Robert T. Mossey

Renal Vascular Disease Causing End-Stage Renal Disease, Incidence, Clinical Correlates, and Outcomes: A 20-Year Clinical Experience

In the United States, the incidence of end-stage renal disease to hypertension has increased sharply over the last 8 years, especially in elderly white dialysis patients who demonstrate very poor survival rates. The 5-year survival rates were near 20% for patients 65 to 74 years old and 9% for those > or = 75 years of age. Our program experienced a sharp increase in cases of end-stage renal disease due to renal vascular disease after 1982. Renal vascular disease was characterized clinically in 83 of 683 dialysis patients either by angiography or asymmetric kidney size in patients with evidence of systemic atherosclerosis, hypertension, insignificant proteinuria, and a benign urinary sediment. The median age was 70 years, with 84% of the patients being older than 61 years. These patients had 56% 2-year, 18% 5-year, and 5% 10-year survival rates, which are quite similar to the 1992 US Renal Data System data. Patients with renal vascular disease have a significantly worse prognosis than other diagnostic groups, most likely due to their older age, underlying vascular disease, and coronary artery disease. We feel that a significant number of elderly white hypertensive patients described in the 1992 US Renal Data Service report have renal vascular disease as a cause of end-stage renal disease, highlighting the need to establish correct renal diagnoses. Hypertension should not be the end-stage renal disease diagnosis in elderly white hypertensive patients if clinical criteria suggest a diagnosis of renal vascular disease.

Listeriosis in patients with long-term hemodialysis and transfusional iron overload

Over a four-year interval, four cases of Listeria monocytogenes bacteremia were observed among a population of 127 patients undergoing long-term hemodialysis. None had an underlying malignancy or were recently receiving immunosuppressive medications. A search for a predisposing factor suggested a relationship to transfusional iron overload. Although still a rare infection, the possibility of listeriosis must be kept in mind by physicians caring for patients undergoing hemodialysis, particularly those requiring blood transfusions.

Serum immunoreactive erythropoietin levels in patients with polycystic kidney disease as compared with other hemodialysis patients.

Serum erythropoietin levels were randomly collected and measured by a sensitive radioimmunoassay in a hemodialysis population. For analysis, the patients were divided into two groups: those with polycystic kidney disease and those with other kidney diseases. In 12 polycystic kidney disease patients, serum erythropoietin was 22.6 +/- 2.4 mU/ml, hematocrit 29.7 +/- 1.0%, and absolute reticulocyte count 17.0 +/- 4.1 X 10(4)/microliters. In 24 other kidney disease patients, serum erythropoietin was 12.4 +/- 0.7 mU/ml, hematocrit 21.2 +/- 0.8%, and reticulocyte count 7.5 +/- 1.5 X 10(4)/microliters. Serum erythropoietin was 18.5 +/- 0.7 mU/ml in normal controls. Polycystic kidney disease patients manifested higher hematocrit, reticulocyte counts, and serum erythropoietin levels when compared to other kidney disease patients (p less than 0.01). The data suggest (1) an inappropriately low serum erythropoietin level for the severity of anemia in uremic hemodialysis patients and (2) that greater availability of erythropoietin results in more effective erythropoiesis, even in the uremic environment.

Comparison of methods for measuring albumin in peritoneal dialysis and hemodialysis patients

Serum albumin levels have been used extensively as an indicator of morbidity in patients with end-stage renal disease. Recent evidence suggests that albumin levels vary considerably in hemodialysis patients depending on the laboratory method used, but formulas for comparing albumin values by different methods have not been developed. We prospectively evaluated the effects of measuring albumin by three different methods on paired plasma and serum from 23 patients on continuous ambulatory peritoneal dialysis (CAPD) and 53 patients on chronic maintenance hemodialysis. Plasma and serum gave virtually identical results independent of method used. In CAPD patients, bromcresol green and nephelometry gave nearly identical albumin measurements through the entire range of plasma levels. In contrast, bromcresol purple gave values that were 9.9 percent +/- 1.3 percent lower (P < 0.05). Hemodialysis patients showed a similar pattern with close agreement between bromcresol green and nephelometry, but bromcresol purple gave lower albumin levels by 19.1 percent +/- 1.2 percent (P < 0.05). The discrepancy in albumin in CAPD patients was significantly less than in the hemodialysis patients (P < 0.05), suggesting that there were fewer interfering substances in the blood of CAPD patients than in hemodialysis patients. Linear regression analysis was used to develop simple formulas for comparing albumin values obtained by the different methods in CAPD and hemodialysis patients. These studies show that values for albumin in blood vary significantly by method of analysis in CAPD and hemodialysis patients. By the use of these formulas, it becomes possible to compare albumin values between centers using different methods for the purpose of quality management.

PLASMA ANGIOTENSINS IN ANEPHRIC HUMANS : EVIDENCE FOR AN EXTRARENAL ANGIOTENSIN SYSTEM

The recent identification of messenger RNAs encoding renin and angiotensinogen in nonrenal tissues raises the possibility that angiotensins (Ang) may be formed extrarenally and released into the plasma. The aim of this investigation was to test the hypothesis that plasma angiotensins may originate from extrarenal sites. Twenty-five patients with chronic renal failure (six surgically anephric and 19 with kidneys in situ) were studied prior to and after a standard hemodialysis treatment. Angiotensins were measured by extraction. high-pressure liquid chromatography (HPLC) separation, and radioimmunoassays. In patients with kidneys present, plasma renin activity (PRA) was 3.1 ± 0.7 ng Ang I/ml/h. Ang I, Ang II. and Ang III levels were 70.6 ± 9.0. 44.0 ± 9.8, and 20.2 ± 3.6 pg/ml, respectively. In all six anephric patients PRA was undetectable ±0.1 ng Ang I/ml/h). Ang I and Ang II were detected in four anephric patients, and Ang III was detected in three anephric patients (Ang I, (10.4 ± 5.2; Ang II, 2.6 ± 1.2; Ang III. 2.7 ± 1.5 pg/ml, n = 6). At the completion of dialysis treatments, which reduced body weight by 2.5 ± 0.2 kg in patients with kidneys and by 2.1 ± 0.3 kg in anephric patients, there were no significant changes in PRA or plasma angiotensins in either group. Reduction in body water by hemodialysis did not increase the concentration of angiotensins in plasma. We conclude that there is a small but definite component of plasma angiotensin that is produced by nonrenal mechanisms and that is not stimulated by volume depletion.

Minimal change nephropathy associated with sclerosing mesenteritis

A 65-year-old man with sclerosing mesenteritis developed the nephrotic syndrome. Percutaneous renal biopsy revealed classical histologic findings of minimal change nephropathy with a mild interstitial nephritis. Immunomodulation with prednisone led to a rapid and complete remission of the proteinuria but did not alter the course of the underlying sclerosing mesenteritis. The association of lymphomatous and nonlymphomatous neoplasms with minimal change nephropathy has been well-described. Our review of the literature indicates a parallel association of malignant lymphoma with sclerosing mesenteritis and a variety of disorders that constitute a spectrum of disease. The occurrence of this histopathologic form of renal injury and therapeutic response in the setting of a known lymphoreticular disorder suggests a role for a generalized alteration in cell-mediated immunity and not a tumor-induced elaboration of a factor(s) that directly damages the glomerular filtration barrier.

Kappa-chain nephropathy associated with plasma cell leukemia.

A 45-year-old-woman had plasma cell leukemia (PCL) and mild renal insufficiency. Renal biopsy findings were compatible with kappa-chain nephropathy. Our case adds PCL to the list of plasma cell dyscrasias associated with kappa- and/or lambda-chain nephropathy.• A 45-year-old-woman had plasma cell leukemia (PCL) and mild renal insufficiency. Renal biopsy findings were compatible with κ-chain nephropathy. Our case adds PCL to the list of plasma cell dyscrasias associated with κ- and/or λ-chain nephropathy.