Clinical indicators which necessitate renal biopsy in type 2 diabetes mellitus patients with renal disease.

BACKGROUND: The diagnosis of diabetic nephropathy (DN) is always based on clinical grounds. However, the necessity for renal biopsy of type 2 diabetes mellitus (DM) patients with renal disease to establish the diagnosis remains unclear. METHODS: We retrospectively studied 50 type 2 diabetic patients performed with renal biopsy between December 2002 and December 2006. Based on renal pathology, patients were divided into group I: DN alone, group II: non-diabetic renal disease (NDRD) superimposed on DN and group III: isolated NDRD. Factors like DM > 10 years, retinopathy, previous minimal proteinuria without sudden heavy proteinuria, no glomerular haematuria and non-small-sized kidney were collected to evaluate their sensitivity, specificity, positive predictive value and negative predictive value for prediction of DN or NDRD in type 2 diabetic patients. RESULTS: Group I consisted of 24 patients, group II 15 patients and group III 11 patients. Acute interstitial nephritis was the most prevalent second renal disease in our study. Sensitivity and specificity for group I was poor in five features except high sensitivity in no sudden heavy proteinuria (83.3%) and non-small-sized kidney (95.8%). Comparable retinopathy, sudden heavy proteinuria and haematuria (p > 0.05) was noted between the three groups. Significant biopsy indicators included higher serum albumin, lower urinary daily protein excretion and lower 24-h creatinine clearance (C(Cr)) rate (p < 0.05). CONCLUSION: Our study demonstrated that DM > 10 years and retinopathy did not exclude NDRD in type 2 DM patients, and need for renal biopsy. Higher serum albumin, lower urinary daily protein and 24-h C(Cr) were indicative for biopsy to exclude NDRD.

A crossover comparison of intermittent oral and intravenous administration of calcitriol on the parathyroid hormone concentration in hemodialysis patients.

Active vitamin D3 is used commonly in hemodialysis patients with severe secondary hyperparathyroidism. Intermittent pulse therapy with active vitamin D3, either orally or intravenously, has been proven to be effective with less hypercalcemic complication than daily oral vitamin D3. We therefore designed a three-phase crossover study to compare the effect of oral and intravenous calcitriol given by intermittent pulse therapy. Thirteen regular hemodialysis patients were enrolled. In phase 1, 1 microgram calcitriol was given orally at bedtime twice a week for 4 months, and then was stopped for 1 month to washout. In phase 2, 1 microgram calcitriol was given intravenously immediately after hemodialysis twice a week for 2 months, and then was stopped for 1 month to washout. Phase 3 repeated phase 1 but lasted for only 2 months. Calcium carbonate was given as the sole phosphate-binding agent if there was no severe hypercalcemia or hyperphosphatemia. Serum parathyroid hormone (PTH) levels decreased dramatically in all three phase therapies. As a result, mid-molecule PTH decreased from 5.71 +/- 2.65 to 3.97 +/- 2.92 ng/ml in phase 1 (p = 0.010), from 4.34 +/- 3.39 to 1.98 +/- 1.76 ng/ml in phase 2 (p = 0.007), and from 2.72 +/- 0.97 to 1.67 +/- 0.71 ng/ml in phase 3 (p = < 0.001). However, there was no difference in the calculation of the PTH declination among the three phases (32, 50 and 42%, respectively). The incidence of hypercalcemia was higher in using calcitriol than without it (23 vs. 6%, p < 0.05), but there was no difference between intravenous and oral calcitriol (35 vs. 19%). The above results suggested that both oral and intravenous calcitriol, with lower doses and intermittent pulse therapy, were equally effective in controlling secondary hyperparathyroidism. The incidences of hypercalcemia were similar in both oral and intravenous calcitriol using 3.5 mEq/1 dialysate calcium concentration and calcium carbonate as the chief phosphate binder.

Adult primary IgA nephropathy and common viral infections.

Serum samples obtained from 69 histopathologically proven IgA nephropathy (IgAN) patients and 563 healthy controls were examined to evaluate the association between IgAN and common viral infections. Antibody titres to cytomegalovirus (CMV), herpes simplex virus (HSV), Vericella-Zoster virus (VZV), Influenza A (Inf. A) and Influenza B (Inf. B) viruses were determined, using a complement fixation test. The viral antibody titres were considered to be positive with dilutions of 1:8 or greater except for Epstein-Barr virus (EBV), studied using immunofluorescence, which was considered to be positive with dilutions of 1:10 or greater. The positive rate of Inf. B antibody in IgAN patients was significantly lower than that in controls. The frequency of positive CMV antibody titres was higher than for controls, but with only borderline statistical significance (P = 0.059). The frequency of positive CMV and Inf. B titres was compared by age in IgAN patients and controls. but showed no statistically significant difference. Comparisons of percentage distributions at each antibody dilution level to the common virus of IgAN patients and controls, but showed no statistically significant difference. Comparisons of percentage distributions at each antibody dilution level to the common virus of IgAN patients and controls were made; however, none showed a statistically significant difference. In conclusion, no absolutely higher frequency of positive antibody titres for common viruses was demonstrated in IgAN patients in this study.

Quality of life assessment in end-stage renal disease patients with maintenance hemodialysis therapy.

This is a pilot study assessing the quality of life for a total of twenty uremic patients being treated with maintenance hemodialysis. It includes eight males and twelve females with a mean age of fifty three years, having been on hemodialysis for an average of forty-five months (from five to 143 months). The quality of life study was obtained from a structured questionnaire, which contained 10 categories including: sense of well-being, sense of mood, family life, marriage life, neighborhood relationships, friend relationships, working ability, job condition, intelligence condition and life satisfaction. Each category consisted of 3 to 5 items, with a maximum score of 100 points. Among these 20 patients, the highest score on the quality of life study is marriage life with 80.4 +/- 10.0 points, the lowest score is life satisfaction with 59.7 +/- 15.3 points. There was no significant difference in the scores of quality of life between different sex groups. The scores in the sense of well-being group greater than 60 years were lower than those less than 60 years with a significant difference (P less than 0.05). A significant difference was also found in both the sense of well-being and sense of mood depending on the duration of hemodialysis therapy. Those who received hemodialysis therapy more than 3 years produced better scores in the sense of well-being and sense of mood category than those who received hemodialysis less than 3 years.

Assessment of proteinuria by using the protein/creatinine ratio of single-voided urine.

Quantitative 24-hour urine protein excretion is used in the diagnosis, the monitoring of therapeutic effects and the prognosis of renal disease. However, this method is time-consuming, cumbersome and often inaccurate. Many studies have shown that the single voided urine protein/creatinine (Pr/Cr) ratio relates well with 24-hour urine protein excretion and can be substituted for evaluating some conditions. In our study, 41 patient with renal disease (25 men, 16 women) with a mean age of 43 years (range, 20-79 years), not only collected 24-hour urine, but also collected single voided urine at four different times. There was an excellent correlation between 24-hour urine protein excretion and the single voided urine Pr/Cr ratio at various degrees of creatinine clearance and ranges of proteinuria. The highest correlation was found in urine specimens collected at 16:00 hours with a correlation coefficient (r) of 0.91. Other urine specimens also showed a good relation with a correlation coefficient of above 0.80. The creatinine clearance (Ccr) greater than or equal to 70 ml/min group showed a better relationship than the Ccr less than 70 ml/min group. The proteinuria more than 1.0 g/day group also showed a better relationship than the group with proteinuria of less than 1.0 g/day. However, these differences were not statistically significant. No significant differences between the different age groups or sexes, using the single voided urine Pr/Cr ratio to estimate the 24-hour urine protein excretion were found. It is concluded that the single voided urine Pr/Cr ratio correlates highly with 24-hour urine protein excretion and could be an alternative means for disease monitoring and screening.