Massimo Maccario

Clinical and prognostic value of serial renal biopsies in lupus nephritis.

Little information is available about the role of repeated renal biopsies in lupus nephritis. We analyzed retrospectively the prognostic significance of serial renal biopsies in patients with lupus nephritis. Thirty-one patients with lupus nephritis underwent two or more renal biopsies during follow-up. The indications for repeated biopsy were as follows: improvement of renal disease but persistence of nonnephrotic proteinuria (group A, 7 patients); persistent or relapsing nephrotic syndrome (group B, 12 patients); and worsening of renal function (group C, 19 patients). After a median follow-up of 10.5 years, 17 patients reached the end point (persistent doubling of plasma creatinine level). At repeated renal biopsy, there was a correlation between improved clinical and histological features for group A. In these patients, treatment was reduced or stopped successfully. Histological features remained almost unchanged in group B. All patients showed an improvement of proteinuria after reinforcement of therapy. In group C, the worsening of renal function was associated with a variable and clinically unpredictable combination of active and chronic lesions. Only the few patients with an elevated activity index and moderate chronicity index showed a favorable and persistent improvement of renal disease after reinforcement of therapy. At multivariate analysis of clinical and histological data at presentation, only male sex was predictive of an adverse outcome (P = 0.015). At repeated renal biopsy, crescents in more than 30% of glomeruli (P = 0.0009) and chronicity index of 5 or greater (P = 0.00006) were associated with the probability of reaching the end point at multivariate analysis. Repeated renal biopsy may be helpful for establishing the prognosis in patients with lupus nephritis, particularly in the presence of worsening of renal function.

Long-term results with cyclosporine monotherapy in renal transplant patients: A multivariate analysis of risk factors

There is little information on the long-term outcome of patients initially assigned to cyclosporine (CsA) monotherapy and requiring the addition of steroid therapy during follow-up. The aim of this report is to describe our experience with 143 first renal transplant recipients (120 cadaver transplants, 23 living donor transplants) randomized to receive CsA monotherapy as a treatment arm of three consecutive controlled clinical trials. Median follow-up was 86 months. Thirty-four percent of the patients remained on the original CsA monotherapy, whereas the remaining 66% required the addition of steroid therapy. Cumulative patient and graft survivals at 11 years were 0.89 (95% confidence interval [CI], 0.83 to 0.95) and 0.62 (95% CI, 0.52 to 0.72), respectively. The 11-year graft survival for converted patients was 0.53 (95% CI, 0.39 to 0.67). Cumulative graft half-life was 19.9 +/- 3.47 (SE) years. According to the Cox model, variables at transplantation that correlated with a lower 11-year graft survival were yearly increases in age (relative risk [RR], 1. 04; P = 0.039), monthly increases in hemodialysis duration (RR, 1.01; P = 0.029), no blood transfusion before transplantation (RR, 1.99; P = 0.043), CsA administration in a double daily dose (RR, 2.35; P = 0.008), and a cadaver donor transplant (RR, 4.76; P = 0.039). Multivariate analysis of time-dependent variables showed that delayed graft function recovery (RR, 2.20; P = 0.019) and the need to add steroid and/or azathioprine therapy (RR, 5.28; P = 0.000) were also correlated with a lower graft survival. Patients who added steroid therapy developed infections (P < 0.001), cataracts (P < 0.001), cardiovascular complications (P = 0.004), and arterial hypertension (P = 0.024) more frequently than patients remaining on CsA monotherapy. Patients administered CsA in a single daily dose received significantly less CsA over the years (P = 0.0042) than patients administered CsA in two divided doses. They also showed a trend toward greater creatinine clearance levels, although not statistically significant. In conclusion, this analysis showed that in patients assigned to CsA therapy alone, good long-term patient and graft survival probabilities can be obtained. In approximately one third of the patients, the use of steroids could be avoided for up to 11 years, and these patients had a better long-term outcome than those who required the addition of steroid therapy. Finally, in patients administered CsA in a single daily dose, the possibility of reducing CsA dosage probably led to better intrarenal hemodynamics with improving creatinine clearances.

Extracapillary glomerulonephritis and renal amyloidosis

We report three patients with well-documented renal amyloidosis who developed rapidly progressive renal failure. Renal biopsies from all three patients showed crescentic glomerulonephritis imposed on renal amyloidosis. All patients were treated with intravenous high-dose methylprednisolone pulses combined with immunosuppressive agents and oral corticosteroids. Partial recovery of renal function was obtained in two patients. For the third patient, treatment had to be stopped after a few days because of a septic arthritis. Renal function continued to deteriorate, and the patient had to be placed on regular hemodialysis. We conclude that extracapillary glomerulonephritis may occasionally complicate a preexisting renal amyloidosis and may be reversible if recognized early and treated appropriately.

Peritoneal dialysis in the nineth decade of life experience in a single center

The clinical outcome of 21 patients on CAPD who were older than 79 years at the time of beginning dialysis is reported in the present paper. These patients represented 5% of 420 patients who were admitted to the CAPD program of our Unit between 1980 and 1995. Fifteen of the patients were men and 6 women, with a mean age of 81 ± 3 years. The median patient survival was 21 months, after 3 years patient survival rate was 30%. The causes of death were cardiovascular (7), cachexia (4), peritonitis (1), liver failure (1) and withdrawal of dialysis (2). The peritonitis rate was 0.6 episodes/year, 45% of episodes were caused by gram + bacteria, 23% by gram - bacteria and in the other episodes peritoneal fluid culture was not performed or no growth was observed. Exit site infection rate was 1 episode every 32 months. Three peritoneal catheters were removed after 1, 14, and 23 months. Most severe complications were dementia (5) and depression (4), severe peripheral vascular disease with pain and ulcers in 3 cases. Quality of life was poor in 4/11 patients surviving after one year. Sixteen patients required a partner for performing the exchanges and many of them needed frequent hospitalization or equivalent care at home.

Nine patients treated for more than 10 years with continuous ambulatory peritoneal dialysis

We have retrospectively examined the clinical outcomes of the 9 patients who survived for more than 10 years in our continuous ambulatory peritoneal dialysis (CAPD) program. Six were men and 3 women aged 50.8 +/- (SD) 11.5 years. Three had been previously treated by hemodialysis. None of them had diabetes or neoplasms, 1 had liver cirrhosis, 3 had ischemic cardiopathy, 1 had peripheral artery disease, and all were hypertensive. The hospitalization rate ranged from 0 to 4.5 days/patient/year, the peritonitis rate was one episode every 57 months. Six patients had no peritonitis during the first 10 years of treatment. Exit-site episodes were one every 46.7 patient months. Six peritoneal catheters were removed from 4 patients. KT/V and peritoneal permeability, assessed by the peritoneal equilibration test, were within the normal range in the majority of the patients. Five patients died between the 121st and the 149th month, and 4 are still alive. Three of them are working. These results show that CAPD can be effective, peritoneal catheters can survive, and some patients can be free from peritonitis episodes for more than 10 years. After the 10-year on CAPD, the survival is poor, and the morbidity is high.

Worse outcome in younger adult renal graft recipients with HCV infection. An 8-year prospective study

Late morbidity remains one of the mot important problems in renal transplantation, and chronic liver dysfunction (CLD) is one of the main factors that may contribute to it. The majority of long-term data about liver disease in renal transplant patient concerns HBsAg positive patients. Since 1989, however, it has become evident that the most frequent cause of liver disease was hepatitis C virus (HCV) infection. Considering that in Italy 20-40 % of dialyzed patients have been found to be anti-HCV positive [3], the contribution of HCV infection to longterm morbidity of transplant patients may be relevant. In this study, we evaluated whether renal transplant patients with HCV infection were at higher risk of death when compared with HCV negative recipients. Results

Continuous ambulatory peritoneal dialysis in patients after intra-abdominal prosthetic vascular graft surgery

The purpose of this study was to assess the feasibility of continuous ambulatory peritoneal dialysis (CAPD) after intra-abdominal prosthetic vascular graft surgery. We report 8 consecutive patients with end-stage renal disease, who previously underwent intra-abdominal prosthetic aortic graft replacement, treated by CAPD between November 1983 and November 1994. All patients received a peritoneal dialysis catheter without technical problems and were dialyzed for a total of 208 months. Six episodes of peritonitis occurred in 4 patients without clinical evidence of any abdominal aortic graft infection. Three patients developed intermittent claudication and 2 died of myocardial infarct. A similar peritonitis and cardiovascular complication rate was observed in a control group of age- and sex-matched CAPD patients with no aortic prosthesis. We conclude that CAPD is feasible in patients with abdominal aortic prosthesis.