with progressive disease. Patients with crescents on their initial renal biopsy or with large numbers of polymorphs in glomerular capillaries corresponding with sterile pyuria were more likely to have deterioration of renal function. The average time from onset of symptoms to development of end-stage renal disease was over 16 years. The patients clinical course could not be anticipated by serum complement profiles, the presence of C3 nephritic factor, or partial lipodystrophy. Pregnancy did not affect the course of the disease. Six patients underwent renal transplantation and the disease recurred on renal biopsy in four. However, only two individuals lost renal allografts due to recurrent DDD.

Urinary red-cell morphology during exercise.

Midstream urine samples were examined by phase-contrast microscopy before and immediately after 48 subjects participated in a long-distance run. Minor abnormalities were found in six samples before exercise. Eighteen subjects developed proteinuria and five haematuria on dipstick testing after exercise. Forty-four subjects had increased urinary red-cell counts after exercise; of these, 33 had counts above the normal range (800/ml). In all subjects urinary red cells were dysmorphic both before and after exercise, indicating a glomerular source. Ten subjects developed red-cell casts and 42 showed an increase in hyaline and hyaline-granular casts after exercise. There were modest increases in urinary white-cell counts in 35 subjects but little change in urine pH or osmolality with exercise. This study confirms that urinary red-cell counts commonly increase appreciably after exercise. The dysmorphic appearance of the red cells together with the presence of red-cell casts indicates a glomerular source for this common form of exercise haematuria.

Renal Disease in Pregnancy. Three Controversial Areas: Mesangial IgA Nephropathy, Focal Glomerular Sclerosis (Focal and Segmental Hyalinosis and Sclerosis), and Reflux Nephropathy

Whether gestation has adverse effects on the course of renal disease is controversial. Three diseases regarding which conflicting opinions are especially noteworthy are IgA nephropathy, focal and segmental hyalinosis and sclerosis, and reflux nephropathy. We analyzed 102 pregnancies in 65 women with IgA nephropathy, noting hypertension in 63% of the gestations (severe in 18%), decreases in renal function in 22%, and biopsy evidence demonstrating a significantly greater amount of glomerular proliferation and crescents as well as focal and segmental hyalinosis and sclerosis when the renal histology from women who were pregnant and those who had never conceived were compared. Our experience with glomerular sclerosis is limited to 28 gestations in 15 patients, but the clinical findings resemble those of women with IgA nephropathy who conceived. Finally, we analyzed 227 pregnancies in 95 women with normal renal function and reflux nephropathy comparing results to 118 gestations in 42 patients with evidence of dysfunction (serum creatinine SCr greater than 1.25 mg/dL). Women with preserved function had good outcomes in general, whereas hypertension (36%) and an accelerated decline in function (8%) were observed in the groups that had moderate renal insufficiency in the initial stage of pregnancy. Increased proteinuria was the best predictor of progression of reflux nephropathy in both groups.

Prevention of Preeclampsia with Heparin and Antiplatelet Drugs in Women with Renal Disease

Summary: In a retrospective cohort study of women with renal disease in pregnancy we investigated if:

Effect of pravastatin on kidney function and urinary protein excretion in autosomal dominant polycystic kidney disease

Objective. Autosomal dominant polycystic kidney disease (ADPKD) is progressive, resulting in end-stage kidney failure in most patients. Experimental and clinical studies have suggested that statins may slow the progression of chronic kidney disease in general and ADPKD specifically. Material and methods. This randomized open-label clinical trial was conducted to assess the effect of pravastatin 20 mg on kidney function and urinary protein excretion in patients with ADPKD. Sixty patients were initially recruited but 49 of these received either pravastatin 20 mg or no treatment for 2 years. Trial visits were conducted every 3 months, assessing kidney function by estimated glomerular filtration rate and 24 h urine creatinine clearance and urinary protein excretion. Results. There were no significant (p > 0.05) changes in markers of kidney function or urinary protein excretion between groups over the 2 years despite a significant fall in total serum cholesterol in pravastatin-treated patients (p = 0.029). Conclusion. This trial found that taking 20 mg pravastatin for 2 years had no significant effect on kidney function or urinary protein excretion in patients with ADPKD. The lack of statistical power limits the external validity of these findings. A larger, longer duration study using a higher dose of a more potent statin is required.

Reduction of proteinuria by rosiglitazone in non‐diabetic renal disease

Aim:  To investigate the effect of a thiazolidinedione on proteinuria in patients with non‐diabetic renal disease.

Membranous glomerulonephritis and Landry-Guillain-Barre syndrome.

Two cases of idiopathic membranous glomerulonephritis associated with acute inflammatory demyelinating polyradiculoneuropathy (Landry-Guillian-Barre syndrome) are described. In both of the patients, the onset of the nephrotic syndrome coincided with the development of severe ascending sensorimotor neuropathy. Although this association has previously been reported in four other isolated cases, it is not generally recognized by nephrologists and may be of significance in the future understanding of the immunopathogenesis of both diseases.

AN UNUSUAL CORONARY ARTERIOCAMERAL FISTULA.

Abstract A case of a coronary arteriocameral fistula in a 28 year old woman is reported. There was an abnormal coronary artery arising from the main pulmonary artery and connecting with both the left coronary artery and the left atrial appendage. In addition, the pulmonary valve was biscuspid and the mitral valve incompetent. The diagnosis of the communication between the pulmonary artery and the left atrium was made with the aid of right heart catheterization and selective cineangiocardiography. However, the communication between the aorta and the fistula was not demonstrated during life. The patient died suddenly four days after cardiac catheterization. Death was attributed to an arrhythmia four days after the investigation. The hemodynamic situation and the anatomic findings are discussed. Partial surgical correction would have been possible but may not have influenced the prognosis.