[Hemodiafiltration with endogenous reinfusion (HFR): biochemical and gas-analytical analysis of the "regenerated" ultrafiltrate]. / Emodiafiltrazione con reinfusione endogena (HFR): analisi biochimica e gas-analitica dell'ultrafiltrato ''rigenerato''.

PURPOSE: During convective techniques, a replacement fluid (R) is necessary that is sterile and pyrogen-free. Using an integrated absorption cartridge, the ultrafiltrate (UF) can be "regenerated"; and used as R. This method is hemodiafiltration with reinfusion (HFR). This study aimed to evaluate the real UF composition after "regeneration" by the resin-charcoal integrated absorption cartridge. METHODS: In eight uremic patients treated with HFR the UF was evaluated at 5, 15, 30, 60, 120, 180 and 240 min after HFR start at the inlet and the outlet resin-charcoal cartridge using the following parameters: urea, creatinine (Cr), uric acid, phosphates, glucose, Beta 2-microglobulin (beta2-m), Na+, K+, Ca++, pH, pCO2, and HCO3-. RESULTS: Blood (%): urea -61.2 +/- 9.7; Cr -55.4 +/- 8.1; uric acid -69.8 +/- 9.3; phosphates -31.8 +/- 15.7; glucose -8.4 +/- 20.5; Beta2-m -60.3 +/- 11.1; pH +0.76 +/- 0.58; pCO2+ 3.3 +/- 8.5; HCO3- +18.1 +/- 13.5. In UF (outlet vs inlet): urea was not adsorbed; Cr and uric acid were adsorbed; phosphates were not adsorbed; glucose was partially adsorbed (only in the 1st 90 min); Beta2-m was almost totally adsorbed; Na+ and K+ were not adsorbed; for pH, pCO2, and HCO3- there were no significant variations between the inlet and the outlet. CONCLUSIONS: HFR seems to be an easy-to-perform hemodiafiltration (HDF) technique, capable of resolving the typical problems of availability and the production of sterile and ultrapure reinfusion solution.

Cephotaxime-associated allergic interstitial nephritis and MPO-ANCA positive vasculitis.

We report a case of reversible acute renal failure after cefotaxime treatment in a patient affected by non-Hodgkin lymphoma. Renal biopsy showed necrotizing vasculitis associated with eosinophil-rich interstitial inflammatory infiltrates and patchy infiltrates of CD20+ lymphoid cells. High serum p-ANCA titers were also detected. Drug withdrawal was closely related with recovery of renal function and disappearance of ANCA. Acute renal failure therefore represented a consequence of ANCA-mediated renal vasculitis and acute interstitial nephritis related to cefotaxime treatment.

Spatial arrangement of subepithelial deposits in lupus and nonlupus membranous nephropathy.

Subepithelial deposits are a common feature of idiopathic membranous glomerulonephritis (MGN) and lupus membranous glomerulopathy (LMGN). We investigated the spatial arrangement of immunoglobulin G (IgG) and C3c fraction of complement (C3c) in the immune deposits of MGN and LMGN with confocal laser scanning microscopy to correlate specific patterns of IgG-C3 interactions with different diseases. Ten patients with MGN and 8 patients with LMGN (World Health Organization class VB) were selected. A determination of the spatial arrangement of the two fluorochromes and the glomerular area occupied by each fluorochrome was performed for each case. Our results showed MGN specimens have an orderly distribution of IgG and C3c, with each deposit showing an outer ring of sole IgG. IgG was always more abundant than C3c (1,619 +/- 271 v 790 +/- 105 micrometer(2), P = 0.002). In LMGN, IgG and C3c were haphazardly arranged, with deposits made of C3c only and an outer ring of IgG only rarely present. Also, the relative amounts of the two antigens were variable, and two groups could be identified (group 1: IgG, 5,515 +/- 1,179 micrometer(2) v C3c, 4,810 +/- 1,174 micrometer(2); P = 0.02; group 2: IgG, 3,358 +/- 658 micrometer(2) v C3c, 4,047 +/- 740 micrometer(2); P = 0.03). Our data show that diffuse IgG capping of the subepithelial immune deposits is diagnostic of MGN. The absence of an orderly three-dimensional arrangement in LMGN deposits (ie, outer ring of IgG) is likely to render active complement components more readily available to inflammatory activities.

Sepsis-induced acute renal failure: unusual clinical presentation.

We report 4 cases of sepsis-induced acute renal failure (ARF) with peculiar clinical presentation in which the renal biopsy was the only clue to a correct diagnosis. We observed 66 cases of ARF in a 4-year experience. Seven (11%) were associated with sepsis; in 3 of these (4.5%) a shock was present. Clinical picture of the remaining 4 cases (6%) was characterized by ARF with oligoanuria and proteinuria (> 2 g/L), fever, resistant to antimicrobial therapy, negative hemocultures and severe systemic symptoms. Such a presentation could suggest a non-infectious systemic disease; renal biopsies were carried out. Histological findings consisted of microabscesses of variable size in the interstitium and within the tubular lumina. A full-dose, broad-spectrum, i.v. antimicrobial therapy was started, with favourable outcome and recovery of renal function. Our clinical experience points out that the clinical picture of ARF in course of sepsis may be variable and that its relationship with septicaemia could not be readily discernible.

Impact of recombinant human erythropoietin treatment on left ventricular hypertrophy and cardiac function in dialysis patients.

The results of anemia correction by recombinant human erythropoietin (rHuEPO) therapy with regard to cardiac function and left ventricular hypertrophy in dialysis patients are controversially discussed. The aim of the study was to assess the effects of therapy rHuEPO on cardiac morphology and function in dialysis patients. We studied 11 clinically stable hemodialysis patients with severe renal anemia (hematocrit <27%) and increased left ventricular mass index (LVMi) with no history of coronary or valvular heart disease, systemic disease, severe hyperparathyroidism, hypertension stage 2 or higher, transfusion-dependent anemia, and concurrent rHuEPO treatment. The patients were treated with rHuEPO administered subcutaneously once or twice weekly at a mean dose of 80 +/- 31 IU/kg week until the hematocrit was >30% and underwent a complete Doppler echocardiographic study at baseline and at follow-up (after 12.2 +/- 2.9 months). At follow-up, ejection fraction and fractional shortening significantly increased from 62.7 +/- 13.8 to 67.8 +/- 9. 7% (p < 0.05) and from 35.5 +/- 9.8 to 39.4 +/- 7.1% (p < 0.05), respectively, whereas mean velocity of circumferential fiber shortening demonstrated a trend towards amelioration from 1.18 +/- 0. 23 to 1.27 +/- 0.27 circ/s (n.s.). LVMi and morphological data remained unchanged throughout the study. Nevertheless, LVMi changes showed two different behaviors with respect to baseline values: in 6 patients with higher baseline values, LVMi decreased from 229 +/- 36 to 191 +/- 45 g/m2 (p < 0.05), while it worsened in 5 patients with less marked LVMi, increasing from 141 +/- 32 to 186 +/- 40 g/m2 (p < 0.05). Our data demonstrate that partial correction of renal anemia with rHuEPO therapy seems to improve cardiac performance and to induce a regression of left ventricular hypertrophy, particularly in patients with greater baseline hypertrophy, ultimately confirming the multifactorial pathogenesis of left ventricular hypertrophy.

Systemic lupus erythematosus with membranous glomerulonephritis and uterine vasculitis.

We report a case of lupus vasculitis with uterine localization and concurrent membranous nephropathy. Immunofluorescence study suggested the occurrence of an immune complex nephropathy and a pauci-immune pathogenesis of vasculitis. Our case points out the event of tissue damage in two organs mediated by different pathogenetic mechanisms. In addition, uterine vasculitis without pregnancy may be observed in patients with systemic lupus erythematosus nephritis.