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Objectives: Posttransplant diabetes mellitus is a common and serious metabolic complication after renal transplant. Patients with uremia are known to have abnormal glucose metabolism characterized by insulin resistance and defects in insulin secretion, which are ameliorated to some extent with renal replacement therapy and more so with renal transplant. However, the diabetogenicity of calcineurin inhibitors compounds this state of dysglycemia and promotes the development of diabetes in some patients. It is not clear whether pretransplant dysglycemia is a risk factor for posttransplant diabetes mellitus and, if so, which between insulin resistance and pancreatic β-cell dysfunction is a major determinant in predicting posttransplant diabetes mellitus. Here, we examined the roles of the pretransplant oral glucose tolerance test, glycated hemoglobin (HbA1c) levels, and homeostatic model assessment-derived insulin resistance and beta-cell function in the prediction of posttransplant diabetes mellitus and the course of these indexes posttransplant. Our aim was to examine the correlations between these factors and their changes posttransplant with the development of posttransplant diabetes mellitus., Materials and Methods: Pretransplant fasting blood was drawn from patients for plasma glucose, insulin, C-peptide, and HbA1c levels, which was followed by a 2-hour oral glucose tolerance test. After transplant, patients were followed for 6 months to detect posttransplant diabetes mellitus. Serum insulin, C-peptide, and glycated hemoglobin levels were reexamined in patients with posttransplant diabetes mellitus at 1 and 6 months., Results: Twenty-one patients (29%) developed posttransplant diabetes mellitus. Pretransplant HbA1c was associated with development of posttransplant diabetes mellitus (odds ratio 27.04) on logistic regression. Homeostatic model assessment-derived insulin resistance improved significantly at 6 months posttransplant, whereas beta-cell function remained lower than pretransplant levels in patients with posttransplant diabetes mellitus., Conclusions: Pretransplant HbA1c may be used as a predictive marker for posttransplant diabetes mellitus. Insulin resistance but not beta-cell function improves in patients with posttransplant diabetes mellitus at 6 months posttransplant.

Collapsing focal segmental glomerulosclerosis (cFSGS) is characterized by rapid progression to end-stage renal disease (ESRD). We evaluated the clinicopathological spectrum of cFSGS and compared its clinical behavior to steroid and tacrolimus (TAC)-resistant noncollapsing focal segmental glomerulosclerosis (FSGS). All patients (>14 years) diagnosed with cFSGS were enrolled in the study. Staining for differentiated podocyte markers such as WT 1, PAX and KI67 were performed in all patients. The outcome and histological features of cFSGS was compared with a prospectively followed cohort of steroid and TAC-resistant noncollapsing FSGS. The study included 22 cFSGS patients and 19 cases of steroid and TAC-resistant FSGS. Complete remission, partial remission, steroid resistance, progression to ESRD and death were observed in 13.6%, 4.5%, 27.3%, 36.4% and 18.2% patients, respectively. Patients with cFSGS had higher serum creatinine and more advanced tubulointerstitial changes compared to resistant FSGS. Twenty-six percent of therapy resistant noncollapsing FSGS progressed to ESRD after two years of stopping TAC. However, there was no difference in progression to ESRD between cFSGS and therapy-resistant noncollapsing FSGS at the end of two years. Glomerular collapse in the setting of FSGS is poorly responsive to treatment and has a high rate of progression to ESRD. The long-term prognosis of cFSGS and steroid and TAC-resistant FSGS are similar.

The occurrence of renal allograft mucormycosis is uncommon, but its association with renal papillary necrosis has not been reported. We describe such an association in a patient who survived on peritoneal dialysis after nephrectomy and antifungal therapy.

Introduction: Treatment of patients with chronic hepatitis C (CHC) is difficult in the setting of end stage renal disease (ESRD). The present study aimed to analyze the treatment outcome in patients with CHC and ESRD, being evaluated for kidney transplantation., Methods: Data of 65 patients of ESRD with CHC (males: 53, mean age: 39.2 +/- 14.4 years) was analysed retrospectively. Patients were treated with either pegylated or conventional interferon (IFN) without ribavirin. Treatment response was assessed for rapid virological response (RVR), early virological response (EVR), end of treatment response (ETR) and sustained virological response (SVR)., Results: All patients were receiving hemodialysis (duration 1-60 months). Sixteen patients (25%) (genotype 1: 11, genotype 3: 4, genotype 2: 1) agreed for treatment (13 pegylated IFN and 3 conventional IFN). RVR was achieved in 7 patients (44%) and out of 11 patients (69%) who achieved EVR, ETR was achieved in 7 (44%) patients. Seven patients (44%) dropped out during treatment (2 because of side effects). SVR could be demonstrated in one of 7 patients who achieved ETR (6 patients were lost to follow up after ETR)., Conclusions: In our experience, dropouts before, during and after treatment are a major problem in patients with CHC and ESRD. Of those who complete treatment, around half of them are able to achieve the end of treatment response.

Background: There are no national data on the magnitude and pattern of chronic kidney disease (CKD) in India. The Indian CKD Registry documents the demographics, etiological spectrum, practice patterns, variations and special characteristics., Methods: Data was collected for this cross-sectional study in a standardized format according to predetermined criteria. Of the 52,273 adult patients, 35.5%, 27.9%, 25.6% and 11% patients came from South, North, West and East zones respectively., Results: The mean age was 50.1 ± 14.6 years, with M:F ratio of 70:30. Patients from North Zone were younger and those from the East Zone older. Diabetic nephropathy was the commonest cause (31%), followed by CKD of undetermined etiology (16%), chronic glomerulonephritis (14%) and hypertensive nephrosclerosis (13%). About 48% cases presented in Stage V; they were younger than those in Stages III-IV. Diabetic nephropathy patients were older, more likely to present in earlier stages of CKD and had a higher frequency of males; whereas those with CKD of unexplained etiology were younger, had more females and more frequently presented in Stage V. Patients in lower income groups had more advanced CKD at presentation. Patients presenting to public sector hospitals were poorer, younger, and more frequently had CKD of unknown etiology., Conclusions: This report confirms the emergence of diabetic nephropathy as the pre-eminent cause in India. Patients with CKD of unknown etiology are younger, poorer and more likely to present with advanced CKD. There were some geographic variations.

Background: Late referral of patients with chronic kidney disease (CKD) to a nephrologist has been shown to be associated with greater morbidity and adverse clinical outcomes., Methods: We did a prospective cross-sectional study of 2490 consecutive, newly diagnosed patients with end-stage renal disease (ESRD) referred to the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh over 2 years. The referral pattern was classified on the basis of the interval between first visit to a nephrologist and initiation of renal replacement therapy (RRT). If the patient reported later to a nephrologist, the disease would have progressed more, and the time interval to initiation of RRT would thus be shorter. A time interval of < 3 months was classified as late referral (LR), 3-12 months as intermediate referral (IR) and > 12 months as early referral (ER). The demographic and clinical characteristics and co-morbid conditions were compared, and factors associated with LR and outcomes were evaluated., Results: About 75% of patients were referred late. Poor socioeconomic status, low level of education and reduced access to reimbursement of treatment costs contributed to LR. The aetiology of ESRD could not be established in a larger number of LR patients as compared to the other groups. LR patients had a higher prevalence of uraemic complications and required emergency dialysis more frequently. A higher proportion of LR patients were lost to follow up because they could not afford to continue dialysis. Early mortality was higher in the ER group than in the other groups. ER patients were older, more likely to have diabetic nephropathy and a higher burden of co-morbid conditions. They were also more likely to choose continuous ambulatory peritoneal dialysis or undergo transplantation. Only 28% of all patients continued RRT beyond 3 months., Conclusion: A large majority of patients with ESRD in India seek medical attention late, usually in advanced stages of CKD with uraemic complications. LR is more frequent in younger patients and those with non-diabetic kidney disease, and is associated with poor socioeconomic status, lack of education and poor outcomes.

Aim: Whether or not completing the hepatitis B vaccination in patients who have undergone kidney transplantation in the middle of incomplete vaccination schedule leads to development of protective antibody titres is not known. This study was designed to determine whether the strategy of completing hepatitis B virus (HBV) vaccination after transplantation is efficacious., Methods: Sixty-four end-stage renal disease (ESRD) patients were screened for hepatitis B surface antigen (HBsAg), antibodies to hepatitis B surface antigen (anti-HBs), hepatitis B e-antigen (HBeAg) and HBV DNA. HBsAg negative patients received four doses of 40 µg recombinant HBV vaccine. Schedule was continued in after transplantation period if it was incomplete before transplant. Anti-Hbs titres were evaluated at 1, 3, 6, 9 and 12 months., Results: Past HBV infection was noted in 12 patients: 10 by serology plus viraemia and two by viraemia alone. Of the 46 patients without current or past HBV infection who had received at least two doses of the vaccine before transplant, 17 each had received two and three doses and 12 had completed the schedule. Seventeen (37%) exhibited protective titres. Patients who had completed vaccination were more likely to have protective titres than those incompletely vaccinated (P = 0.02). Five patients responded to post-transplant vaccination., Conclusion: Partially vaccinated patients do not mount an adequate antibody response despite continued vaccination in the post-transplant period, whereas complete vaccination provides protection in 60%. The present study data highlights the need of administration of a full schedule of HBV vaccination before kidney transplantation. Nucleic acid-based tests can identify occult HBV infection., (© 2011 The Authors. Nephrology © 2011 Asian Pacific Society of Nephrology.)

Background: BK polyoma virus (BKV) has emerged as an important cause of acute and chronic allograft injury in renal transplant recipients. Reactivation of latent infection requires reduction in cell-mediated immunity. We hypothesized that BKV could get reactivated in the urinary tract of patients with end-stage renal disease (ESRD) and impact the allograft function after these individuals undergo transplantation., Methods: We prospectively examined the urine specimens of 68 ESRD patients and their donors for BKV inclusion containing decoy cells with Papanicoulau staining and immunohistochemistry. Polymerase chain reaction was carried out to confirm the presence of viral DNA. Urine examination was repeated 3-9 months after transplantation and during episodes of graft dysfunction. All graft dysfunction episodes were investigated by biopsy. BKV-associated nephropathy was confirmed by immunoperoxidase staining. Graft loss and doubling of serum creatinine were the study end-points., Results: Decoy cells were detected in 22 ESRD patients and four donors (P < 0.0001). All 22 continued decoy cell excretion after transplantation and two fresh excreters were noted. Patients exhibiting decoy cells had more frequent graft dysfunction episodes (67% vs 30%, P = 0.003) and higher serum creatinine value (P < 0.001). About 33% patients achieved the combined end-points in the BK viruria group, compared with 11% in the non-decoy cell excreters (P = 0.03). Histologically proved BKV nephropathy was noted in 7% cases; all decoy cell excreters., Conclusion: We conclude that reactivation of latent BKV infection can occur in ESRD and confers an increased risk of graft dysfunction after transplantation. The mechanism of graft dysfunction in decoy cell excreters who do not develop overt nephropathy needs more studies.

We studied tear flow in 23 renal transplant patients receiving cyclosporine A. Four minute Schirmer test was done once before and three times after starting cyclosporine A. Average tear flow was 9.7+/-0.9 before treatment and 15.9+/-1.1 at 1-2 months after renal transplant, 16.5+/-1.3 at 3-5 months and 17.6+/-1.4 at 8-10 months. Tear flow was significantly increased following oral cyclosporine treatment.

The relative safety of parenteral iron preparations is a controversial issue in the management of anemia in chronic kidney disease (CKD), as direct head-to-head comparative trials are lacking. In this study, patients of CKD were randomized to receive intravenous low molecular weight iron dextran (ID), sodium ferrigluconate complex (SFGC), and iron sucrose (IS) at doses and infusion rates recommended by the product manufacturer. One time test dose was used only for ID and SFGC. A total of 2,980 injections (n = 339) of i.v. iron was given, and 49 patients (14.45% per patient) and a total of 56 adverse events (1.88% per infusion) were noted. Odds ratios (OR) of serious adverse drug events (ADE; i.e., death, anaphylaxis, or suspected immuno-allergic events) per patient was not significant between ID vs. SFGC (3.566) and SFGC vs. IS (2.129), whereas that between ID vs. IS (7.594) was highly significant (p = 0.034). OR of serious ADE exposure was significantly higher in ID vs. SFGC (OR = 5.670, p = 0.0147) and ID vs. IS (OR = 7.799, p < 0.001). No significant difference was seen between the three groups in terms of non-serious ADEs. Drug discontinuation occurred significantly more often with ID. One patient who developed anaphylactoid reaction with SFGC and ID tolerated iron sucrose well.

The methylenetetrahydrofolate reductase (MTHFR) C677T gene polymorphism has been shown to be associated with cardiovascular disease and in patients with end-stage renal disease (ESRD). However, the relationship between MTHFR polymorphisms and cardiovascular disease (CVD) in patients on hemodialysis has not been examined. The aim of this study was to assess the association of polymorphisms of MTHFR gene with homocysteine (Hcy) and intimal medial thickness (IMT) in patients on hemodialysis. We performed case-control study involving107 patients with ESRD and 103 healthy controls. Plasma Hcy was measured in all the subjects and these subjects were genotyped for three MTHFR polymorphisms (C677T, A1298C, and G1793A). We observed significantly higher Hcy levels in patients as compared to controls. The frequency of MTHFR 1298CC genotype was significantly higher in ESRD patients than in controls (21.4% vs. 2.9%); the frequency of the MTHFR C677T genotypes did not differ between groups (26.1% vs. 17.4%). Compound heterozygous MTHFR 677CT/1298AC genotypes showed maximum association with the risk of ESRD (OR: 12.8; 5%CI: 1.64-10.01, P < 0.05). Concurrent occurrence of MTHFR 677CC wild genotype with either 1298CC or 1793GA significantly increased the risk of disease (OR: 7.20; 95%CI: 2.06-2.51, P < 0.001 and OR: 7.60; 95%CI: 1.68-34.35; P < 0.05, respectively). MTHFR 1298CC genotype was associated with higher Hcy levels. IMT was also significantly higher in patients with the 1298CC genotype (P < 0.05). Thus, A1298C polymorphism of MTHFR gene appears to be associated with the severity of carotid atherosclerosis and co-occurrence of MTHFR polymorphisms may be a risk factor for CVD in patients on hemodialysis.

Evaluation of body composition provides clinically useful information in several diseases including chronic kidney disease. Bioimpedance analysis (BIA) is a simple, cheap, and noninvasive tool for monitoring body composition. We performed BIA in 451 healthy adults and 162 end-stage renal disease (ESRD) patients. Resistance (R) and reactance (Xc) values were obtained at 50-kHz frequency using a tetrapolar impedance meter. Body compartments were derived using population-specific regression equations. Phase angles (arctan Xc/R) were calculated and impedance vector distribution was determined using the RXc graph method. Compared to healthy population, ESRD patients had similar post-dialysis resistance with lower reactance and phase angle, indicating decreased soft tissue mass and inadequate ultrafiltration. BIA equations estimated decreased fat mass index and intracellular water, whereas the total body and extracellular water percentages were increased. Sex-specific reference RXc plots with 95, 75, and 50% tolerance ellipses were drawn for the healthy population. A significant difference was noted in the vector positions and 95% confidence ellipses of the two sexes and body mass indices of 25. In conclusion, we present the reference BIA parameters for Indian population. ESRD patients show significant body compartment alterations. The RXc score graph can differentiate ESRD patient from normal controls and can be used to monitor nutrition and hydration status.

Chronic renal failure is a devastating medical, social, and economic problem for patients and their families in India and Pakistan. Reliable data on the true incidence and prevalence of end-stage renal disease (ESRD) in India and Pakistan are lacking because no national registries exist. Among reported cases, chronic glomerulonephritis is the most common cause, accounting for more than one third of patients, while diabetic nephropathy accounts for approximately 20% of all patients in India. Delayed diagnosis and failure to institute measures to slow the progression of renal failure have resulted in a predominantly young ESRD population, with a median age of 44 years. Because of financial constraints, less than one third of all patients referred to a tertiary care center receive any kind of renal replacement therapy. Most hemodialysis patients who stop treatment and die do so because of cost constraints within the first three months, and approximately 5% of patients are started on ambulatory peritoneal dialysis. Renal transplantation is the cheapest option, but < 10% of all patients with ESRD have a transplant. Cyclosporine, azathioprine, and prednisolone continue to be the backbone of post-transplant immunosuppression, but cyclosporine is stopped in a significant proportion of patients at one year post-transplant to cut down costs. Living related donor transplants constitute 70% of all transplants; two thirds of the donors are females, while more than three fourths of all recipients are males. Spouses account for 20% of donors from within families. Almost 30% of transplanted kidneys are donated by living unrelated donors, while cadaver donors account for only 2%. More resources must be mobilized to care for these patients; early detection of renal disease must be facilitated, and measures to delay ESRD must be implemented.

Background: Cutaneous sensitivity to the tuberculin antigen is thought to indicate latent tuberculosis infection (LTBI). Some guidelines suggest treating end-stage renal disease (ESRD) patients for LTBI on the basis of tuberculin positivity. The prevalence of tuberculin sensitivity and cutaneous anergy in Indian patients with ESRD and the utility of the tuberculin test for predicting post-transplant tuberculosis are not known., Methods: We prospectively studied cutaneous tuberculin reactivity and anergy in 108 ESRD patients and 100 age- and sex-matched healthy controls. Mumps antigen and tetanus toxoid were used as control antigens. Patients who failed to react to all antigens were classified as anergic. Seventy-nine patients underwent living donor kidney transplants and were followed-up for approximately 2 years., Results: About 44% of ESRD patients and 66% of controls showed tuberculin reactivity (P = 0.0018). The prevalence of anergy was significantly higher in the ESRD population (44% vs 16%, P<0.001). The haemoglobin, serum albumin and creatinine values were significantly higher amongst the tuberculin-reactor ESRD patients. Tuberculin positivity and anergy rates in a subgroup of well-nourished ESRD patients were similar to the control population. Four patients developed tuberculosis after transplantation. Tuberculin test had a sensitivity of 50% and a specificity of 52% for post-transplant tuberculosis., Conclusions: In comparison to healthy controls, tuberculin reactivity rates are lower and anergy rates higher in Indian ESRD patients. There is a significant relationship between markers of nutritional status (haemoglobin, albumin and creatinine) and cutaneous reactivity. Pre-transplant Mantoux positivity has low sensitivity and specificity for predicting post-transplant tuberculosis.

Background: Rapid decline of renal function in a diabetic suggests the presence of a nondiabetic kidney disease (NDKD). We designed a prospective study to evaluate the factors associated with a rapid decline in renal function in patients with type 2 diabetes., Methods: Over a 2 and a half year period, all patients with type 2 diabetes who presented with documented doubling of serum creatinine in less than 4 weeks or recently diagnosed advanced renal failure were identified. Patients with prerenal causes, urinary tract obstruction, or systemic disease causing renal failure were not included. Renal histology was studied in all cases., Results: A total of 26 patients satisfied the inclusion criteria. Over 75% had serum creatinine >4 mg/dL at presentation and 62% were dialysis dependent. Renal histology showed mixed lesions of diabetic nephropathy (DN) and NDKD in 11 cases, only DN in nine, and pure NDKD in six. Diffuse proliferative glomerulonephritis (DPGN) was the commonest NDKD (27% cases), all on a background of DN. History of preceding cutaneous or pharyngeal infection was available in five cases. The proportion of postinfectious glomerulonephritis in diabetics with rapidly progressive renal failure was over six times that of the nondiabetic adult RPRF population during the study period. Four patients had acute interstitial nephritis and three showed crescentic glomerulonephritis. Other lesions included amyloidosis, atheroembolic disease, and renal papillary necrosis (one each). The frequency of microscopic hematuria and retinopathy was similar in those with pure DN and NDKD. Four out of seven cases with DPGN showed partial recovery whereas the other three remained unchanged., Conclusions: About two-thirds of patients with type 2 diabetes presenting with rapid decline of renal function in a tropical environment show NDKD. The high incidence of postinfectious glomerulonephritis in this group is possibly related to the high prevalence of skin and soft tissue infections; and could contribute to progressive kidney disease.

Combined liver and kidney transplantation is the ideal treatment for patients with end-stage renal failure secondary to primary hyperoxaluria and systemic oxalosis, with a functioning liver providing replacement of the deficient enzyme and a functioning kidney providing the route of excretion for the oxalate crystals. Pancytopenia from bone marrow infiltration of oxalate crystals is a rare complication of primary hyperoxaluria, and its reversal following transplant has not been described. We report the first case of pancytopenia from marrow infiltration by oxalate crystals reversing following a successful kidney transplant alone. Although kidney alone transplants do not provide the best chance of survival or quality of life as compared to a combined kidney and liver transplant, a well functioning kidney transplant is able to take care of the systemic oxalate load and ameliorate, at least for a period of time, the systemic complications of oxalosis.

Recurrence of amyloidosis secondary to chronic infections in the renal allograft is highly unusual. We report the recurrence of amyloid in the graft within one year after transplantation in a patient with systemic AA amyloidosis secondary to tuberculosis. The diagnosis of tuberculosis was made in the immediate post-transplant period on the basis of good therapeutic response of fever and chest infiltrates to anti-tubercular chemotherapy.

In the absence of national registries, no reliable data are available on the incidence and prevalence of end-stage renal disease (ESRD) in India and Pakistan. The incidence of ESRD is likely to be higher than that reported from the developed world, with chronic glomerulonephritis being the most common cause, accounting for more than one third of patients, while diabetic nephropathy accounts for about one fourth of all patients in India. Patients are generally younger (mean age 42 years) at the time of detection of ESRD and two-thirds first see a nephrologist after they have reached end stage. Treatment of ESRD is a low priority for the cash-strapped public hospitals and in the absence of health insurance plans, less than 10% of all patients receive any kind of renal replacement therapy. The vast majority of patients starting hemodialysis die or stop treatment because of cost constraints within the first three months, and less than 2% patients are started on ambulatory peritoneal dialysis. Although renal transplantation is the cheapest option, only about 5% of all patients with ESRD end up having a transplant. Living related donor transplants constitute 30 to 40% of all transplants in India, but there is a conspicuous gender bias with female donors donating kidneys for their male relatives. Cadaveric transplantation has yet to pick up and accounts for less than 2% of all transplants. The enactment of legislation to regulate renal transplantation in India has not been able to prevent unrelated (paid) donor transplants, which constitute 60 to 70% of all renal transplants. Cyclosporine, azathioprine and prednisolone continue to be the backbone of post-transplant immunosuppression, with cyclosporine being stopped in a significant proportion at one year post-transplant to cut down costs. Increasing awareness of renal disease amongst the population and general practitioners could result in early diagnosis of chronic renal failure and give opportunity for preventive strategies to delay the onset of ESRD. Preemptive transplantation and use of generic cyclosporine can help bring down the costs of treatment. Innovative and affordable health insurance policies can also increase the number of patients who receive effective treatment for ESRD in these two countries.

Cardiac arrhythmias are noted in a significant proportion of chronic renal failure (CRF) patients on hemodialysis (HD), and may contribute to cardiovascular mortality. A number of factors have been implicated in the genesis of these arrhythmias. The role of silent myocardial ischemia (SMI), however, has not been evaluated systematically. We prospectively studied 38 unselected CRF patients on regular HD by continuous Holter monitoring starting 24 hours before HD, lasting through the dialysis session and continued for 20 hours thereafter. The recordings were analyzed for frequency, timing and severity of supraventricular and ventricular arrhythmias and SMI as identified by ST-segment depression. Ventricular arrhythmias during HD were noted in 11 (29%) patients (group I), and were potentially life-threatening (Lown Class III and IVa) in 13%. The remaining 27 patients (group II) had no ventricular arrhythmias during HD. There was no difference in the age, sex ratio, duration of HD, blood pressure, fluctuations in weight, hematocrit, predialysis creatinine, sodium, potassium, calcium or inorganic phosphate levels between patients in the two groups. The number of patients with clinical ischemic heart disease was significantly greater in group I. SMI was noted in 72% and 33% of group I and II patients respectively (p = 0.026). 46% of those with and 25% of those without ST changes during HD developed ventricular arrhythmias during HD. Both SMI and ventricular arrhythmias were noted most frequently during the last hour of dialysis. Hypertension, diabetes mellitus and ischemic heart disease were observed more frequently amongst patients with SMI. Ventricular arrhythmias are detected in a significant proportion of CRF patients on HD. These are probably related to coronary artery disease since silent myocardial ischemia is also noted more frequently during HD in these patients. Further studies incorporating coronary angiography are needed in a larger number of patients to establish a definite causal relationship.

Posttransplant diabetes mellitus is a well-recognized complication of renal transplantation. Although such patients are at risk for the development of de novo diabetic glomerulosclerosis with increasing graft survival, this has rarely been reported. We describe a patient with posttransplant diabetes mellitus who developed end-stage renal failure due to diabetic glomerulosclerosis 12 years after renal transplantation.

Lipid profile and postheparin lipolytic activity (PHLA) were investigated in 21 patients with acute renal failure (ARF), 24 with chronic renal failure (CRF), and 23 healthy volunteers. Plasma triglycerides were significantly elevated in ARF (155.19 +/- 72.39 mg/dL) as well as CRF (166.79 +/- 72.36 mg/dL), as compared to controls (89.91 +/- 23.41 mg/dL, p < .001). PHLA was determined at 5, 10, 30, and 60 min after intravenous heparin (100 U/kg) and was observed to be reduced in ARF (7.82 +/- 1.41 mumol FFA/mL/h) as well as CRF (8.44 +/- 1.68 mumol FFA/mL/h) at 10 min, as compared to the values in the control subjects (12.03 +/- 2.43 mumol FFA/mL/h, p < .01). No correlation was found between PHLA and plasma triglycerides in ARF or CRF. In 15 patients in each group, PHLA subfractions, hepatic triglyceride lipase (HTGL), and lipoprotein lipase (LPL) were determined at similar time intervals after heparin. Both fractions were found to be reduced significantly (p < .01) in ARF as well as in CRF versus controls. These findings indicate that the lipid alterations in acute and chronic renal failure share common features including hypertriglyceridemia and reduced PHLA and its subfractions HTGL and LPL.

A 45-year-old patient with tuberous sclerosis and bilateral renal angiomyolipomas who presented with chronic renal failure is reported. Although bilateral renal angiomyolipomas are commonly associated with tuberous sclerosis, the occurrence of chronic renal failure in the absence of associated cystic disease of the kidneys as seen in this patient is very rare.

Corticotropin-dependent Cushing's syndrome was detected in a 32-year-old male suffering from membranous nephropathy and chronic renal failure. Cortisol dynamics revealed high basal cortisol, loss of circadian rhythm, and nonsuppressibility with low-dose dexamethasone. However, the latter was suppressible with high-dose dexamethasone. Treatment with ketoconazole led to a remarkable response both clinically and biochemically. The occurrence of Cushing's syndrome in a patient with chronic renal failure is extremely rare and poses significant diagnostic and therapeutic problems.

Autonomic functions were evaluated in 25 nondialyzed patients with chronic renal failure and eight controls. Eight patients were reassessed after 6.6 +/- 1.0 weeks of hemodialysis and 12 patients were restudied 24 +/- 4.0 weeks after renal transplantation. In addition, six patients who had been on maintenance hemodialysis for a duration of 21.5 +/- 3.0 weeks were also studied. Autonomic function tests, including blood pressure and heart rate response to sudden loud noise, mental arithmetic, hand immersion in cold water, Valsalva maneuver, change in posture and respiration, were performed using brachial artery cannulation and continuous monitoring by electrocardiogram. Baroreceptor sensitivity slope was determined using bolus injections of phenylephrine. Supine and standing plasma norepinephrine levels were measured. The cold pressor test, response to sudden loud noise and mental arithmetic were normal in nondialyzed patients with chronic renal failure, suggesting an intact efferent sympathetic pathway. The plasma norepinephrine concentration varied widely but the mean value was similar to the control group (P greater than 0.05). Expiration/inspiration ratio, lying/standing ratio, Valsalva ratio and the baroreceptor sensitivity slope were significantly abnormal (P less than 0.001) in nondialyzed patients. This indicates a defective efferent parasympathetic pathway and depressed baroreceptor sensitivity. The blood pressure response to phenylephrine was lower in the uremics, suggesting a reduced end-organ responsiveness to alpha agonists. The presence of hypertension did not affect autonomic function. The heart rate response to standing and the baroreceptor sensitivity were significantly lower (P less than 0.05) in patients who developed hypotension during hemodialysis. Lower baroreflex sensitivity could contribute to hypotension during dialysis. Autonomic functions remained unaltered after short- and long-term dialysis.(ABSTRACT TRUNCATED AT 250 WORDS)

We studied the profile of nephropathy in 250 patients, 177 males and 73 females, with type 2 diabetes mellitus. The mean age was 55.9 +/- 8.8 years. Therapy for control of diabetes included diet alone in 1.6%, oral hypoglycaemic agents in 90.6% and insulin in 7.8%. Glycaemic control was satisfactory in 4.8%, fair in 41.2% and poor in 54.0%. Blood sugar values were normal without any therapy in 33 out of the 206 patients (16%) after the onset of renal insufficiency. The mean interval between the onset of diabetes and the appearance of proteinuria was 9.5 +/- 7.05 years. Proteinuria appeared within one year in 23 patients (9.2%), 1-5 years in 32 (12.8%), 6-10 years in 86 (34.4%) and more than 10 years in the remaining 109 patients (43.6%). Proteinuria was of nephrotic range in 17.6% of patients. Renal insufficiency was present in 206 (82.4%) patients and occurred 10.5 +/- 7.5 years after the detection of diabetes. Hypertension was present in 61.2% and was first detected 7.5 +/- 7.4 years after onset of diabetes. Endstage renal disease occurred 11.8 +/- 6.8 years after the onset of diabetes mellitus. Thus, clinical evidence of diabetic nephropathy is present in most patients with type 2 diabetes mellitus within a decade after the detection of diabetes. Subsequent progression to end-stage renal failure is rapid in the face of poorly controlled hypertension and hyperglycemia in the economically poor countries.

193 patients (142 adults and 51 children) with acute PSGN were followed long term. Sixty percent had elevated serum creatinine and 14% had nephrotic range proteinuria at the onset. By two years 28 patients (14%) had died from uremia, and 19 were lost to follow up. Amongst the remainder, 8 patients (4%) had developed mild to moderate renal insufficiency, 12% were hypertensive, and 22% had urinary abnormalities. Of the 146 patients alive at 2 years, 107 were followed up to 10 years (mean 4.8 years). In addition to the 8 patients with renal insufficiency at 2 years, another 7 developed renal failure subsequently. Four out of these 15 patients progressed to uremia within 4 to 10 years after the onset of disease. Hypertension and persistent urinary abnormalities were present in 15% and 24% respectively. Progression to uremia occurred in 6% of children and 20% of adults. Nephrotic range proteinuria, renal insufficiency at the onset, and crescents in more than one third of glomeruli indicated a poor prognosis.

Nine fatal cases of systemic mucormycosis observed in association with renal failure are described. Four patients were hospitalized for chronic renal failure as a consequence of chronic glomerulonephritis, myeloma kidney, chronic pyelonephritis, and polycystic kidney disease, respectively; and five patients presented with acute renal failure. The underlying causes in three of these five patients were gentamycin nephrotoxicity, acute gastroenteritis, and allograft rejection, respectively, and in the remaining two, acute renal failure was the result of extensive renal vascular and parenchymal invasion by mucor hyphae. Tissue invasion with mucormycosis was documented during life in two patients and at autopsy in seven patients. The infection was disseminated in five patients, and isolated pulmonary and rhinocerebral involvement occurred in two patients each. Our observations have shown that patients with renal failure are prone to develop mucormycosis, which carries a grave prognosis if therapy is not instituted in time.