Lars-Eric Lins

Long-term prognosis of post-infectious renal scarring in relation to radiological findings in childhood — a 27-year follow-up

In a previous report the long-term prognosis of 30 patients with renal scarring after pyelonephritis in childhood was described. In this study, we have related the extent of renal scarring present in childhood to the conditions in early adulthood. A radiological progression of searring from childhood to adulthood was seen in one-third of the kidneys. The 7 patients with bilateral scarring in childhood had a smaller renal area, lower glomerular filtration rate and higher plasma vasopressin at follow-up than 13 healthy controls. The 20 patients who had unilateral searring in childhood had a smaller renal area, lower glomerular filtration rate, higher diastolic blood pressure and higher plasma renin at follow-up than controls; 4 had hypertension. The most important finding was that children with unilateral disease are at risk of serious long-term complications. Filtration fraction at follow-up was higher in patients with extensive renal scarring in childhood compared with those with a normal renal area or small scars in childhood (r=−0.43,P<0.05). This may indicate glomerular hyperfiltration by remnant glomeruli. This paper emphasizes the potential seriousness of childhood urinary tract infections especially when early infantile infections are overlooked. A follow-up of more than 4 decades may be necessary before the ultimate prognosis can be established, especially in patients with unilateral renal disease. It is advised that most patients with post-infectious renal scars are followed as high-risk patients, and that treatment continuity is established between paediatricians, nephrologists and, when required, obstetricians.

Monocyte and Granulocyte CD11b/CD18, CD62L Expression and slCAM-1 Concentration in the Interdialytic Period

We studied cell surface modulation of CD11b/CD18 and CD62L on monocytes and granulocytes, sICAM-1 concentrations and the responsiveness of cells to exogenous fMLP in patients in the intra- (0-4 h Cuprophan dialysis) and interdialytic period (5-28 h) and in healthy subjects (0-24 h). The high CD11b/CD18, low CD62L granulocyte phenotype occurred rapidly during dialysis. By contrast, CD62L increased on the subpopulation of monocytes in circulation initially during dialysis and CD11b/CD18 was mobilized much slower. In the interdialytic period, the CD62L/(CD11b/CD18) ratio was reduced up to 12 h after start of treatment on both monocytes and granulocytes. This ratio was significantly lower than in healthy subjects up to 8 h after start of treatment. The responsiveness of granulocytes to exogenous fMLP, in terms of CD11b/CD18 mobilization, was significantly reduced in patients during and after hemodialysis as compared to that on granulocytes obtained from healthy controls. Monocytes were more refractory to fMLP up to 4 h after dialysis. sICAM-1 was significantly increased in patients before dialysis as compared to controls and remained elevated and fairly stable throughout treatment and in the interdialytic period. The variation in the expression of adhesion molecules on monocytes and on granulocytes in the interdialytic period was not related to the presence of activating serum factors remaining in the circulation after treatment. Our findings emphasize the importance of including the interdialytic period in the evaluation of dialysis membrane biocompatibility, especially when effects on monocytes are of interest.

Evaluation of impedance technique for fluid-volume monitoring during hemodialysis

Fluid-volume changes during hemodialysis were studied in 30 patients at four separate treatments in each patient. Readings of fluid-volume changes obtained by a fluid-balance monitor with non-invasive tetrapolar impedance technique were compared to changes in weight caused by the treatment. A correlation coefficient of r=0.90 (p<0.001) was found. A survey of papers describing impedance measurements during hemodialysis or diuresis is also presented.

Symptomatic Recurrent Urinary Tract Infections in Patients with Renal Scarring in Relation to Fecal Colonization with P-Fimbriated Escherichia Coli

We evaluated prospectively 49 women with renal scarring and a history of febrile urinary tract infections in regard to the incidence of recurrent symptomatic urinary tract infection and fecal colonization with P-fimbriated Escherichia coli. During a 3-year followup 26 patients (53 per cent) had symptomatic urinary tract infection (0.036 infections per patient-month), including 8 (16 per cent) who had 9 new episodes of febrile urinary tract infection, while 33 (67 per cent) had Escherichia coli bacteriuria (10(5) bacteria per ml. urine in pure culture). Thus, patients with previous febrile urinary tract infections and renal scarring have a high risk for recurrent infections. For comparison, the incidence of symptomatic urinary tract infection also was determined in 35 women with a recent episode of acute nonobstructive pyelonephritis and with normal kidneys on excretory urography. These patients had 0.031 symptomatic infections per patient-month. The fecal flora were examined twice a year for P-fimbriated Escherichia coli in 48 patients with renal scarring. Of these patients 21 (44 per cent) had at least 1 fecal colonization with a P-fimbriated Escherichia coli strain. However, in only 1 instance was a relationship detected between the presence of P-fimbriated Escherichia coli in the fecal flora and the development of subsequent febrile urinary tract infection. The findings indicate that fecal sampling twice a year is not of value to predict future urinary tract infections in adults with renal scarring.

P-Fimbriae Receptors in Patients with Chronic Pyelonephritis

The adherence of fluorescein isothiocyanate-labeled P-fimbriated Escherichia coli to uroepithelial cells from 19 women with chronic pyelonephritis was determined with the fluorescence-activated cell sorting technique. The application of this method has made it possible to study bacterial binding to a large number of cells. Renal function was determined in all patients and the recurrences of P-fimbriated Escherichia coli bacteriuria, cystitis and acute pyelonephritis during a 3-year followup were studied. We found a significant correlation between the P-fimbriae receptor accessibility on uroepithelial cells and glomerular filtration rate (r equals -0.75, p less than 0.001). Uroepithelial cells from the patients with chronic pyelonephritis and renal insufficiency had a higher binding capacity of P-fimbriated Escherichia coli than uroepithelial cells from patients with a normal glomerular filtration rate. There was no correlation between kidney function and the availability of P-fimbriae receptors in a control group of patients with polycystic kidney disease.

Whole body impedance measurements reflect total body water changes. A study in hemodialysis patients

Fluid volume changes during hemodialysis was monitored by continuous whole body impedance measurements. The fluid changes recorded using this method was compared to fluid volume changes measured in plasma water (PV) using125I-albumin, and extracellular volume (ECV) using51Cr-EDTA before and after treatment, and total body water (TBW) changes reflected by continuous bed scale monitoring. Changes in impedance correlated to TBW changes, r=0.80, p<0.001, while correlations to changes in ECV and PV were: r=0.57 and r=0.55, respectively, p<0.05. Alterations in body fluid volumes recorded with whole body impedance is best correlated to total body water changes.The use of continuous whole body impedance monitoring has been shown to offer a simple non-invasive method for recording total body water changes during hemodialysis.