ANCA-associated glomerulonephritis in the very elderly.

Antineutrophil cytoplasmic autoantibody (ANCA)-associated pauci-immune glomerulonephritis (GN) is the most common finding in very elderly patients biopsied for acute kidney injury. Appropriate treatment strategies in this age group are currently undefined since it is unclear whether the benefits of immunosuppression exceed the risks. We retrospectively evaluated a cohort of 78 cases of biopsy-proven pauci-immune GN in individuals aged >80 years of whom 72% were p-ANCA and 20% were c-ANCA positive. The patients treated with immunosuppression had a significantly lower incidence of end-stage renal disease (ESRD) 1 year after biopsy (36%) compared with untreated patients (73%; P=0.03). Only peak serum creatinine before biopsy and the use of immunosuppression influenced progression to ESRD. There was no significant difference in the 1-year mortality rates between these groups (46 vs 64%; P=0.3). However, when follow-up was extended beyond 2 years, immunosuppression was associated with a lower risk of death (HR 0.33, 95% CI 0.11-0.97) and death or ESRD (HR 0.16, 95% CI 0.06-0.42) in multivariable models.

Adult minimal-change disease: clinical characteristics, treatment, and outcomes.

Minimal-change disease (MCD) counts for 10 to 15% of cases of primary nephrotic syndrome in adults. Few series have examined this disease in adults. A retrospective review was performed of 95 adults who had MCD and were seen at a single referral center. Examined were presenting features, response to daily versus alternate-day steroids, response to second-line agents, relapse patterns, complications of the disease and therapy, presence of acute renal failure (ARF), and outcome data. Sixty-five patients received daily and 23 received alternate-day steroids initially. There were no differences in remissions, time to remission, relapse rate, or time to relapse between daily- and alternate-day-treated patients. More than one quarter of patients were steroid resistant. At least one relapse occurred in 73% of patients; 28% were frequently relapsing. A significant proportion of frequently relapsing patients became steroid dependent. Second-line agents were used for steroid dependence, steroid resistance, or frequent relapses. No single agent proved superior. There were more remissions with second-line agents in steroid-dependent patients compared with steroid-resistant patients, and remissions were more likely to be complete in steroid-dependent patients. ARF occurred in 24 patients; they tended to be older and hypertensive with lower serum albumin and more proteinuria than those without ARF. At follow up, patients with an episode of ARF had higher serum creatinine than those without ARF. Four patients progressed to ESRD. These patients were less likely to have responded to steroids and more likely to have FSGS on repeat renal biopsy. In this referral MCD population, response to daily and alternate-day steroids is similar. Second-line agents give greater response in patients who are steroid dependent. ARF occurs in a significant number of adult MCD patients and may leave residual renal dysfunction. Few patients progress to ESRD.

The temporal sequence of periosteal attachment after elevation.

This study investigated the adherence of periosteum to bone after elevation to document the temporal sequence of healing at the periosteal/bone interface. There has been a lack of consensus among surgeons as to the time required for healing at this interface; some believe that the healing achieves significant strength in a few days, whereas others believe that the periosteum does not adhere to the bone for many weeks. The aim of this study was to document the time course for healing, completeness of the reattachment, and structural characteristics of the union of bone and periosteum. To test the hypothesis, scalp flaps were elevated in a subperiosteal plane and were reattached in 40 adult guinea pigs and controls. The individual groups were studied at 3, 6, 12, 30, and 90 days postoperatively. Postmortem study consisted of analysis of the mechanical and histologic findings. Strength of adherence was documented by measuring the force required for reverse avulsion of the flaps with an Instron Mini 44 tensiometer. The specimens were also submitted for electron microscopic examination. The mean tension recorded in the plateau phase of avulsion of the flaps was as follows: controls, 78 g; experimental at 3 and 6 days, not applicable (weak adherence not permitting exposure for reverse avulsion); 12 days, 39 g (p = 0.0001); 30 days, 58 g (p = 0.0012), and 90 days, 63 g (p = 0.0229). There was a significant difference between all groups and the controls. Electron microscopic study showed collagen deposition at the bone periosteal interface, which became progressively more organized in the groups studied at 30 and 90 days, with decreasing amounts of inflammation and inflammatory cells. This study demonstrated that healing at the bone/periosteal interface progresses at a rate consistent with healing of most other wounds, dispelling many widespread beliefs that the adherence at this interface was accelerated. The temporal sequence of healing at the periosteal bone interface should be considered in the various procedures in which periosteal flaps are elevated. For example, there is clinical relevance in subperiosteal brow lift procedures, in which the periosteum should be reattached by a fixation technique that will remain stable for a minimum of 30 days to allow adequate adherence between the bone and periosteum at the postoperative elevated brow position.

Nephrotic proteinuria associated with high-dose pamidronate in multiple myeloma.

Five patients receiving increased dose or frequency of pamidronate beyond the recommended dose (90 mg/monthly) exhibited nephrotic proteinuria (range 3.96-24 g/24 h). On dose reduction or discontinuation, three of these patients showed decreased proteinuria to normal levels (< 1 g/24 h), and proteinuria decreased to 4.5 g/24 h from a peak of 24 g/24 h in one patient. One patient on haemodialysis (hence not evaluable) had proteinuria of 2 g/24 h and elevated creatinine levels. One other patient continued to show elevated creatinine levels (272.8 micro mol/l). Renal biopsies obtained in two patients revealed focal segmental glomerulosclerosis.