Factors associated with poor outcomes in patients with lupus nephritis.

The objective of this study was to identify the factors associated with important clinical outcomes in a case-control study of 213 patients with lupus nephritis. Included were 47% Hispanics, 44% African Americans and 9% Caucasians with a mean age of 28 years. Fifty-four (25%) patients reached the primary composite outcome of doubling serum creatinine, end-stage renal disease or death during a mean follow-up of 37 months. Thirty-four percent African Americans, 20% Hispanics and 10% Caucasians reached the primary composite outcome (P < 0.05). Patients reaching the composite outcome had predominantly proliferative lupus nephritis (WHO classes: 30% III, 32% IV, 18% V and 5% II, P < 0.025) with higher activity index score (7 +/- 6 versus 5 +/- 5, P < 0.05), chronicity index (CI) score (4 +/- 3 versus 2 +/- 2 unit, P < 0.025), higher baseline mean arterial pressure (MAP) (111 +/- 21 versus 102 +/- 14 mmHg, P < 0.025) and serum creatinine (1.9 +/- 1.3 versus 1.3 +/- 1.0 mg/dL, P < 0.025), but lower baseline hematocrit (29 +/- 6 versus 31 + 5%, P < 0.025) and complement C3 (54 +/- 26 versus 65 + 33 mg/dL, P < 0.025) compared to controls. More patients reaching the composite outcome had nephrotic range proteinuria compared to controls (74% versus 56%, P < 0.025). By multivariate analysis, CI (hazard ratio [95% CI] 1.18 [1.07-1.30] per point), MAP (HR 1.02 [1.00-1.03] per mmHg), and baseline serum creatinine (HR 1.26 [1.04-1.54] per mg/dL) were independently associated with the composite outcome. We concluded that hypertension and elevated serum creatinine at the time of the kidney biopsy as well as a high CI are associated with an increased the risk for chronic renal failure or death in patients with lupus nephritis.

Obstructive vs nonobstructive dilatation of the renal collecting system in children: distinction with duplex sonography.

OBJECTIVE: The resistive index in cortical or arcuate renal arteries of children was calculated to determine whether obstructive uropathy could be differentiated from nonobstructive dilatation. SUBJECTS AND METHODS: Kidneys (n = 176) were prospectively evaluated by using duplex Doppler sonography in patients 3 days to 20 years old. Obstruction was confirmed by renography with furosemide and/or by surgery. RESULTS: The normal resistive index was 0.57 +/- 0.06 and the normal difference in resistive indexes between kidneys was 0.03 +/- 0.02 (n = 15). Abnormal values indicative of ureteropelvic junction obstruction were defined as the normal mean +/- 2 SD (i.e., a resistive index of > or = 0.70 plus a difference in resistive indexes between kidneys of > or = 0.08). Patients with unilateral dilatation and obstruction at the ureteropelvic junction (n = 20) had a mean resistive index of 0.77 +/- 0.05 and a difference in resistive indexes between kidneys of 0.16 +/- 0.05 (p < .001 compared with patients with normal kidneys and p < .001 compared with patients with unilateral dilatation without obstruction). Patients with unilateral dilatation but without obstruction (n = 16) had a mean resistive index of 0.63 +/- 0.06 and a difference between kidneys of 0.06 +/- 0.04 (values within normal limits). The positive and negative predictive values of the obstruction criteria for unilateral collecting system dilatation were 95% and 100%, respectively. After successful surgical correction of ureteropelvic junction obstruction (n = 29), patients had a normal mean resistive index of 0.61 +/- 0.05 and a normal difference between kidneys of 0.03 +/- 0.03. Five patients examined both before and after surgery showed a statistically significant drop in the resistive index of the obstructed kidney (0.75 +/- 0.03 to 0.65 +/- 0.05, p < .05) after surgery and a small rise in the resistive index of the contralateral kidney (0.56 +/- 0.04 to 0.63 +/- 0.04, p < .02). CONCLUSION: The resistive index appears to be an effective parameter for the evaluation and follow-up of unilateral obstructive or nonobstructive ureteropelvic junction dilatation in children.

Percutaneous renal biopsy in infants and young children.

Records of 55 percutaneous renal biopsies performed in 53 children aged 5 days to two years were reviewed. Radiographic or ultrasound imaging techniques were not utilized during the biopsy procedure. Forty-nine of 55 biopsy attempts yielded sufficient tissue for histologic evaluation (89.1%). Transient gross hematuria not requiring intervention was the sole complication and was noted in 6 of 55 biopsy attempts (10.9%). Percutaneous renal biopsy can be performed safely in very young children and the success of the procedure is comparable to that in older children.