Hypertension and progression of nephropathy in diabetic and non-diabetic chronic kidney disease patients.

BACKGROUND: Hypertension is associated with more rapid progression of chronic kidney disease. Several studies have shown that treating hypertension in patients with chronic kidney disease and proteinuria may attenuate the decline in glomerular filtration rate. STUDY OBJECTIVE: The study evaluates the prevalence of hypertension and its association with chronic kidney disease progression in patients without and with diabetic nephropathy. METHODS: Patients with CKD stage 2-4 were followed up by a nephrologist for 12-52 months. A total of 137 patients were included in the study, 70 with non-diabetic CKD and 67 with type 2 diabetes and diabetic nephropathy. Demographic and clinical parameters were recorded at initiation and during follow-up. Glomerular filtration rate was estimated by the Cockroft-Gault formula and progression of CKD by the slope of the estimated GFR decline. RESULTS: Out of 70 patients in the non-diabetic group, 34 were males, (mean age 50.37+/-12.2 years). Out of 67 diabetic patients, 30 were (males, mean age 57.8+/-8.4 years). 77% in the non-diabetic group had SBP above 140 mmHg. The higher SBP was associated with older age, (53.16+/-10.8 vs 40.9+/-12.2 years, p<0.0001). Diastolic blood pressure above 90 was present in 73%. Pulse pressure above 80 had 5.7% and was associated with older age (p<0.02). Progression of chronic kidney disease correlated inversely with age, and positively with diastolic blood pressure and proteinuria (p=0.005, p=0.019 and p=0.02 respectively). Multiple regression analysis showed that only younger age and higher proteinuria were predictive for chronic kidney disease progression (p=0.00002). 6% of pts in the diabetic group had SBP below 140, 19% between 140 and 160, and 75% above 160 mmHg. Diastolic blood pressure below 80 had only 6% of patients, between 80 and 90 had 37% and above 90 mmHg had 57%. Pulse pressure below 80 mmHg had 55% and it was correlated positively with age, p=0.009. Progression of chronic kidney disease in the diabetic group correlated positively with mean arterial pressure, systolic blood pressure and proteinuria, (p=0.017, 0.036 and 0.000000 respectively) and inversely with age (p=0.0003). Multiple regression analysis showed that proteinuria, age and SBP were the only predictors for chronic kidney disease progression in diabetics. CONCLUSION: Isolated systolic hypertension predominates the older age groups, proteinuria and age significantly correlate with GFR decline in both groups, and SBP is associated with more rapid progression of CKD in the diabetic patients.

Plasmaexchange in the treatment of myasthenia gravis associated with thymoma.

BACKGROUND: All patients with thymomatous Myasthenia Gravis (MG) should undergo early and total thymectomy, but controversy abounds in the choice of chronic immunosuppressive agents. The value of plasmaexchange (PE) in MG has been clearly established in preoperative preparation and treatment of myasthenic crisis. Whether PE may be used in the chronic long-term therapy of patients with thymomatous MG in addition to conventional immunosuppressive agents and cholinesterase inhibitors is yet to be answered. CASE HISTORY: We present a 40-year old woman with an 11 year history of MG. Thymectomy was done during the first year of the disease and the histopathologic finding was thymoma. To sustain clinical remission after thymectomy she continued with immunosuppression with methylprednisolone and cyclosporin A (or azathioprine) in addition to cholinesterase inhibitors. Despite the almost continuous immunosuppression, the disease course continued with fluctuating myasthenic weakness which few times progressed to myasthenic crisis requiring mechanical ventilation. During myasthenic crisis we performed 6-8 plasmapheresis at 2-3 day intervals in addition to conventional immunosuppressive therapy. The disease rapidly worsened in January 2000 and we started with intermittent plasmapheresis (3-6 procedures at 2-3 day intervals, every 6-8 weeks) in order to sustain remission. With this therapeutic protocol, during 20 months follow-up we managed to prevent myasthenic crisis and to avoid ventilatory support. CONCLUSIONS: Plasmaexchange could be used as a successful and safe therapeutic tool in chronic long-term therapy in addition to conventional immunosuppressive agents to sustain remission in patients with MG. This is particularly important in the treatment of patients with thymomatous MG because they have an increased frequency of myasthenic crisis and often respond poorly an to immunosuppression with steroids or other immunosuppressants.

Living related renal transplantation--the use of advanced age donors.

AIM: Efforts to increase the donor pool and available organs included some unconventional kidney transplantation. One of these was including elderly donors for both, living and cadaver kidney transplantation. The aim of the study was to review our single centre experience with living donor transplants from elderly advanced age donors. PATIENTS AND METHODS: During a period of 7 years, 71 living related renal transplantations were performed. Twenty-six of them were over 65 (mean 69+/-4, range 65 to 81), but 10 were over 70 years of age. The survival rate was compared with 45 transplants from younger donors (mean age 51+/-6, range 24 to 59). The cold and warm ischemia time, the preservation procedure and blood vessels anastomosis time were comparable in both donor groups. The immunosuppression included sequental quadruple protocol with ATG, PRED, AZA and CyA replacing ATG after 7 days. The triple drug (AZA, PRED, CyA) maintenance therapy was applied to all recipients. RESULTS: Kaplan-Meier 1-, 3- and 5-year graft survival was 88.0%, 79.2% and 68%, respectively, for advanced donor age group and 90.2%, 82.4% and 74%, respectively, for younger donor group. The difference was slightly statistically significant (p < 0.05). In 6 patients who received graft from elderly donors, a delayed graft function was observed, whereas only in one in the younger donor group. CONCLUSION: Despite the worse results in the elderly donors' transplants, we consider the advanced age donors as an important source of kidneys contributing to solving the actual organ shortage, especially in our region.

Plasmapheresis in treatment of acute oligoanuria in crescentic glomerulonephritis.

Plasmapheresis therapy can provide an approach in the treatment of crescentic glomerulonephritis by mechanically removing nephritogenic factors from the circulation, both antiglomerular basement membrane antibodies and circulating immune complexes as well as antineutrophil cytoplasmic antibodies (ANCAs). We present our experience with plasmapheresis treatment in patients with acute oligoanuria caused by crescentic glomerulonephritis. We used membrane plasmapheresis to treat 11 patients with crescentic glomerulonephritis with more than 80% crescent formation on biopsy and with acute onset of the disease and acute oligoanuria. The immune complex form of the disease was documented in 7, the antiglomerular basement membrane antibodies mediated (anti-GBM) form in 2, the ANCA-associated form in 1 case, and the recurrent anti-GBM form in 1 patient. Plasmapheresis was performed 2-3 times weekly using Bellco BL 500 and Gambro 2000 PF plasma filters. The total number of plasma exchanges (2,000-2,200 ml each) for each patient was 5-9. The treatment was associated with steroids and cyclophosphamide. The improvement of renal function with the start of diuresis and significant decrease of creatinine from the range of 786-1,301 microM at the start of the treatment was noted in 5 of the 11 patients. The duration of remission without hemodialysis was 6-12 months. Treatment with plasmapheresis in cases with recurrent anuria was without benefit. We can conclude that plasmapheresis can delay end-stage renal failure in cases with acute onset of crescentic glomerulonephritis.

Autonomic nervous system dysfunction and volume nonresponsive hypotension in hemodialysis patients.

Studies were conducted in 9 dialysis patients with volume-nonresponsive hypotension, 6 dialysis patients with volume-responsive hypotension and in 10 normal subjects in an effort to evaluate the role of dysfunction of the autonomic nervous system (ANS) in the genesis of volume-nonresponsive hypotension. ANS function was evaluated by the Valsalva maneuver, handgrip exercise, and by the response of heart rate and blood pressure to change of posture from a supine to a standing position. Patients with volume-nonresponsive hypotension displayed significant derangements in the function of ANS as compared to normal subjects and to patients with volume-responsive hypotension. Data show that dysfunction of ANS plays an important role in the genesis of volume-nonresponsive hypotension in dialysis patients.