Masato Tadokoro

Prednisolone Co-Administered with Losartan Confers Renoprotection in Patients with IgA Nephropathy

Background.Treatment options for progressive IgA nephropathy are limited. Methods. We performed a small, randomized controlled trial to evaluate the effects of prednisolone (PSL, 30 mg/dL, gradually tapered to 5 mg/dL over two years) plus 50 mg/day of losartan (LST, an angiotensin II receptor blocker) or PSL alone on IgA nephropathy. We separated 38 patients (age, 33 ± 11 years; creatinine clearance, 103 ± 31 mL/min; proteinuria, 1.6 ± 0.5 g/day) into two groups that were treated with either PSL plus LST or PSL alone, and compared the proteinuria and creatinine clearance after two years. Baseline and histopathological data did not significantly differ between the two groups. Results. Two years of treatment in both groups significantly decreased proteinuria compared with baseline, and PSL plus LST (from 1.6 ± 0.6 to 0.3 ± 0.1 g/day, p < 0.05) was more effective than PSL alone (from 1.6 ± 0.3 to 0.5 ± 0.1 g/day, p < 0.05). Creatinine clearance in both groups was similar at the start of study but significantly differed at the end of the study (PSL plus LST, 104.3 ± 36.4 to 100.4 ± 38.9 mL/min; PSL alone, 103.4 ± 28.5 to 84.8 ± 34.3 mL/min, p < 0.05). Conclusions. Combined therapy with PSL plus LST appears to be more effective than PSL alone in reducing proteinuria and protecting renal function in patients with IgA nephropathy.

Relationship between Carotid Artery Intima-Media Thickness and Atherosclerotic Renal Artery Stenosis in Type 2 Diabetes with Hypertension

Aim: To assess the relation between intima-media thickness (IMT) of the common carotid artery and atherosclerotic renal artery stenosis (ARAS) ≧50% (one or both renal arteries) in type 2 diabetic patients with hypertension. Methods: We performed a retrospective study of type 2 diabetic patients with hypertension who underwent magnetic resonance angiography or digital subtraction angiography for renal artery stenosis at the National Cardiovascular Center or at the Nagasaki Municipal Medical Center between May 1999 and May 2001. Renal artery stenosis was defined as a narrowing of the artery to at least 50% of normal. Thirty type 2 diabetic patients with hypertension (17 men and 13 women, mean age 65.4 ± 7.6 years) were identified and divided into two groups: those with ARAS in one or both renal arteries (n = 15) and those without ARAS (n = 15). We used high-resolution B-mode ultrasonography to measure the IMT of the common carotid artery. Results: With and without ARAS were 9 men and 6 women (mean age 65.0 ± 7.6 years) and 8 men and 7 women (mean age 65.7 ± 6.8 years), respectively. The IMT of the carotid artery was significantly greater in patients with ARAS than in patients without ARAS (1.07 ± 0.10 vs. 0.84 ± 0.12 mm, p < 0.01). However, the only clinical findings that statistically significantly differed were systolic blood pressure and plasma renin activity. Conclusion: Our findings suggest that the measurement of the IMT of the carotid artery may be useful as a noninvasive screening method for the defection of ARAS even in asymptomatic type 2 diabetic patients.

Histologically confirmed superimposition of post-streptococcal acute glomerulonephritis during IgA nephropathy

We describe a 39-year-old Japanese man with post-streptococcal acute glomerulonephritis (PSAGN) super-imposed on long-term immunoglobulin A nephropathy (IgA-N). The histological findings of the first renal biopsy, done at 21 years of age, revealed mild mesangial proliferative glomerulonephritis with mesangial IgA deposition. Nineteen years later, acute nephritic syndrome with hypocomplementemia and an increasing anti-streptolysin O (ASO) titer developed 2 weeks after the onset of an upper respiratory infection. A second renal biopsy revealed severe segmental endocapillary proliferative and exudative glomerulonephritis, with fibrocellular crescents in about 40% of the glomeruli. Immunofluorescence showed that more C3 than IgA was deposited in the mesangium and that the IgA deposits had decreased. Electron microscopy revealed “hump” electron-dense deposits on the epithelial side of the glomerular basement membrane. These features were consistent with PSAGN superimposed on IgA-N. After 2 weeks of observation, blood pressure, C3 level, and ASO titer had returned to normal, although the persisting nephritic syndrome necessitated steroid therapy. Six months after the onset of the acute nephritic syndrome, the patient remained asymptomatic, except for microhematuria.

Prognosis of Patients with Rounded Atelectasis Undergoing Long-Term Hemodialysis

We present 4 patients undergoing hemodialysis in whom thoracic computed tomography (CT) suggested a diagnosis of rounded atelectasis (RA) with pleural effusion. The clinical setting and follow-up CT of all 4 patients confirmed this diagnosis. The pleural fluid of each appeared serosanguineous or hemorrhagic and predominantly consisted of lymphocytes. Biochemical analysis of this fluid revealed high levels of total protein, lactate dehydrogenase and glucose. Bacterial culture and polymerase chain reaction for Mycobacterium tuberculosis DNA was negative. Pleural biopsy specimens from 2 of the 4 patients showed evidence of fibrinous change and mesothelial cell hyperplasia. Pleural effusion from all 4 patients did not respond to either fluid restriction or aggressive hemodialysis-induced dehydration. The subsequent clinical course and thoracentesis were repeated, and in 1 patient, this was followed by tetracycline pleurodesis. However, 2 patients died during pre-pleurodesis and 1 died during post-pleurodesis, all due to respiratory failure. We propose that the clinical setting and follow-up thoracic CT and thoracentesis of patients receiving long-term hemodialysis confirmed a diagnosis of rounded atelectasis with uremic pleural effusion. We also propose that the prognosis of patients with refractory pleural effusion receiving long-term hemodialysis would be improved by early pleurodesis.

Acetazolamide assisted Tc-99m MAG3 renography to assess renal blood flow reserve

Objective: The present study examines whether or not baseline and acetazolamide (ACZ) Tc-99m MAG3 renography can assess renal blood flow reserve.Methods: Renography proceeded for 50 min after sequential injections of 370 MBq Tc-99m MAG3 for baseline renography and 10 min after a 1,000 mg injection of ACZ for ACZ renography. Effective renal plasma flow of renal cortex (cERPF) in each kidney and the percentage change in cERPF of those parameters (ΔERPF) were obtained before and after the administration of ACZ in 10 subjects without hypertension or diabetes (normal group), in 10 with essential hypertension (hypertensive group) and in 10 who had Type 2 diabetes with hypertension (diabetic group). A placebo test was performed in the 10 without hypertension or diabetes using distilled water instead of ACZ (placebo group).Results: The placebo test performed in the 10 without hypertension or diabetes using distilled water instead of ACZ indicated that the parameter variance between the two types of renogram was below 3.2%. The cERPF of baseline and ACZ Tc-99m MAG3 renography and δERPF in the normal, hypertensive and diabetic groups were 89±10 and 110±10 ml/min, 89±14 and 117±22 ml/min, 100±23 and 112±23 ml/min, respectively, and 24.5±13.5%, 26.0±9.7% and 12.3±11.1%, respectively. The difference in the cERPF value was significant in the normal and hypertensive groups whereas this did not change in the diabetic group before or after ACZ administration.Conclusions: We suggested that the δERPF determined by baseline and ACZ Tc-99m MAG3 renography is a useful parameter for assessing renal blood flow reserve.

Evaluation of Tc-99m MAG3 dynamic renal scintigraphy with an aneurysmal type renal arteriovenous fistula.

Tc-99m MAG3 renal scintigraphy was performed before and after transcatheter steel coil embolization in a 55-year-old man with an aneurysmal type left renal arteriovenous fistula (AVF). Before embolization, dynamic renal scintigraphy revealed characteristic accumulation compatible with the hemodynamics of an aneurysmal type AVF in the vascular phase. Embolization changed the split renal function in the treated side, and shunt flow through the fistula disappeared. Dynamic renal scintigraphy might be very useful in evaluating patients with hemodynamic renal AVF scheduled for transcatheter embolization.

Functional and morphological study of the peritoneal membrane in CAPD patients.

腹膜硬化症の1例を含むCAPD 6例について, 腹膜の機能および形態変化を検討した.症例1はCAPD導入時より, 十分な除水を行うために高張液を使用していた. 除水量の減少が徐々に進行し, 4年7か月でCAPD継続困難と判断され, カテーテルを抜去した. カテーテル抜去時の腹膜生検にて, 腹膜の著明な肥厚とともに血管内膜の肥厚と内腔の狭小化を認めたことより腹膜硬化症と考えた.除水能の対照的な2例について2.5%透析液2lを使用し, 腹膜機能の検討を行った. 透析液・血漿浸透圧比の時間的推移の検討では, 除水能良好例 (症例2) は浸透圧比の低下を認めず, 除水量は経過とともに順調に増加したのに対し, 除水能不良例 (症例3) では浸透圧比の低下が急速に進行し, 2時間目以後は除水量増加がほとんど認められなかった. 尿素窒素とクレアチニンの透析液/血漿比の時間的推移は両例に差を認めなかった.CAPD剖検例 (症例4-6) について腹膜の病理組織学的変化を検討した. いずれもCAPD導入後1年未満のものであったが, すでに腹膜の肥厚をきたしていた. なかでも2か月間の短期CAPDにて除水能, 溶質除去能ともに良好であった症例において, すでに腹膜の軽度肥厚が認められたことは注目すべきことと思われた.

A case of continuous ambulatory peritoneal hemodialysis patient complicated with IgA myeloma, multiple bone fractures and liver failure

最近, 透析患者の発癌率が高いことが注目されている. 今回, 我々は慢性腎不全にてCAPD療法中にIgA型骨髄腫を合併し, 多発骨折および肝不全にて死亡した一例を経験したので報告する.患者は38歳の男性でCAPD療法中に肋骨多発骨折および腰椎圧迫骨折をきたし, 免疫電気泳動および骨髄穿刺にてIgA型骨髄腫の合併が判明した. CAPD療法と血液透析との併用療法を行ったが, 肝不全にて死亡した. 骨髄腫に対してcyclophosphamideを使用し, 透析中の血中濃度を測定したので併せて報告する.