Search

The prognosis of monoclonal gammopathies with multiple myeloma and renal involvement is poor, and the indication for renal replacement therapy is controversial. Few studies address the value of renal histology for determining prognosis according to initial pathology findings.We studied the course of 118 patients with multiple myeloma according to renal biopsy lesions. The monoclonal component was identified and quantified in serum and urine. Tumor cell mass was classified as stage 1, 2 or 3, according to Durie and Salmon. End-points were death, or survival on dialysis, or serum creatinine level at last examination.Renal biopsy showed myeloma kidney in 48 cases (41%), AL-amyloidosis in 35 (30%), light chain deposit disease in 22 (19%), chronic tubulointerstitial nephritis in 12 (10%) and cryoglobulinaemic kidney with multiple myeloma in 1. Maintenance haemodialysis was required in 46 patients (39%), earlier (P0.0001) in myeloma kidney (mean: 3 months after diagnosis) than in AL-amyloidosis (mean: 15 months) and light chain deposit disease (mean: 18 months). Median survival was 12 months in myeloma kidney, 24 months in AL-amyloidosis and 48 months in light chain deposit disease. Dialysis increased survival in light chain deposit disease, in contrast with myeloma kidney and AL-amyloidosis patients whose survival was shorter when dialysed. The main cause of death during first year of dialysis was cardiac involvement in AL-amyloidosis, and sepsis or cardiac insufficiency in myeloma kidney. There was a trend to increased survival with multidrug chemotherapy which seemed to slow progression to end-stage renal failure. At last follow-up (median: 12 months, range 1-297), 65 (55%) patients had died. By multivariate analysis, independent predictors of survival were: age70, serum creatinineor = 300 micromol/l, and serum calciumor = 2.5 mmol/l.Initial renal biopsy helps predict prognosis in patients with multiple myeloma and renal involvement. Maintenance haemodialysis is a reasonable indication in light chain deposit disease and AL-amyloidosis, especially in patients aged70. Multidrug therapy tends to prolong survival and slow progression to end-stage renal disease.

Renal histology remains the keystone of diagnosis in most parenchymal renal diseases and especially in glomerulopathies [1–3]. Sampling of renal tissue by percutaneous needle biopsy was described by Iversen and Brun in 1951 [4]. This procedure is usually safe, provided contraindications are respected [5–10]. Such contraindications include uncontrolled hypertension and/or bleeding disorders, which can favor severe perirenal hematoma. Even when these contraindications are heeded, systematic computerized tomography (CT) showed that the incidence of perirenal hematoma discovered by CT scan (irrespective of its clinical manifestation) is 57 to 85% [11, 12]. In the absence of contraindications, there are patients in whom the slightest possibility of a complication necessitating lombotomy for hemostasis would be ethically incompatible with renal biopsy. This is the case, for instance, in patients with morbid obesity or with chronic respiratory insufficiency, in whom general anesthesia might represent a considerable hazard. Finally, there are cases where the size or the anatomical location of the kidney makes renal tissue sampling difficult or impossible. Ultrasound or CT scan-guided biopsy [13–15] does not always obviate such pitfalls. Other, more invasive methods have been proposed to sample kidney tissue, for instance by means of a short lombotomy [16–21], but this approach, which in addition necessitates the use of an operating room and several days of hospitalization, is similarly inapplicable in a patient with severe bleeding disorder or morbid obesity. We have described a novel technique of renal biopsy using the transjugular route, inspired from that used for liver biopsy in patients with clotting disorders in whom the percutaneous route would similarly be precluded [22–24]. This new technique was published in abstract form [25], and we reported our preliminary results on 50 cases [26]. The goal of this Technical Note is to analyze our present experience on 200 procedures carried out in 195 patients.

We performed a retrospective study on 26 patients with moderate renal failure (mean GFR = 51 +/- 21 ml min-1 1.73 m-2), hypertension and atherosclerosis. Apart from three patients who had completely normal renal Doppler ultrasonography, all patients underwent renal angiography. Three groups of kidneys with different atherosclerotic renal artery involvement were identified: Group 1, 24 kidneys with no renal artery stenosis (RAS); Group 2, 18 kidneys with mild (25% and50% diameter) RAS; and Group 3, 10 kidneys with moderate (50% diameter) RAS. We used a two-day protocol with frusemide plus enalapril 99Tcm-MAG3 scintigraphy. The mean parenchymal transit time (MPTT), time to the maximum activity (time to peak) of the renal curve (Tmax), residual activity and split renal uptake were evaluated. The measured parameters did not differ before and after enalapril in Group 1 or in Group 2. In Group 3, MPTT and residual activity differed significantly (P0.025) before and after enalapril. The Tmax before and after enalapril, MPTT before and after enalapril and residual activity after enalapril differed significantly (P0.05) between Groups 1 and 3 and between Groups 2 and 3. Threshold values were obtained to maximize diagnostic accuracy. The Tmax, MPTT and residual activity after enalapril gave satisfactory results, and MPTT performed best with a 75% positive predictive value and a 98% negative predictive value for the diagnosis of renal artery stenosis. We conclude that MPTT, measured after enalapril administration, is a useful parameter to detect renal artery stenosis in patients with hypertension, atherosclerosis and moderate renal insufficiency.

To identify the demographic, clinical, and pathologic features and the prognosis of renal disease in a series of patients with infectious or postinfectious proliferative glomerulonephritis (GN), data were collected from records of 76 adult patients admitted from 1976 to 1993 to 2 neighboring suburban hospital nephrology units, whose catchment population consists of patients living in a suburban borough of Paris with a below-average socioeconomic status. Thirty-four patients (45%) were alcoholics, diabetics, or intravenous illicit-drug users. Sixty-six patients presented with acute nephritic and/or nephrotic syndrome. Acute renal failure was present in 56 (76%) and required dialysis in 14. The diagnostic workup comprised at least 1 renal biopsy in each case. The patient's background, site of infection, clinical course, laboratory variables, and, when available, bacteriologic findings were analyzed in each case to interpret the evolution of the disease. Initial renal biopsy disclosed endocapillary GN in 44 patients, crescentic GN in 26, and membranoproliferative GN in 6. Ten patients had endocarditis. Staphylococci and Gram-negative strains, not streptococci, were the most common bacteria identified. The origin of sepsis was mainly the oropharynx (21), the skin (19) and the lung (14); 19 cases involved multiple sites of infection. Eight patients died (11%), and 20 (26%) recovered renal function, but GN followed a chronic course in 38 (50%), rapidly requiring maintenance dialysis in 6. Poor prognostic factors included age over 50 years, purpura, endocarditis, and glomerular extracapillary proliferation. Twenty-six patients underwent repeat renal biopsy 1 month to 11 years after the initial presentation. The main finding, irrespective of the interval since the first biopsy, was that ongoing or new iatrogenic infection acquired during hospitalization was almost invariably acquired during hospitalization was almost invariably associated with developing glomerular proliferative changes. This study shows that infectious proliferative GN remains common, but that its epidemiology has changed from what was observed until 2 decades ago. The responsible bacteria, when identified, now comprise a majority of staphylococci and Gram-negative strains, in contrast to the streptococci which predominated 3 decades ago. Infectious GN affects with increasing frequency patients with an underlying condition responsible for immunosuppression, especially alcoholism, even in the absence of cirrhosis. Destructive glomerular proliferation persists, especially but not exclusively until infection has been eradicated, and despite rescue treatment with corticosteroids and/or cytostatic drugs. Thus, the prognosis is poor, and infectious GN often ends in renal death. Infection continues in this decade to represent a frequent and probably often overlooked cause of end-stage renal failure.(ABSTRACT TRUNCATED AT 400 WORDS)

A novel technique to obtain renal biopsy specimens from patients in whom percutaneous renal biopsy is contraindicated is described. After adaptation of equipment used for transjugular liver biopsy, 50 such patients underwent transjugular renal biopsy: specimens of renal tissue were obtained from 44 patients, and glomeruli were found in 38 specimens. No major complications were observed and histological examination of the biopsy specimens led to changed diagnosis or management in 13 patients. Transvenous renal biopsy should be considered when percutaneous biopsy is contraindicated or has failed.

The spectrum of the renal manifestation in a population of thirteen persons is reviewed. The renal parenchymal complications are diverse including a specific nephropathy. These aspects are discussed.

Sixty-five patients with acute glomerulonephritis underwent biopsy within the first 6 months of the disease. All specimens were examined by light microscopy, 23 by electron microscopy and 13 with immunofluorescent technics. Three types of lesions were differentiated on morphologic grounds: 1.(1) Endocapillary glomerulonephritis with humps in 35 patients. Of these, 29 had a follow-up period from 1 to 10 years; 23 of them had a full recovery whereas in the remaining 6, proteinuria and/or hematuria with or without renal insufficiency persisted. Severe endocapillary proliferation, atypical humps and diffuse crescents signified a poor prognosis. However, associated focal crescents or capillary wall lesions did not prevent full clinical recovery. 2.(2) Endocapillary glomerulonephritis without humps in 15 patients. All of them recovered fully. 3.(3) Other types of glomerular lesions in 15 patients, including extracapillary glomerulonephritis (rapidly progressive glomerulonephritis with crescents) in 5, membranoproliferative glomerulonephritis in 4, focal proliferative glomerulonephritis in 3, focal glomerular sclerosis in 2 and dense deposit disease in 1 patient. Ten of these patients are living (follow-up 2 to 14 years), but only one has recovered fully.

Cent patients atteints d'uremie majeure, et hospitalises d'urgence, ont eu une echotomographie renale, abdominale et/ou cardiaque dans les 48 heures suivant leur admission. Chez 58 malades atteints d'insuffisance renale aigue (IRA), l'echographie a oriente vers un obstacle des voies excretrices dans 15/16 cas, une IRA sans obstacle dans 39/40 cas et une thrombose des veines renales et/ou de la veine cave inferieure dans deux cas. Les echographies abdominale et cardiaque ont parfois permis de decouvrir la cause d'un etat septique associe: collection intra-abdominale (4 cas), endocardite bacterienne (3 cas) ou pericardite purulente (1 cas). Chez 42 malades atteints d'insuffisance renale chronique, l'echographie a precise que les reins etaient diminues de taille (31 cas), normaux (7 cas) ou augmentes de taille (4 cas), dont 3 cas de polykystose renale. L'echographie semble, chez l'insuffisant renal, un examen fiable pour affirmer ou eliminer un obstacle des voies excretrices, ou une maladie polykystique; preciser la taille des reins; reconnaitre un foyer septique extra-renal associe; et permettre un reperage du rein avant biopsie transcutanee. Cet examen renseigne plus difficilement sur la nature et sur le siege de l'obstacle, ou sur l'etat des vaisseaux renaux. Il n'a actuellement que peu d'interet pour decouvrir une lithiase pyelo-ureterale ou pour preciser la nature d'une nephropathie organique chez l'adulte.

Renal biopsies were performed in 211 patients within 10 days of excretory urography or renal arteriography in which diatrizoate, iothalamate or ioxithalamate had been used. In 47 renal specimens, osmotic nephrosis of the proximal tubular cells was found. Previous renal function had been normal in 10 patients, moderately impaired in 19, and severely impaired in 18. Tubular atrophy and/or necrosis was associated with histological features in 29 of 47 patients. Diffuse osmotic nephrosis was more often found in patients biopsied soon after roentgenography and also with severe renal insufficiency, but was not necessarily associated with declining renal function. The mechanism(s) by which contrast media may induce osmotic nephrosis remains unclear.

Diagnostic procedures and long-term prognosis in bilateral renal cortical necrosis. Thirty-eight patients with bilateral renal cortical necrosis (BRCN) were studied with special reference to etiology, diagnostic procedures and ultimate prognosis. BRCN was of obstetrical origin in 26 patients and more frequent during the third trimester of pregnancy (21%) than earlier (1.5%). Renal biopsy, renal arteriography and hemodynamic data were useful procedures in the early differentiation of total from patchy BRCN. In patients with patchy BRCN, the percentage of destroyed glomeruli on the kidney biopsy specimen was lower than in those with total BRCN, renal arteriography showed that the cortical nephrogram was present but non-homogeneous and mean renal blood flow (MRBF) (85Kr method) fell within the range observed in patients with acute tubular nephropathy undergoing full recovery. In patients with total BRCN, cortical tissue was uniformly necrotic, the cortical nephrogram was completely absent, MRBF was always below 50 ml/100 g·min and a first component was never recognizable. Biological evidence of intravascular coagulation was inconstant. Intrarenal vascular thrombi were only found in the renal biopsy specimens of those patients with short survival. Partial recovery occurred in 16 patients and GFR increased over a one year period. Subsequent deterioration of renal function occurred in nine patients requiring chronic hemodialysis and/or renal transplantation. Diagnostic et pronostic lointain des necroses corticales bilaterales des reins. Trente-huit malades atteints de necrose corticale bilaterale des reins (NCR) ont ete specialement etudies du point de vue de l'etiologie, des methodes de diagnostic et du pronostic lointain. La NCR a ete d'origine obstetricale chez 26 malades et a ete plus souvent observee pendant le troisieme trimestre de la grossesse (21%) que plus precocement (1, 5%). La biopsie renale, l'arteriographie renale et les donnees hemodynamiques ont ete utiles pour distinguer les NCR totales et partielles. Chez les malades atteints de NCR partielle, la biopsie renale a montre que le pourcentage de glomerules detruits etait plus bas que dans les NCR totales, l'arteriographie renale a montre que la nephrographie corticale etait presente mais non-homogene et le flux sanguin renal moyen (FSRM) (methode au 85Kr) restait compris dans les limites observees chez les malades atteints de nephropathie tubulaire aigue avec guerison complete. Chez les malades atteints de NCR totale, le tissu renal cortical etait uniformement necrotique, la nephrographie corticale totalement absente, le FSRM etait toujours inferieur a 50 ml/100 g·mn et aucun premier composant n'etait individualisable. Les preuves biologiques d'une coagulation intravasculaire ont ete inconstantes. Des thrombi vasculaires intrarenaux n'ont ete rencontres en biopsie que chez les malades ayant une courte survie. Une recuperation partielle a ete observee chez 16 malades et la FG a continue a s'elever au-dela de la premiere annee. Une aggravation secondaire de la fonction renale est survenue chez neuf malades, necessit ant des hemodialyses periodiques et/ou une transplantation renale.

Uremic and non-uremic complications in acute renal failure: Evaluation of early and frequent dialysis on prognosis.Five hundred patients were treated for acute renal failure between 1966 and 1970; 279 patients (Group I) were treated before and 221 patients (Group II) were treated after the systematic institution of prophylactic hemodialysis.Significant improvement was not observed in patients with severe pre-existing diseases or extensive extrarenal lesions (41 patients); such patients usually died from non-uremic complications before or during dialysis.Hemodialysis was required in 320 patients.Overall mortality was reduced by prophylactic hemodialysis from 42% (Group I) to 29% (Group II), and it was significantly lower in all patient categories: post-surgical (from 54 to 38%), post-trauma (from 55 to 33%).The frequency of uremic symptoms, and mortality related thereto, was substantially lowered.Deaths due to gastrointestinal hemorrhage decreased from 14 to 5% and those due to septicemia fell from 24 to 12%.Adequate nutritional care and better prophylaxis of sepsis contributed to the improvement in mortality. Complications uremiques et non uremiques dans l'insuffisance renale aigue: Influence des dialyses frequentes et repetees sur le pronostic.500 malades atteints d'insuffisance renale aigue ont ete hospitalises entre 1966 et 1970, dont 279 ont ete traites avant (Groupe I) et 221 apres l'institution systematique d'hemodialyses prophylactiques (Groupe II).Le pronostic n'a pas ete modifie chez les malades ayant une affection severe pre-existante ou des lesions extra-renales etendues (41 cas); ces sujets sont decedes de complications non uremiques avant toute dialyse ou malgre celle-ci.Des hemodialyses ont ete necessaires dans 320 cas.La mortalite d'ensemble a ete reduite de 42% (Groupe I) a 29% (Groupe II); la mortalite s'est abaissee significativement dans toutes les categories de malades, y compris les insuffisances renales chirurgicales (54 a 38%) et post-traumatiques (55 a 33%).La frequence et la mortalite dues aux complications uremiques a ete franchement diminuee.Les deces provoques par une hemorragie digestive se sont abaisses de 14 a 5% et ceux en rapport avec une septicemie de 24 a 12%.Un apport nutritionnel suffisant et une meilleure prophylaxie des etats septicemiques ont ete des elements importants dans l'amelioration generale du pronostic.

1. In forty-one patients who underwent renal homotransplantation the following measurements were made: (a) blood flow and its distribution in the transplanted kidney as measured by the 85Kr washout method; (b) renin release in the renal vein of the transplant; (c) arteriovenous difference in plasma renin activity (PRA) of the recipient's remaining left kidney. 2. Eleven transplanted patients were normotensive. Renal haemodynamic data were comparable with those obtained in potential kidney donors. 3. Three hypertensive patients had chronic rejection. The mean renal blood flow and the percentage of flow in the first component of the washout curve were reduced. Renin release from the transplant, however, was normal. 4. Ten hypertensive patients had transplant artery stenosis. In eight of them renin release from the graft as well as peripheral PRA were within normal range. This result is similar to experimental data obtained in Goldblatt renovascular hypertension. The two patients with the tightest artery stenosis had an elevated renin release from the transplant. 5. Thirteen hypertensive patients had elevated arteriovenous difference in PRA of the recipient's own left kidney. Peripheral PRA was significantly higher than in normotensive patients. Left nephrectomy relieved hypertension in ten of them; three have not so far undergone nephrectomy. 6. In four other cases hypertension was also relieved by removal of the patient's own kidney; however, the arteriovenous difference in PRA of that kidney fell within normal range.

Excerpt To the editor: In his paper on cephaloridine (Ann Intern Med79:561-565, 1973), Dr. Mandell reviewed the nephrotoxicity of this drug. He stated that "numerous reports also attest that treatm...

Excerpt To the Editor:Human immunodeficiency virus (HIV)-associated nephropathy usually manifests as the nephrotic syndrome with glomerular lesions of focal and segmental glomerulosclerosis. The di...