Urinary C5b-9 excretion and clinical course in idiopathic human membranous nephropathy

Recent reports suggested that the presence of terminal complement complex (C5b-9) in urine from patients with idiopathic membranous nephropathy (IMN) may indicate on-going immunological damage. This report documents the relationship between C5b-9 excretion and clinical outcome in 35 adult patients with biopsy-proven IMN and progressively declining renal function. There were two groups of patients. Group I received one of three treatment regimens: prednisolone alone, prednisolone and chlorambucil, or prednisolone and cyclophosphamide (N = 22). Group II received no immunosuppressive therapy (N = 17). Three of the 18 patients receiving immunosuppressive drugs had more than one treatment regimen as they experienced a clinical relapse during the study period; hence 22 treatments were available for analysis. Urine samples were collected regularly and urinary C5b-9 (uC5b-9) was determined by ELISA. Both groups were similar with respect to age, sex distribution, and the duration of follow-up. An improvement in proteinuria and creatinine clearance was noted in the immunosuppressed group. Thirty-five patients were excreting C5b-9 initially (18 from group I and 17 from group II); 17 patients continued to excrete C5b-9 at the end of the observation period. These 17 patients had a significantly worse clinical outcome when compared to the 18 patients whose C5b-9 excretion became negative, either spontaneously or with treatment (P < 0.005). These results indicate that continuing C5b-9 excretion is correlated with a poor clinical outcome. They also suggest that uC5b-9 is a dynamic marker of ongoing immunological injury, and therefore may be useful in the initial assessment and monitoring of patients with IMN and in identifying patients who may derive benefit from immunosuppressive therapy.     

Corticosteroids in the treatment of tuberculous pleurisy. A double-blind, placebo-controlled, randomized study

Although several studies on tuberculous (TB) pleurisy suggest that the addition of corticosteroids to anti-TB therapy may have beneficial effects, these agents are not used routinely. To assess the effects of short-term oral prednisone therapy in TB pleurisy, 74 patients were randomly assigned in a double-blind fashion to treatment with either placebo or prednisone at a dose of 0.75 mg/kg/d for up to 4 weeks with gradual reduction over an additional 2 weeks. All subjects received a standard 3-drug anti-TB chemotherapy regimen for 6 months. TB pleurisy was diagnosed by histologic study and/or culture of pleural biopsy specimens obtained at thoracoscopy. Complete drainage of the effusion was performed simultaneously. Outcome measures were assessed periodically for 24 weeks, including indexes of morbidity and pleural thickening. After randomization, four patients were excluded from the final analysis. Of the 70 patients analyzed, 34 received prednisone and 36 received placebo. Demographic and clinical characteristics of the treatment groups were comparable at the time of hospital admission. Although a statistically significant improvement in symptoms occurred earlier in the prednisone group (8 weeks) than in the placebo group (12 weeks), between-group comparison showed no significant differences at any of the follow-up evaluations. The proportion of subjects in the prednisone group (53.1%) with residual pleural thickening at 6 months did not differ significantly from that of the placebo group (60%). Pleural effusions did not recur in any of the patients. Initial complete drainage of the effusion was associated with greater symptomatic improvement than any subsequent therapy. We conclude that standard anti-TB therapy and early complete drainage is adequate for the treatment of TB pleurisy. The addition of short-term oral prednisone therapy neither results in clinically relevant earlier symptom relief nor confers a beneficial effect on residual pleural thickening.     

Steroid therapy during the early stage of progressive IgA nephropathy. A 10-year follow-up study

This study was undertaken to clarify the effect of corticosteroids on the long-term clinical course of the early stage of progressive IgA nephropathy. The early stage of progressive IgA nephropathy was defined as having moderate proteinuria between 1 and 2 g/day, creatinine clearance values of 70 ml/min or more, and a histological severity score of 7 or more. The number of patients who fulfilled these three conditions during 12 years from 1972 and then were continuously followed up for 10 years or more in our renal unit was 46. Twenty of them received steroid treatment for an average period of 18 months, and the remaining 26 patients had no steroid treatment. The initial data of proteinuria, creatinine clearance values, frequency of hypertensive cases, and histological scores of 7 or more were not different between the two groups: 1.4 +/- 0.4 vs. 1.3 +/- 0.3 g/day, 85 +/- 14 vs. 88 +/- 13 ml/min, 25 vs. 38%, and 10.7 +/- 2.5 vs. 11.0 +/- 3.0, respectively. During the follow-up period of 10 years, the renal survival rate was significantly different between the two groups (100 vs. 84% 5 years after starting therapy and 80 vs. 34% 10 years later; p < 0.001). The final creatinine clearance values were significantly different between the two groups (54 +/- 35 vs. 20 +/- 29 ml/min; p < 0.005). On the other hand, the patient groups with mild histological changes or decreased renal function due to moderate proteinuria showed no significant differences in the final outcome. These results indicate that corticosteroids are beneficial in stabilizing the renal function for a long time during the early stage of progressive IgA nephropathy, although this study was not a randomized one.     

Psychodynamic changes through systematic desensitization.

Attempted to integrate psychoanalytic theory and the data from behavior therapy, specifically systematic desensitization. It was found that snake phobics could be significantly discriminated from a group of normals on a measure of castration anxiety. Following systematic desensitization of the fear of harmless snakes, (a) 10 treated snake phobics were significantly lower on manifest anxiety than 10 nontreated snake phobics, but not as low as 10 normals; (b) treated snake phobics were significantly lower than nontreated snake phobics on a TAT measure of castration anxiety, but not as low as normals; and (c) treated snake phobics were not significantly lower than nontreated snake phobics on a Rorschach measure of castration anxiety, and both were significantly higher than normals. (20 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Erster Bericht über eine kontrollierte klinische Untersuchung zur Prednisolon-Behandlung der thorakalen Sarkoidose

117 patients with histologically confirmed mediastino-pulmonary sarcoidosis stage I and II without extrapulmonary manifestations were included in a controlled therapeutic trial. 92 patients remained for analysis. Among these 54 were treated for 6 or 12 months with prednisolone and isoniacid; 38 were not treated. 6 and 12 months after beginning the observation, improvement was more frequent in the treated group. After 3 years and 5 years (45 patients only) however differences were no more evident: improvement was observed in about 80 per cent, complete remission in about 65 per cent in treated and untreated patients. In both groups, patients presenting dissemination in the lungs had worse results than those with hilo-mediastinal adenopathy associated or not with pulmonary dissemination. Prednisolone seems to have effects in the early phase of sarcoidosis but is apparently not so effective in respect to the general development of the illness and in preventing pulmonary fibrosis. Therefore strict indication for therapy with corticosteroids of sarcoidosis exist when progressive pulmonary dissemination and/or reduction of pulmonary function is evident.     

Corticosteroids as adjunctive therapy for diffuse alveolar hemorrhage associated with bone marrow transplantation. University of Nebraska Medical Center Bone Marrow Transplant Group

BACKGROUND: Diffuse alveolar hemorrhage is a frequent complication of treating malignancies with high-dose chemotherapy and bone marrow transplantation and is associated with very high mortality. This disorder's association with pulmonary inflammation, its coincidence with marrow recovery, and the usefulness of corticosteroids for treating other pulmonary hemorrhage syndromes provided the rationale for this study. METHODS: We retrospectively studied 65 episodes of diffuse alveolar hemorrhage that has occurred in 63 of 603 consecutively treated patients who had undergone high-dose chemotherapy with bone marrow transplantation. Patients were divided into three groups according to the therapy they had received for diffuse alveolar hemorrhage: supportive therapy alone (n = 12); low-dose corticosteroids (30 mg or less of methylprednisolone or its equivalent; n = 10); and high-dose corticosteroids (more than 30 mg methylprednisolone or its equivalent; n = 43). The primary outcome measures were overall survival and survival to hospital discharge, occurrence of respiratory failure requiring intubation, and development of infections subsequent to the diagnosis of diffuse alveolar hemorrhage. RESULTS: Overall survival at the end of the follow-up period was significantly higher for the high-dose corticosteroid group compared with the supportive therapy group (P = 0.005); however, treatment with low-dose steroids did not increase survival over supportive therapy alone (P = 0.198). In addition, survival to discharge was significantly increased for the high-dose group compared with the other two groups combined (33% versus 9.1%, P = 0.038). Respiratory failure after the diagnosis of diffuse alveolar hemorrhage developed in only 12 of the 22 unintubated patients in the high-dose group compared with 9 of the 10 initially unintubated patients in the other two groups (P = 0.056). Although the incidence of infections was high (40%) subsequent to diffuse alveolar hemorrhage, neither high-dose nor low-dose corticosteroid treatment significantly increased the risk of infections (P > 0.4, all comparisons). CONCLUSIONS: In this study, high-dose corticosteroid therapy for diffuse alveolar hemorrhage related to bone marrow transplantation was associated with improved total survival and survival to hospital discharge, and decreased development of respiratory failure in these patients. These results suggest the therapy is beneficial, and further prospective studies are warranted to verify the effectiveness of the treatment.     

Unsatisfactory results of a first-generation modular femoral stem implanted without cement. A 4- to 9-year follow-up study

In a attempt to clarify the effects of methylprednisolone pulse therapy on the insidious (subacute) type of crescentic glomerulonephritis with slow, but steady deterioration of renal function and poor response to treatment, we analyzed the clinical course of 24 patients (male:female = 15:9) with a mean age of 48.5 years. They fulfilled the following criteria: 1) crescents were observed in more than 50% of the glomeruli, 2) the increment of serum creatinine (Cr) could be determined sequentially on three or more occasions before treatment, and reciprocals of serum Cr declined with slopes of less than 1.0 x 10(-2) dl/mg/day, 3) corticosteroids and/or immunosuppressants were administered. The patients were divided into two groups: pulse therapy group (P) (15 patients), to which methylprednisolone 500 or 1,000 mg a day was administered intravenously for three consecutive days, and a conventional therapy group (C) (9 patients). There were no differences between groups P and C in clinical parameters, including sex, age, underlying diseases, urinary protein, blood pressure, serum Cr and slope of 1/Cr before treatment, and pathological findings, including percentages of glomeruli with crescents and degree of interstitial lesions. However, improvement of serum Cr, which was defined as a decline to the normal range or less than half of the pretreatment level, was observed in 9 (60%) in group P vs. only 1 (11%) in group C (p < 0.05). Re-biopsies were performed after treatment in 6 patients of group P with an improvement of serum Cr, and showed a decrease in the rate of crescent formation and almost complete loss of cellular crescents. At 1, 2 and 3 years follow-up, the renal survival rates were 86, 70 and 53%, respectively, in group P vs. 67, 14 and 14% respectively, in group C (p < 0.05). No serious side effects were observed in group P. These results suggest that methylprednisolone pulse therapy may be very effective for the insidious type of crescentic glomerulonephritis.     

Nephritis in systemic lupus erythematosus in children

Twenty-five patients, aged six to 18 years, with lupus nephritis, followed for two to 103 months (median 22 months), have been classified according to renal histology into groups with diffuse proliferative glomerulonephritis (18), focal proliferative nephritis (2), and membranous nephropathy (5). Correlations have been made among specific histologic groups, clinical findings, renal function studies, urinary findings, and response to therapy. In sequential renal biopsies, lesions progressed in most patients with diffuse proliferative and membranous changes; however, chronic renal failure occurred in only one patient and the five-year survival rate (60.9%) is better than previously reported in pediatric patients.     

A case of malignant rheumatoid arthritis complicated by secondary amyloidosis and membranous nephropathy

A 30-year-old man had been treated for malignant rheumatoid arthritis from 1989 with a non-steroidal anti-inflammatory drug, then bucillamine for six months and prednisolone. Mild proteinuria appeared in May 1994, 4 years after bucillamine therapy was conducted. The patient was admitted to our hospital for a renal biopsy in July 1994. The specimen revealed secondary amyloidosis and membranous nephropathy (MGN). These findings suggest that MGN unrelated to bucillamine therapy might have occurred with secondary amyloidosis in rheumatoid arthritis.     

Prevalence of diabetic nephropathy in adult patients with chronic kidney failure

Diabetic nephropathy is a frequent cause of end-stage renal failure in patients admitted for renal replacement therapy. PURPOSE: To evaluate the prevalence of DN, as the underline disease, in patients with ESRF. METHODS: 1,303 [male (M) = 767 and female (F) = 536] patients with ESRF who were on a waiting list for cadaver kidney transplant at Nephrology Unit-University Hospital (HC-UNICAMP), from August/90 to June/93--group 1--and 193 (M = 112 and F = 81) patients admitted for renal replacement therapy in a year period (April/92 to March/93), in the city of Campinas, State of S?o Paulo, Brazil, were studied. RESULTS: The prevalence of DN was 10.1% in group 1 and 17.6% in group 2 (x2 = 7.15; p = 0.007), being the third cause of ESRF in both groups, and it was preceded by glomerulonephritis and arterial hypertension. In group 1 the reduction of number of patients with increase in duration of dialysis was significantly greater in patients with diabetic nephropathy (x2 = 30.9; p < 0.001). Among patients with DN 35 (26%) in group 1 and 6 (18%) in group 2 had less than 35 years when they were admitted for renal replacement therapy and are likely to be type 1 (insulin-dependent) diabetic patients. CONCLUSION: In our studied groups DN was a frequent cause of ESRF.     

Lack of effects of recombinant growth hormone on muscle function in patients requiring prolonged mechanical ventilation: a prospective, randomized, controlled study

OBJECTIVE: To evaluate the benefit of recombinant human growth hormone administration on muscle strength and duration of weaning in critically ill patients undergoing prolonged mechanical ventilation. DESIGN: Prospective, randomized, controlled, single-blind study. SETTING: Intensive care unit. Patients: Twenty patients requiring > or = 7 days of mechanical ventilation for acute respiratory failure. INTERVENTION: Random assignment to receive either 0.43 IU (approximately 0.14 mg) recombinant growth hormone/kg body weight/day (treated group), or saline (nontreated group) for 12 days. MEASUREMENTS AND MAIN RESULTS: Nutritional support was guided by indirect calorimetry. Cumulative nitrogen balance was positive throughout the study period in the treated group 17.3 (44.9 +/- 17.3[SEM] g/12 days) vs. the nontreated group (-65.8 +/- 11.8 g/12 days) (p<.0001). Despite similar initial plasma concentrations, recombinant growth hormone supplementation resulted in marked increases in growth hormone, insulin like growth factor-1, and insulin concentrations (p<.05, .02, and .0001, respectively, vs. nontreated group). Body impedance determined net fat-free mass increased in the treated group (0.8 +/- 0.6 kg) vs. the nontreated group (-1.1 +/- O.5 kg) (p<.03). Initial peripheral muscle function, assessed by computer-controlled electrical stimulation of the adductor pollicis, was similarly lower in treated and nontreated groups than sex and age-matched normal controls, and decreased further during the study period. Arterial blood gases, cumulative total mechanical ventilation time, and number of hrs/day of mechanical ventilation during weaning were similar in both patient groups. Only three of the ten patients in each group were weaned from mechanical ventilation by day 12. CONCLUSIONS: Daily administration of recombinant growth hormone in mechanically ventilated patients with acute respiratory failure promotes a marked nitrogen retention. However, this reaction is accompanied neither by an improvement in muscle strength nor by a shorter duration of ventilatory supports.     

Drug utilization patterns and outcomes associated with in-hospital treatment with risperidone or olanzapine

This study compared the drug-utilization costs and indicators of clinical outcomes associated with the use of risperidone and olanzapine in a hospital setting. We conducted a nonrandomized, retrospective chart review of consecutive patients identified as presenting with psychotic symptoms on inpatient wards at Riverview Hospital in British Columbia and given either risperidone or olanzapine as their first new drug after reassessment (n = 30 per treatment group). Data were collected for up to 120 days. No significant differences were observed between groups in terms of sex, age, duration of illness, or diagnosis. The mean dosage of risperidone for responders was 4.89 +/- 2.56 mg/d, whereas that for olanzapine was 17.19 +/- 3.88 mg/d. The associated daily drug-acquisition costs were significantly different, at CA$4.69 for risperidone and CA$11.52 for olanzapine. Notes in patient charts indicated that a significantly greater proportion of risperidone-treated patients (60.0%) than olanzapine-treated patients (26.7%) responded to therapy, as indicated by improvement in at least one target symptom (P < 0.01). Forty percent of patients initially treated with risperidone were discharged on their original therapy, compared with 13.3% of patients treated with olanzapine (P < 0.05). These results were not substantially affected by correction for markers of illness severity or treatment resistance. Overall, no significant differences in side effects were recorded in the patient records of the two groups. Within this cohort of patients, risperidone treatment was associated with lower drug-acquisition cost and better treatment outcomes than olanzapine.     

Long-term results of two schedules of treatment for toxic multinodular goitre with radioiodine therapy

Results of the long-term effects of two schedules of radioiodine therapy I131 in 130 toxic multinodular goitre patients were evaluated. Seventy five patients (group I) were treated with low doses and 55 patients (group II) with calculated high doses adjusted for thyroid weight (0.5-1 mci/g) and radioiodine uptake. Follow up (mean +/- SEM) was 4.5 +/- 0.4 years and 4.8 +/- 0.6 years respectively (P > 0.1). At the end of follow up, hyperthyroidism was successfully reversed in 78% (Group I) and 82% (Group II). In group I hypothyroidism was present in 5% of patients, while it was 12.5% in group II patients. The total dose per gram of thyroid tissue was not significantly different in both the groups (.058 mci +/- .0054 VS .073 +/- .0054 mci/g). However in group II the number of I131 administration was significantly lower (1.5 +/- 0.2) than in group I (3.2 +/- 0.4). The percentage of patients who were adequately treated in Group II with single dose was more as compared in group I (62% in group II versus 40% in group I). Euthyroidism was reached in a shorter time after treatment in group II (median time 0.8 year in group II Vs 1.1 yrs in group I) It is concluded that radioiodine is an effective treatment for toxic multinodular goitre with a significant low incidence of post therapy hypothyroidism in patients treated with low doses as compared to higher doses of radioiodine therapy.     

Malignant tumors in hemodialysis patients

We reviewed the incidence of malignant tumors among 923 patients with chronic renal failure, treated with hemodialysis (HD) in seven dialysis centers in Serbia between January 1983 and July 1993. Neoplasms were diagnosed in 45 cases (4.9%). The mean age of the cancer patients was 58.7 years. Eighteen cases (40.0%) were diagnosed in the first year after starting HD treatment and 21 (46.7%) cases were detected less than 5 years after induction of HD treatment. Most of the cancer patients (60.0%), especially the patients with Balkan endemic nephropathy (31.1%), developed cancer of the urinary tract. We concluded that HD patients have a several times greater risk of developing malignant tumors than the general population.     

Fish oil therapy in IgA nephropathy

IgA nephropathy often progresses to endstage renal failure over a period of many years, and any therapy directed to IgA nephropathy will most likely have to be administered over an extended period of time. Therefore, optional therapy should be effective and free of long-term adverse effects. Besides fish oil, prednisone has also been investigated for treatment of IgA nephropathy, with a lack of consistent results; severe adverse effects are common with long-term use. Several studies have shown positive although not overly impressive results; therefore optimal therapy for slowing the progression of renal failure secondary to IgA nephropathy has not been established. Problematic issues with available studies included the following: (1) most of the clinical studies previously discussed were short-term, contained small numbers of patients, and most but not all were uncontrolled; (2) early reports involving fish oil therapy demonstrated conflicting results regarding its efficacy, including one study that observed increased progression of renal disease in patients treated with fish oil; however, recent studies have shown more promise for fish oil therapy for up to 2 years of treatment; and (3) since most of the studies were conducted over a short period of time, it is difficult to assess long-term effects and safety of oil treating IgA nephropathy, a disease that progresses to ESRD over 10-20 years. However, given the low number of adverse effects and apparent low risks associated with this relatively safe food supplement therapy observed in most clinical trials of up to 2 years duration, fish oil may slow the progression of renal failure in patients with IgA nephropathy. Therefore, with appropriate monitoring of renal function and blood tests, treatment with fish oil 6-12 g/d should be considered in patients with IgA nephropathy.     

Long-term prognosis for tonsillectomy patients with IgA nephropathy

A retrospective study of 85 patients with IgA nephropathy was undertaken to determine the long-term effect of tonsillectomy. Forty-three patients (24 males and 19 females) had received tonsillectomies (Group A) and 42 patients (17 males and 25 females) had not (Group B). These patients had been followed up for more than 5 years after renal biopsy. The average age at the initial renal biopsy was 25.72 years in Group A, and 33.16 years old in Group B. The average period of renal biopsy to tonsillectomy in Group A was 10.47 months. The average follow-up period was 8 years and 9 months in both groups. At the beginning of treatment, the two groups were well matched in terms of creatinine clearance, urinalysis, and blood pressure. Six patients in Group A and eight patients in Group B were treated with steroids. The glomerular injury detected at the renal biopsy was more extensive in Group A than in Group B. Renal function in the two groups was compared. The clinical remission rate in Group A was significantly higher than in group B (P<0.05). The stable renal function rate in Group A was significantly higher than in Group B (P<0.05). The renal survival rate was 97.7% in Group A and 83.3% in Group B, but there was no significant difference between the two groups. Histologically, the rate of remission of the minor lesion in Group A was significantly higher than in Group B (P < 0.05). Our results showed that tonsillectomy for IgA nephropathy was clinically of great value.     

Effect of daunorubicin on the growth of adenovirus

Data on 40 patients with Staphylococcus aureus endocarditis treated with appropriate antibiotics in adequate dosage at the University of Cincinnati Medical Center hospitals between January 1961 and June 1975 were analyzed. The overall mortality was 40 per cent. The mortality was 11.1 per cent in patients under 50 years old and 63.6 per cent in patients over 50 years old (p less than 0.01). Seven patients were narcotic addicts who had no underlying disease and were under 50 years old; all survived. For patients without underlying diseases, the mortality was 0 per cent in those under 50 years old and 75 per cent in those over 50 years old. Patients who died had a greater number of major underlying diseases (pre-existing cardiac disease, diabetes mellitus, alcoholism and/or cirrhosis) than the survivors. Patients over 50 years old had significantly more major underlying diseases than patients under 50 years old (p less than 0.001). Among patients over 50 years old, those who died had more complications than the survivors while the number of underlying diseases were comparable. A group of patients treated with gentamicin during the first two to three weeks of therapy in addition to a penicillin was compared to a similar group treated with a single antibiotic. The mortality of both groups was 40 per cent.     

Long-term oral corticosteroid therapy does not alter the results of immediate-type allergy skin prick tests

BACKGROUND: Medications can modulate the results of skin prick tests (SPTs). Short-term corticosteroid therapy does not alter IgE-mediated skin tests, but the impact of long-term oral corticosteroid therapy on SPT results is unclear. A prospective study was carried out in patients with steroid-dependent asthma who received oral corticosteroids for a long period to determine whether this treatment reduced skin test reactivity. METHODS: Thirty-three patients with steroid-dependent asthma (median age, 59 years) were compared with 66 patients with asthma who served as a control group, matched for age, sex, and atopic status. SPTs with codeine phosphate and a screening battery of standardized allergen extracts were performed before commencement and after at least 1 year of daily oral prednisone treatment (median duration, 2 years; median daily dose, 20 mg). RESULTS: Fifteen patients with corticosteroid-dependent asthma were allergic before treatment, and their sensitization was not changed by long-term treatment with oral corticosteroids. The median wheal diameters induced by codeine phosphate were similar in both groups. The median wheal diameters induced by allergens, and more specifically, by Dermatophagoides pteronyssinus and D. farinae were similar in both groups and did not change in the steroid group after treatment. CONCLUSIONS: Systemic corticosteroid therapy (prednisone, 10 to 60 mg/day) for 2 or more years does not seem to alter SPT reactivity.     

Effects of enalapril during continuous nitrate therapy: analysis of diameter of coronary arteries and platelet cyclic guanosine monophosphate

To investigate the effects of enalapril, an angiotensin-converting enzyme inhibitor, on nitrate tolerance during continuous nitrate therapy, coronary artery diameters and platelet cyclic guanosine monophosphate (cGMP) levels were measured before and 2 minutes after intracoronary injection of nitroglycerin 200 microg in 60 patients with coronary artery disease and were compared among 20 patients treated with nitrates (nitrate group), 20 patients treated with both nitrates and enalapril (enalapril group), and 20 untreated patients (control group). The percent increase in platelet cGMP and coronary dilatation in the nitrate group was significantly less than in the control group, but the percent increase in the enalapril group was significantly greater than that in the nitrate group. These results indicate that enalapril may be helpful as concomitant therapy to maintain the effect of nitrates during continuous nitrate therapy.