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.

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.

Epoetin-beta (Recormon-Roche) in the treatment of renal anemia in patients with chronic renal failure.

UNLABELLED: In the study a clinical assessment is made of the results of treatment of patients with renal anemia by epoetin-beta. MATERIAL AND METHODS: Thirty two patients (22 women, 10 men) with chronic renal failure and anemia, ranging from 18 to 77 years of age (mean age 46.29 +/- 5.84), were recruited for the study. All patients underwent treatment with epoetin-beta (Recormon, Boehringer-La Roche). The criterion for inclusion in the study was presence of severe anemia (HGB < 90 g/l). Extrarenal causes for the anemia were excluded in all patients. The main treatment objective was to increase hemoglobin to 100-120 g/l. All patients received concomitant iron supplementation at constant control of the iron status. The predialysis patients were administered iron perorally (200 mg/day) while the patients on chronic hemodialysis were given iron parenterally (intravenously) (Venofer, 100 mg/day). RESULTS: Anemia was significantly corrected. Hemoglobin level rose significantly from 77.15 +/- 2.32 g/l before treatment to 110.71 +/- 6.25 g/l at the end of month three. It remained less than 100 g/l for the time of study only in one patient. Neo-Recormon had a considerable positive effect on the overall condition of patients. No significant changes were found in the rate of progression of renal failure nor were there any marked side effects and intolerability to the drug observed. CONCLUSIONS: Anemia was significantly corrected in the renal anemia patients treated with epoetin beta. In predialysis patients iron supplementation can be effectively administered orally. If given in high doses (more than 4000 IU/kg), epoetin-beta can cause rapid increase of the hematologic parameters, especially in the initial phase of treatment; this affects adversely arterial pressure which necessitates changes in the antihypertensive therapy. Erythropoietin therapy reduces and even eliminates the need of transfusion in patients with chronic renal anemia.

Acute renal failure--etiologic and therapeutic considerations. A five-year experience at a single institution.

In the present study we highlight the epidemiology, etiologic spectrum, and evaluation of ARF in adults. We then expand on the pathophysiologic mechanisms of renal failure and discuss the rationale for current therapeutic strategies in ARF patients. A total of 79 patients (45 male, female 34), aged 18-75 years (median age 51.2 +/- 17.7 years) with acute renal failure were studied in 5 years (January 1990 through October 1995). Emergency hemodialysis sessions following an acute anuric episode were instituted in 39 cases (49.3% of all patients). The median number of hemodialysis procedures per patient treated at our institution was 3.2 +/- 1.9. The total number of acute interstitial nephritis-associated ARF was 40. In 30 of them (75%) the acute renal insult included a combination of several therapeutic antimicrobial agents, in 2 cases (5%) ARF followed the administration of nonsteroidal anti-inflammatory drugs, in 1 (2.5%) it resulted from a combined therapeutic regimen and in the remaining 5 (12.5%) from the application of a single drug. Acute interstitial nephritis developed in 2 patients following a viral infection. In the hemodialysis-treated ARF group 12 patients (29.77%) had interstitial nephritis and 2 patients (5.13%) presented with renal impairment for an unspecified period of time preceding the development of overt ARF. In a subset of this group of patients, ARF occurred in 7 patients (17.95%) following an urologic intervention, in 8 patients (20.51%) as a consequence of thermal or mechanical trauma or intoxication and in 3 cases (7.69%) it resulted from fever of unknown origin. Three patients with postoperative peritonitis and 4 other (10.26%) with postoperative complications were encountered in our series. No cases of septic abortion-related or obstetric-related ARF were recorded. 92.3% of all hemodialysis-treated patients seen at our Institution had received a combination of antibiotics and only 2 patients had been pre-treated with a single antimicrobial agent. Our results underscore the strong tendency towards diversity in the etiologic spectrum of clinical entities causing ARF and the increase in the number of acute interstitial nephritis. These factors highlight the importance of precise dosing and administration of drugs, especially antibiotics, as well as the duration of antibiotic treatment.