Search

Consensus guidelines are provided for the conservative management of adult patients with chronic and progressive renal failure, together with a brief review of the evidence relating to various treatable complications. Blood pressure control, diet, hyperlipidaemia, calcium and phosphate metabolism, anaemia and acidosis are considered.

For the past 40 years members from the Christchurch departments of paediatrics, nephrology, radiology, pathology and nuclear medicine have studied the entity of vesicoureteric reflux and its main complication of reflux nephropathy. Initially the natural history of vesicoureteric reflux was examined by investigating 350 infants with urinary infection by intravenous urography and micturating cystourethrography. The 40% demonstrating reflux were followed up for approximately 12 years. The study showed that infancy and early childhood were the critical periods for renal damage to occur, that the damage was confined to those kidneys subjected to severe degrees of reflux, that lesser degrees of reflux were not associated with renal damage and that a spontaneous lessening of the severity of reflux occurred with increasing age. Other aspects of reflux nephropathy also have been studied including pathogenic mechanisms resulting in renal damage, ultrasonography to examine fetal anatomy, radioisotopic methods for demonstrating renal scarring and reflux, and the long term follow up of adults with reflux nephropathy.

Aim: To determine the outcome of renal transplants from living related donors., Methods: Retrospective analysis of 33 living related donor renal transplants done between March 1976 and 31 December 1994 at Christchurch Hospital., Results: One of the 33 renal transplants patients received an ABO incompatible kidney and was excluded from the statistical analysis. Twenty-one (66%) of 32 grafts continue to function. The 1, 5 and 10 year graft survival rates were 82%, 73% and 48%, respectively. The estimated 1 and 10 year patient survival rates were 96% and 94%, respectively. With the introduction of cyclosporin the 1 and 5 year graft survival rates increased to 90% and 80%, respectively. Three patients received donor specific transfusion preconditioning and one patient a skin graft from the prospective donor. Four patients (12.5%) had current and/or peak panel reactive antibody titres of more than 25%. Three of these grafts failed after 2, 95 and 463 days. Two grafts were lost due to catastrophic vascular complications., Conclusion: The overall outcome for patients who were not highly sensitised was excellent. The degree of sensitisation of the recipient, and the extent of atherosclerotic vascular disease in the recipient, were major predisposing factors for the graft loss due to rejection and vascular complications during the early post transplant period.

Aim: To assess the outcome of patients with renal failure presenting to a regional nephrology unit., Methods: The records of patients with plasma creatinine concentration > or = 0.30 mmol/L who presented between 1 January 1988 and 31 December 1993, or were already under follow up, were studied., Results: The outcome of 491 patients (293 males) aged from 4.8 to 88.8 years, 123 of whom had acute renal failure, was assessed at 30 June 1994. Thirty seven (30%) of the patients with acute renal failure had died. Of the 372 patients with chronic renal failure 139 had started regular dialysis treatment and 95 were dead, including 27 patients, with a mean age of 71 years, who died of untreated end-stage renal failure (ESRF). For 11 (40%) of these patients the patient and/or family made the decision not to start dialysis treatment. The rates of treatment of ESRF are lower in Canterbury and Westland than those in the Auckland region. The latter can be explained partly by the differences in the demography of the respective populations., Conclusion: Death from untreated ESRF is uncommon in Canterbury and Westland. The rates of treatment of ESRF with regular dialysis are lower than in the Auckland region.

Aim: To review our experience using acitretin for the skin complications in renal transplant recipients., Methods: Fifteen longterm caucasian renal transplant recipients suffering skin complications were treated with acitretin (10-50 mg daily), a second generation retinoid. Indications for its use were progressive actinic keratoses, widespread warts or recurrent skin malignancies. The therapeutic benefit was assessed by the general condition of of the skin and the number of skin malignancies excised, and the side effects by regular enquiry, skin examination and laboratory tests., Results: All 15 patients reported that the skin became softer and smoother. Actinic keratoses and warts improved or disappeared. Six patients had been on acitretin for over 12 months. The number of malignancies decreased in four of these six patients. Nine patients had cutaneous side effects due to acitretin necessitating a reduction in dose in five patients and discontinuation in the remaining four patients. No patient had any disturbance of their liver or renal function tests or lipid profile. No interaction was found between cyclosporin A and acitretin (seven patients)., Conclusions: Most patients treated with acitretin experienced subjective improvement and actinic keratoses and warts improved or disappeared. Its effect on the skin malignancy rate was variable. Acitretin was reasonably well tolerated. The benefits of this drug remain anecdotal, making a prospective, multicentre, placebo controlled study essential.

Aim: Assess the pregnancies of our female renal transplant recipients and to document long term maternal and fetal outcome., Methods: Between 7 June 1972 and 31 December 1992 112 females had at least one renal transplant. Sixty-four of these 112 women were in the reproductive age and had a functioning graft., Results: Nine women had 16 pregnancies which resulted in 11 live births and three first trimester abortions. Two unplanned pregnancies were terminated. Mean age at transplantation was 17.2 yr [range 16-22.5 yr] and mean interval from transplant to pregnancy was 6.8 yr [range 1.8-9.0 yr]. Prednisone and azathioprine were used in all patients and cyclosporin in five. For seven of the successful pregnancies plasma creatinine remained < or = 0.10 mmol/L. One of these women developed allograft nephropathy 5 years after delivery and returned to dialysis 9 years later. For the other four successful pregnancies the preconception plasma creatinine was 0.12-0.14 mmol/L. The woman with two successful pregnancies had a halving of glomerular filtration rate during the second pregnancy, but it has remained stable for 15 years; one was poorly compliant with her immunosuppressive regimen and reached endstage renal failure two years after delivery; one developed cyclosporin nephrotoxicity, but 18 months later renal function was stable after a dosage reduction. Ten infants were delivered by caesarean section, four of them urgently. Three babies were preterm and five growth retarded. One died of sudden infant death syndrome at four months. All other infants developed normally., Conclusion: There is no contraindication to pregnancy in female transplant recipients who have stable graft function and controlled blood pressure. Management of such pregnancies should be by shared obstetrical/nephrological/paediatric care.

Aim: To assess the long term follow up of patients with reflux nephropathy., Methods: Two hundred and ninety-four patients over 15 years of age (females 235; caucasians 288) presented between 3 wk and 72 yr of age (mean 17.3 yr; SD 14.4 yr). One hundred and seventy-six had unilateral reflux nephropathy and 118 had bilateral reflux nephropathy diagnosed on intravenous urography and/or a DMSA scintigraphy., Results: The majority of patients, particularly women, presented with a urinary tract infection. Twenty-five patients (8.5%) had hypertension at presentation, 15 (5.1%) loin or abdominal pain, 14 (4.8%) proteinuria and six (2%) renal insufficiency. At the last follow up (mean age 34.2yr; SD 13.7yr; range 15-81yr), 113 patients (38%) had hypertension or were on antihypertensive therapy. This was significantly more frequent in those with severe bilateral renal parenchymal scarring. Proteinuria was present in 92 (31%); 40 of these had renal insufficiency. Seventy-one (24%) had a creatinine clearance < 70 mL/min and 43 (15%) a urinary tract infection. Eighteen patients had suffered from a urinary calculus. Proteinuria and renal insufficiency were significantly more frequent in those with severe bilateral reflux nephropathy., Conclusion: All patients with reflux nephropathy who have proteinuria, hypertension or renal insufficiency should be under regular follow up.

Aim: Review our 9 year experience using cyclosporin A (CyA) in a triple immunosuppressive regimen for renal transplantation., Patients: Between 1 October 1984 and 30 June 1993 117 patients had a total of 130 renal transplants. This review was confined to 52 of these patients who had been on CyA for at least 12 months and had remained under regular surveillance in this clinic., Results: Patients were given 10 mg/kg of CyA prior to transplantation then 8 mg/kg/d in two divided doses after the onset of graft function. The maintenance dose was tapered to a mean of 3.5 mg/kg/d (SD 1.4) within 9 months and thereafter ranged from 3.0-3.4 mg/kg/d. Individual patients differed significantly in the trough whole blood CyA concentrations that they produced on a certain dose. Chronic CyA nephrotoxicity occurred in 3 patients and equivocal changes in another patient, while on a CyA dose of 3.0-4.0 mg/kg/d., Conclusion: CyA was an effective drug as part of a triple immunosuppressive regimen for renal transplantation. Chronic CyA nephrotoxicity was an unpredictable finding and occurred with doses as low as 3.0-4.0 mg/kg/d and with drug concentrations within the recommended therapeutic range. All patients on CyA should be under regular supervision and early graft biopsy undertaken if there is evidence of graft dysfunction.

Aim: To document the skin manifestations of renal transplant recipients., Methods: The findings in 52 patients (27 males; mean age 43.5 yr; range 22-74 yr; SD 12.0) with a stable renal transplant for a mean of 115.6 mth (range 3-258; SD 70.6). Thirty seven patients were on prednisone and azathioprine and 18 on prednisone, azathioprine and cyclosporin., Results: Including prior observations, 48 cutaneous malignancies were identified in nine patients, with the ratio of squamous cell to basal cell carcinoma being 1.2:1. No metastases were detected. Actinic keratoses were present in 20 patients and tended to be multiple and present on sun exposed skin. A wide range of nonneoplastic lesions was documented, including warts in 75%. Human papillomavirus was isolated from 43% of warts., Conclusions: Renal transplant recipients require regular skin examination. Patients with high recreational or work related sun exposure prior to, or after transplantation, and those who have had a previous skin malignancy, should be identified as high risk patients for skin cancer and have regular dermatological follow up.

Aim: To assess the long term outcome of patients with IgA nephropathy., Method: The outcome of 151 patients (120 male; mean age 32.5, median age 29.6, SD 15.4 years; 146 Caucasian) with biopsy-proven IgA nephropathy. The patients were enrolled between 30 April 1973 and 21 August 1992., Results: Ninety-five (63%) of the patients presented with microscopic haematuria, with or without proteinuria and/or renal insufficiency. At presentation renal insufficiency was present in 34% and hypertension in 48% of patients. During a mean follow up period of 63.3 months (range 0-233 months) 12 patients have reached end stage renal failure, five have died of a nonrenal cause and 25 were lost to follow up. The actuarial renal survival rate was 92.6% at five years and 91.1% at both 10 and 15 years. A significantly poorer renal survival rate was seen in those patients with a plasma creatinine > or = 0.12 mmol/L, hypertension, a serum albumin of < 35 g/L, or a 24 hour urinary albumin excretion > or = 1.0 g at presentation, and this became apparent within the first few years of follow up., Conclusions: The long term outcome of IgA nephropathy is better than previously reported. Those patients with a poor prognosis can be identified with considerable certainty at presentation.

We report three cases of heavy albuminuria occurring in hypertensive patients with unilateral or bilateral renal artery stenosis. In two of the patients the albuminuria and hypertension were corrected by removing the ischaemic kidney. The mechanism of the albuminuria, particularly in atheromatous renal artery stenosis, is probably multifactorial.

Aim: to study prospectively patients presenting with membranous nephropathy., Methods: the outcome of 51 patients (33 male; mean age 50.8 SD 17.7 years; 49 caucasian, two Maori), aged 14 years and over, with membranous nephropathy was studied prospectively. The patients were enrolled between 1 July 1972 and 30 June 1991. Patients with systemic lupus erythematosus were excluded. Membranous nephropathy was secondary to drug therapy in eight (gold 3, nonsteroidal antiinflammatory drug 3, penicillamine 1, captopril 1). All patients were hepatitis B surface antigen negative. The majority of patients did not receive immunosuppressive therapy., Results: forty-seven (92%) presented with the nephrotic syndrome, eight (16%) with a plasma creatinine > or = 0.15 mmol/L and 28 (55%) with hypertension. The patients were followed for a mean of 5.4 years, the median being 3.9 years and range four months-19 years. The 10 year cumulative renal survival was estimated to be 78% and overall survival 66%. Six patients have entered a renal replacement programme and six have died of nonrenal causes. Of the remaining 39, eight have renal insufficiency, 27 hypertension and 22 proteinuria. Complete remission occurred in 17 (33%)-11 spontaneously, four following withdrawal of the offending drug and two after immunosuppressive therapy. Poor prognostic indicators at presentation included renal insufficiency, need for antihypertensive therapy, pathological stage IV on renal biopsy and older age., Conclusions: membranous nephropathy is an indolent disease with a good chance of spontaneous remission. In most patients immunosuppressive treatment appears unwarranted.

A prospective, randomised trial was undertaken to compare the efficacy of ciprofloxacin and netilmicin for the treatment of acute pyelonephritis. Forty-three patients were enrolled and 34 (29 women) completed the protocol. Fifteen of 17 patients treated with ciprofloxacin and 15 of 17 treated with netilmicin were cured. All patients were treated for five days. One patient relapsed after ciprofloxacin and another had a reinfection, while two relapsed after netilmicin. Five of six patients with a urinary tract abnormality were cured. Side effects were generally mild and rapidly reversible. Patients treated with ciprofloxacin spent a mean of 3.7 days in hospital compared with 5.3 days for those treated with netilmicin. The difference in duration of hospital stay was statistically significant (p less than 0.01). Both drugs proved highly effective and safe for the treatment of severe acute pyelonephritis.

Twenty-five patients with a renal transplant for 15 months to 19.4 years, hyperlipidaemia and stable graft function underwent three months of dietary management. Plasma lipid and apolipoprotein concentrations and lipoprotein electrophoresis were measured after a 12 hour fast at enrollment and after three months of diet. The aims of diet were to reduce energy intake in the overweight, restrict fat to 25-30% of total intake, reduce saturated fat content to less than 10% of total energy and cholesterol to less than 300 mg/d. After three months of diet there was a significant fall in mean cholesterol/HDL cholesterol risk ratio and a rise in mean HDL cholesterol concentration. Six patients reverted to a normal lipoprotein electrophoretic pattern with a significant reduction in mean total cholesterol, LDL cholesterol, cholesterol/HDL cholesterol ratio, apoprotein B and apoB/apo A-1 ratio. Most of the other patients who made dietary modifications showed some improvement in their lipid parameters. Dietary modification should be the initial approach to the management of posttransplant hyperlipidaemia.

The long term complications of renal transplantation were assessed in 36 patients who had lived for 10 or more years with a functioning renal transplant. Thirty-three patients were alive with a mean plasma creatinine of 0.13 mmol/L (SD 0.07). A 62 year old women died from a myocardial infarction 11 years after transplantation and two women developed chronic rejection and returned to dialysis after 17 years. Nineteen patients have required antihypertensive therapy, five have suffered ischaemic heart disease and two a cerebrovascular event. Malignancy has developed in 13 patients, with four having two or more organs involved. Skin cancers (9 squamous cell, 4 basal cell) were present in all 13 patients and recurred in six. The other malignancies included carcinoma of cervix (2), cervix and bladder (1) and thyroid (1). Three patients have required parathyroidectomy for autonomous hyperparathyroidism, two splenectomy for hypersplenism, and one bilateral hip replacement for avascular necrosis of the femoral heads. The development of hypertension, vascular disease and malignancy are the most important long term complications after renal transplantation. Strategies must be formulated to reduce the morbidity and mortality from these causes.

Over a 14 year period 17 patients (nine men) with Wegener's granulomatosis and renal involvement had a renal biopsy. All patients had a necrotising glomerulonephritis and 15 had evidence of crescent formation in glomeruli. Fourteen patients were treated with both prednisone and cyclophosphamide and three with prednisone and azathioprine. The five year patient survival rate was 73% and the renal survival rate 68%.

Persistent microscopic haematuria, especially when present in young individuals and associated with proteinuria, is generally of glomerular origin. Important causes include glomerulonephritis and Alport's syndrome. A new type of benign familial haematuria has now been reported characterised by little or no proteinuria, no deafness or hypertension and no deterioration of renal function. Examination by electron microscopy of renal biopsy material shows thinning or attenuation of the glomerular basement membrane. A family with thin basement membrane nephropathy is reported to illustrate this newly recognised entity. This disorder should be considered in any patient with persistent microscopic haematuria. Pathologists who assess renal biopsy material should pay greater attention to an ultrastructural morphometric analysis of the glomerular basement membranes of at least two glomeruli.

Colony counts on 122 clean-catch mid-stream urine specimens were determined with Bacturcult and compared with those obtained using the quantitative pour plate method. The suggested criteria for using Bacturcult resulted in an unacceptably high number of false positive cultures. It has been shown that over 100 colonies in the proscribed area on the cellophane sleeve correlated well with pour plate colony counts of over 100 000/ml. Bacturcult was found to be a simple and convenient method for performing a quantitative colony count on a urine specimen. It could be recommended for use in domiciliary practice, out-patient clinics and in population screening programes.

A randomised trial was undertaken to compare the efficacy of netilmicin and ceftriaxone for the treatment of severe or complicated urinary tract infections. Forty-seven patients completed the study. Twenty-three of 24 patients treated with netilmicin and 21 of 23 treated with ceftriaxone were cured. One patient treated with netilmicin had a mild, reversible disturbance of renal function. Six patients developed diarrhoea after ceftriaxone treatment.

In one year 19 patients aged 73 SD 8 yr were referred with renal failure (plasma creatinine 0.14-0.52 mmol/l; urea 7.9-39.5 mmol/l; potassium 2.9-6.1 mmol/l, who were taking amiloride/hydrochlorothiazide (ten), amiloride alone (one) or triamterene/hydrochlorothiazide (eight). Six patients were taking other diuretics. Sixteen patients were being treated for hypertension and three for fluid retention; five hypertensive patients were also taking non-steroidal anti-inflammatory drugs (NSAID). Four patients were hypokalaemic, three were volume-depleted. All potassium-sparing diuretics and NSAID were stopped (four required another diuretic). Six-100 days later renal function was improved in 17 patients, unchanged in one and one patient had died of uraemia. Blood pressure was satisfactory on no therapy in 11 patients and two normotensive patients were oedema-free. In elderly patients with renal impairment potassium-sparing diuretics may cause renal failure, sometimes secondary to hypovolaemia, and NSAID may potentiate the effect.

Enoxacin, a new orally absorbed broad spectrum anti-microbial agent, was used to treat 25 patients with moderate or severe urinary tract infections. Many were complicated and associated with renal insufficiency. Eighteen of the 25 were cured, five had a relapse and two became reinfected with a resistant Streptococcus faecalis. Fourteen of the patients reported side effects, including six with a neurological syndrome, one with widespread arthralgia and one with an Achilles tendonitis. Further studies are indicated with this potent drug to assess its role in the management of severe or complicated urinary infections and to assess the optimum dose and duration of therapy.