Treatment of immune nephropathies with high doses of immunoglobulins.

UNLABELLED: The present study presents the results from the application of high doses of gamma-globulin in the treatment of immune (idiopathic and satellite) glomerulopathies. MATERIALS AND METHODS: Twenty patients were treated. Of these 12 were with primary chronic glomerulonephritis, 7--with lupus nephritis and 1--with renal amyloidosis. All diagnoses were verified through a renal puncture biopsy. The following therapeutic scheme was used--85 mg/kg/body weight of gamma-globulin was applied intravenously three times a day every other day till reaching a total course dose of 250 mg/kg/body weight. All patients presented with nephrotic syndrome following conventional treatment with corticosteroids, anticoagulants and anti-aggregants. The blood cell count, the serum creatinine, creatinine clearance, 24 h diuresis and level of proteinuria were monitored. RESULTS AND DISCUSSION: 14 of the patients showed a complete clinical and laboratory remission. Four of them got an incomplete remission with a proteinuria of 2 g/24 h. No positive effect from the treatment was observed in 2 of the patients. All patients with lupus nephritis were influenced positively to a certain extent by the treatment applied. No serious side effects leading to therapy interruption were observed. CONCLUSIONS: 1. The treatment with high doses of immunoglobulin is a good alternative to the pulse immunosuppressive treatment of patients with idiopathic and lupus nephritides, manifested with a nephrotic syndrome and unaffected by a previous conventional immunosuppressive and anticoagulant therapy. 2. The results from the treatment with high doses of immunoglobulin are more pronounced in patients with lupus nephritides, which in turn raises the possibility for an earlier reduction of corticosteroid therapy and avoidance of its side effects. 3. Immunoglobulin therapy is an alternative in the management of nephrotic symptoms in cases with chronic renal failure where an immunosuppressive treatment is irrelevant.

Assessment of serum osteocalcine level in pre-dialysis patients with chronic renal failure.

UNLABELLED: The application of serum osteocalcine as a marker of osseous synthesis in patients with renal osteodystrophy is still disputable because of its predominantly renal excretion. The aim of the present study was to investigate the level of serum osteocalcine in pre-dialysis patients with chronic renal failure (CRF). MATERIAL AND METHODS: 47 patients aged 22-60 years (26 males and 22 females) with chronic renal failure were studied. 23 of them were stage I CRF patients (creatinine up to 353.6 mumol/l) and 24 were stage II and III CRF patients (creatinine up to 800 mumol/l). 35 healthy subjects (15 males and 20 females) were used as controls. Serum osteocalcine was measured by a radioimmunologic assay (ELSA-OSTEO-CIS, France). Serum creatinine, calcium, phosphorus and alkaline phosphatase were detected on a biochemical analyzer "Optima" (Kone Instruments, Finland) using the standard techniques recommended by IFCC. RESULTS: Serum osteocalcine was significantly elevated in patients with stage I CRF (45.61 +/- 7.75 ng/ml), compared to the control group (14.61 +/- 1.02, p < 0.001; u = 3.96). A significant increase was also found in patients with stage II and III CRF (120.48 +/- 15.96 ng/ml, p < 0.001; u = 4.22). No significant difference in osteocalcine level was found between male and female patients (83.77 +/- 15.09 vs. 94.52 +/- 16.88). 32 (68%) patients of the entire sample had osteocalcine above the reference values. These included 11 out of 23 patients with stage I CRF (47%) and 21 out of 24 patients with stage II and III CRF (87%). A moderately positive correlation was established between osteocalcine level and the duration of CRF (0.57), as well as between serum creatinine (0.39) and phosphorus (0.34). A moderately negative correlation was discovered between creatinine clearance (-0.42) and total serum calcium (-0.37). CONCLUSIONS: Serum osteocalcine could be used as a marker for bone synthesis in pre-dialysis patients with CRF. Our results indicate that more than 50% of the patients show evidence for renal osteodystrophy.

Influence of age, sex and body weight on renal osteodystrophy in predialysis patients with chronic renal failure.

UNLABELLED: The aim of the present investigation was to examine the influence of age, sex and body weight on osseous changes in pre-dialysis patients with chronic renal failure (CRF). 87 patients (44 males and 43 females) aged 18-60 years with CRF were studied. The levels of serum creatinine, total and ionized calcium, phosphorus, alkaline phosphatase, intact parathormone and serum osteocalcine were followed up. Body weight is presented as BMI. 47 of the patients were subjected to double X-ray absorptiometry of lumbar vertebra (Lunar) and 40 patients were examined by computed tomography osteometry. RESULTS: No reliable differences in the levels of biochemical parameters in male and female patients with the same degree of CRF were established. A tendency towards an increase in the level of intact parathormone and serum osteocalcine in women with both initial and advanced CRF was recorded. The BMI in patients with advanced CRF was lower as compared to those with initial CRF. Different stages of osseous changes were observed in 29 males (74.35%) and in 25 females (60.97%). A tendency for a higher frequency and severity of osseous changes in men aged up to 40 years was observed. After this age males and females were equally affected. A high positive correlation (r = 0.50) between BMI and the percentage of the normal Bone Mineral Density/Bone Mineral Content in females with CRF stage II and III was noticed. CONCLUSIONS: No significant difference in the frequency and severity of osseous changes in male and female uremic patients was observed. Bone changes were more frequent and pronounced in males up to 40 years of age, while this tendency reversed after the menopause. The higher body weight was beneficial for the osseous changes only in females with advanced CRF, while in all other patients no correlation with densitometric parameters was noticed.

Low protein diet and ketosteril in predialysis patients with renal failure.

UNLABELLED: After a short review of the contemporary understanding of amino acid supplementation to low protein diets in patients with uremia we present the results of administration of ketosteril in 20 low-protein-diet patients on such a diet. MATERIAL AND METHODS: Twenty patients (10 men and 10 women) with stable II and III stage chronic renal failure were assigned to a low protein diet (protein up to 40 g/day). Ketosteril (6 tablets a day) were added to the diet. Some of the basic markers of protein metabolism and nitrogen balance were followed. RESULTS: No evidence of deteriorated protein synthesis was found in the therapy thus administered. Serum urea and creatinine values did not change and even tended to decrease. Glomerular filtration was found to increase insignificantly more markedly in the patients with renal failure in the early stages. CONCLUSIONS: A low protein diet with increased content of essential amino acids and their keto-analogues does not deteriorate the nitrogen balance of patients with chronic renal failure. By adding essential amino acids and keto-analogues a normal protein metabolism is maintained in spite of the reduce intake of protein substances with the diet. Supplementation of the diet of chronic renal failure patients with essential amino acids and keto-analogues allows a considerable reduction of the protein intake to be achieved which brings about reduction of glomerular hyperfiltration which actually retards the progression of renal failure and improves its short-term prognosis.

Cyclosporin A in the treatment of patients with nephrotic syndrome.

OBJECTIVE: To present our experience in the treatment of conventional therapy refractory nephrotic syndrome with cyclosporin A. MATERIAL AND METHODS: The study sample included 22 patients (12 men, 10 women, aged 40.43 +/- 5.93 years). Twenty one patients were diagnosed histologically: 11 were with different histologic variants of chronic gtlomerulonephritis, 7 with lupus nephritis and 3 with renal amyloidosis. Sandimmun Neoral-Sandoz was given orally in a dose of 2-5 mg/kg/24 hours; mean duration of the course of treatment 41.4 +/- 12.4 days. In the course of treatment we followed quantitatively 24-hour proteinuria, diuresis, hematologic parameters, serum creatinine, transaminases, the fat profile, and creatinine clearance. RESULTS: The patients were allocated into 3 groups according to their response to treatment--in 5 patients (22.73%) it achieved complete clinical and laboratory remission, in 8 (36.36%)--partial remission and in 9 (40.91%) it failed. The 24-hour diuresis in the patients with complete and partial remission increased significantly during the third week of treatment (from 1212.5 +/- 114.7 to 2700 +/- 394.61, p < 0.05, t = 3.62). Proteinuria was reduced from 3.47 +/- 0.54 to 1.86 +/- 0.36 g/d (p < 0.05, t = 2.48) at the end of treatment. No substantial change in the antihypertensive therapy was necessary in any of the patients. There was no decline of the renal and liver functions. Neither allergic reactions nor serious side effects that may have caused discontinuation of treatment were observed. Complete or partial clinical and laboratory remission was achieved in 59.09% (13 patients) (confidence interval = 39.2%-78.9%, odds ratio = 0.95). Cyclosporin A therapy is an appropriate alternative in the treatment of refractory nephrotic syndrome in some of the immunologic glomerulopathies. The types of glomerulopathy that are best affected are minimal-change glomerulonephritis, some of the mesangioproliferative glomerulonephritis cases and some forms of lupus nephritis. No effect whatsoever was found in cases with renal amyloidosis.