19th Annual Scientific Meeting Abstracts

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

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• INDICA1ES ORAL PRESENTATION AT THE JOINT ASN-NKF FREE COMMUNICATIONS SESSION • INDICA1ES PRESENTATION AT NKF POSTER SESSION o INDICATES PRESENTATION AT THE ASN-NKF JOINT POS1ER SESSION •

LONG-TERM CYCLOSPORIN (CyA) EFFECTS IN LIVER TRANSPLANT RECIPIENTS. Ser&io R. Acchiardo. Santiago Vera, and Martin Lee. Univ. of TennesseeMemphis, Dept. of Medicine-Nephrology, Memphis, Tennessee. We evaluated the long-term effects of CyA in 44 patients (pts) who received a liver transplant. Mean age 40 ± 12 y., 26 females. Mean follow-up 23.3 m. (range 3 to 60 m.). Pts received CyA, Prednisone and later Azathioprine. Follow-Up (m) Pre-Op 3 BUN (mg/dl) 13 37 S.Cr. (mg/dl) 0.8 1.7 U.Ac. (mg/dl 4.8 9.6 MAP (mmHg) 85 107 CyA (mglkg 9.8

12 31 1.7 8.9 107 7.3

24 28 1.6 9.4 109 7.6

36 35 1.7 7.5 108 4.3

48 32 1.6 7.2 107 4.0

60 34 2.0 7.0 108 4.6

Hypertension (requiring antihypertensive medications) and renal insufficiency (S.Cr. > 1.5 mg/dl) developed within 3 m after the transplant in 75% of the pts. Up to 5 y. renal function remained There was no correlation between relatively stable. the doses of Cy A and the changes in renal function or the changes in blood pressure. Hyperuricemia (uric ac. > 9 mg/dl) developed in 63.8% of the pts, none of these pts developed gout. Renal hystology (8 biopsies and 2 autopsies) revealed vascular lesions and ischemic changes in the kidney. Nephrotoxic effects of CyA were manifested early in a large proportion of pts that received a liver transplant and persisted up to 5 y., but remained stable.

IN'lRADIALYTIC

~ICN:

I«lFILATIC ROLE OF

'!HE INruSICN OF !DlI~ BlCARBC.ffi\TE(Bi), !D1I~ anauDE(SC) AND DEXTROSE(Dw) ~ ACEl'A'IE

DIALYSIS.

J.P.Amorim; I.Bernardo; P.L.Neves. S.Nefrologia Hospital Distrital de Faro. FARO. PORTUGAL. IDH is a major cause of rrorbility in chronic HD patients. Khan S. et al (Abstr2c~ J\.SN 1(87) described the beneficial role of Bi in acetate intolerant patients. (pts). We compared the effect of Bi, Sc and Dw in 19 ESRD pts in acetate dialysis (M4, F15 mean age 64.14). With frequent IDH defined as a symptomatic fall in BP>30/20 mn~g in)60% of the treatments. The patients, on a 3 weekly HD shedule, when evaluated on 4 mid week treatments (Tl-no prophylatic infusion; T2-50Occ 0.9% Sc; T3-46Occ 1,4% Bi; T4 500cc 5% Dw.) During the 4 treatments we evaluated serum bicarbonate, Na, Cl, K, and weight loss (as percentage of dry weight). There were no significant differences on these parameters during the 4 treat ments. The nt.nnber of IDH, however was different: Tl-1.9±0.8; T2-0.7±1.0; T3-0. 7±0. 7; T4··1.2±0.8 (PC:0.00l) • Conclusicn: The infusion of Bi and Sc is a good alternative for the prevention of IDH when bicarbonate dialysis is not available.

ARE HAEMODIAFIL TRATION (HDF) AND ERYTHROPOIETIN (r-HuEPO) THE BEST TREATMENT AVAILABLE IN ESRD PATIENTS? Bruno Di Paolo, Luigi Amoroso, Mario Bonomi ni, Raffaele Colacell i and Alberto Albertazzi. Institute of Nephrology, University of Chieti, Italy. Although standard dialysis (SO) has been the most successful organ replacement therapy, too many cl inical effects of this treatment remain largely hypothetical. To assess the clinical effects of HDF and of the administration of r-HuEPO (Epoietir®, Janssen) a crossing study was undertaken in 6 SO patients (3 x 4 hrs, 1.3 m 2 cuprophane dialyser, blood flow 300 ml/min) f~ lowed by a 6-month HDF period (Polysulphone BL627 BellcC®, OB 300 ml/min, substitution fluid NaHC039.O L/run, treatment duration 4 hrs). r-HuEPO was admini stered as a i.v. bolus three times a week after HDF,i!:! creasing the dosage (25~50 U/kg) until Hb levels w~ re between 10 and 12 g/dL. At the end oJ HDF+ r-HuEPO period: Urea CI 279.50.:!:18.50 vs 163.80.:!:20.50 ml/min, p<.001; Creatinine CI 268.75.:!:22.40 vs 170.50.:!: 28.30 ml/min, p<.001; Kt/V 1.23.:!:O.23 vs 1.01.:!:O.18, p: ns. There was an excellent control of phosphate, acid~ sis, Hb (10.4.:!:1.8 vs 6.7.:!:O.9 g/dL, p<.oo1) and of some electrophysiological parameters of brain activity. In our opinion, we applied the most efficient renel reptsc6ment therapy described so far. Even in a short run, HDF+r-HuEPO have remarkably beneficial effects on the clinical status. Although we did not observe adve~ se effects, we are conscious of potential risks which can be avoided if a careful monitoring of dialysiS patients wi II be pursued. NURSING HOME PLACEMENT OF ESRO PATIENTS. Renal Oiv., Fr. Scott Key Med. Ctr., J. Hopkins Univ. Sch. Med., Baltimore, MD. More than 4% of the general U.S. population )65 yrs. old resides in nursing homes (NH). Since 50% (53,000 pts.) of the U.S. ESRO population is )60 yrs. old, (HCFA: 1987) perhaps 1000-3000 dialysis pts. might be in a NH or considered for nursing home placement (NHP) simply because of the demographics of aging. Few studies address this issue or describe how this problem is managed, so we surveyed by mail the 41 dialysis centers in Maryland. 29/41 (71%) of centers responded, caring for 1920 (approx. 87%) of the ESRO pts. in the state. One center which only served NH pts. referred by the other centers was excluded. In 1988 25/28 centers had considered NHP for more than 108 pts. (4.0 pts./ctr. ± 2.7 SO); they attempted NH referral of 79 pts. (3.1 pts./ctr. ± 2.9 SO); and placed 69 pts. in NH (2.7 pts./ctr. ± 3.0 SO). They cited the following impediments to NHP: NH refuse dialysis pts. (7/25); financial (7/25); no transportation to dialysis center (7/25) and NH staff untrained (5/25). These centers provided dialysis for 59 pts. residing in NH during 1988. (3.1% of their total pts.). Dialysis modalities employed were: CAPO in NH 22/59; in center hemo 32/59: NH hemo 5/59. Conclusions: Approx. 3% of ESRD pts. in MO reside in NH--consistent with demographic predictions. More pts. are considered for NHP than are actually placed and the continued aging of the ESRO population will increase demand for NHP. If NHP is considered worthwhile for an ESRD pt. major impediments must be overcome.

J. Anderson, O. Sturgeon.

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19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

CORONARY ARYERY BYPASS GRAFTING IN PATIENTS WITH END STAGE RENAL FAILURE; THE UNIV. OF WISCONSIN EXPERIENCE Mark Barnett, Herbert Berkoff, Paramjeet Chopra, George Kroncke, Warren Williamson, Hans Sollinger, Munci Kalayoglu, Folkert Belzer. Univ. of Wisconsin Hospitals, Dept. of Surgery, Madison, Wisconsin. This report presents a retrospective long-term follow-up on 49 patients with end stage renal failure undergoing coronary artery bypass between February 1975 and January 1988. Twenty-nine bypass operations were done on patients on chronic dialysis, 17 operations were done on patients with functional renal allografts, and 4 operations were done in patients with chronic rejection requiring dialysis postoperatively. The mean age of the patient group was 44.9 years(range 2967) with 79% males and 21% females. Creatinine levels in patients with functional renal allografts were not significantly different postoperatively. There were no operative mortalities. One patient required reoperation for excessive bleeding. There were 4 leg wound infections, and no sternal wound infections. The mean follow-up period was 40 months(range 1 to 124). Forty-three patients were alive(9l%) and 84% were free of cardiac symptoms. Coronary bypass can be performed safely in patients with end stage renal disease with excellent results.

EWB::T CF REXXMnNANl' (RMH H:JM:t£(lGI) CN ClIIIlHN (CH) Wl'lH PC(R (RMH ~ SUXfSSFUL RENAL 'l'fW&PUINl'ATICN(Tx). S1an:.n Bartoeil*, Bruce Kaiser*. Iraj RIezvani*. JalIrn Palm!!r*. H.J. Baluarte, Tenple thlv .• Sch. of 1>Bi •• St. Cllristq:h:!r's li:lspital far Children. Grorth failure (m. Ca. R:>4' or FBS durirg therapy. BA. advarx:ed with th:l d1rc:rDlq;ric age am GI antilxxlies J:'EIJBiD3j negative. In conclusion. GH adminstration in pediatric Tx ratients with acceptable allq;rraft 1i.n::tien can ~ grcMh. Respcuse to GI lffi!{f be aftected I:7f pre GI HV. baseline GH levels am/or Somatomedin C lE!llels. Possible reasc:ns far lack of re5palSe in M 1rx;1l.de; n:::lI:1IBl l:aselire GI IE!llel. older BA.. better l:aselire HV am erratic CXIIpliame with GI therapy.

TOLERANCE OF ACETATE (Ac) IN HIGH-FLUX HEMODIALYSIS (HD). RH Barth, J Hsu, GM Berlyne. Brooklyn VAMC and SUNY, Brooklyn, NY. Because of its association with intradialytic symptoms in conventional HD, Ac-containing dialysate has been deemed unsuitable for use in highflux HD. We investigated the frequency and severity of symptoms in 8 patients (pts) during 7 highflux HDs with Ac and 7 with bicarbonate (Bic~ dialysate. All HDs were performed using 1.7 m AN-69 polyacryl0r.itrile hollow fiber dialyzers (Hospal Filtral 16) for 3 hr at 500-600 ml/min blood flow rate. Clearance measured in 15 HDs by quantification of dialysate urea was 229 ± 26 ml/min. Results for 106 HDs were as follows: Hemodynamics: Ac Bic P Wt.loss (kg) 3.0 ± 1.2 3.0 ± 1.2 NS Minimum systolic BP 103 ± 18 117 ± 18 <.001 Systolic BP < 100 (#) 42 16 <.05 Saline given (ml/HD) 236 ± 318 82 ± 158 <.005 Symptoms: Nausea 19 2 <.005 Vomiting 15 0 <.005 Pruritus 9 1 <.05 Overall there was no difference in incidence of chest pain, headache or cramps. In two pts there were no symptomatic or hemodynamic differences between Ac and Bic HDs. Post-HD serum Ac levels were 4.24 ± 1.80 mEq/1 in the Ac group and 0.64 ± 0.28 mEq/1 in the Bic group. In 5 conventional cellulose HDs post-HD serum Ac was 4.21 ± 1.90 mEq/l. We conclude that in high-flux HD use of Ac dialysate is associated with an increase in hemodynamic instability and intradialytic symptoms in many but not all pts, and that post-HD serum Ac levels are not higher than in conventional HD.

CORCNARY ARTERY BYPASS GRAFrI~ IN PATIENTS CN CHRONIC DIALYSIS. T. D. Batillk*, S. B. Kurtz. Mayo Artificial Kidney Center, Rochester, Minnesota. Coronary artery disease (CAD) is a major cause of morbidity and mortality in people on chronic dialysis. We examined the results of coronary artery bypass grafting (CABG) in pts on chronic dialysis (minimum 1 month) to evaluate perioperative and long-tem outcane. We identified 23 chronic dialysis pts who underwent CABG between September 1979 and August 1988. Perioperative mortality was 21% (5/23). These pts were not different in age, duration of preoperative dialysis or co-morbid conditions from the survivors. Among the pts dying, 3 (60%) had myocardial infarctions leading to or during coronary angiography, and all had NYHA class IV angina. These pts had more bypasses (4 vs. 2.8) and longer cardioplegia time (145 minutes vs. 102 minutes) than the survivors. Among the survivors, there was a 93.8% (15/16) I-year survival and an 84.6% (11/13) 2-year survival. 93.3% (14/15) and 100% (10/10) 1- and 2-year survivors, respectively, experienced improvements in NYHA anginal class with a decrease in average cardiac meds. It is concluded that a) these pts had a higher perioperative mortality rate than an average nondialysis population. This may be due to such factors as late and irreversible disease suggesting that surgery earlier in pts' course may improve perioperati ve survival, and b) 1- and 2-year survival rates are acceptable, with improvement in pts' symptoms and need for medical therapy. CABG is reasonable in selected dialysis pts with symptomatic CAD.

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS EFFECT OF CHRONIC HEMOD IALY SIS(CHD) ON PLASMA RENIN ACTIVITY(PRA) AND BLOOD PRE SSURE. Donald Ba ums t e i n , Gauda l upe Gonzalez and A. M. Tannenber g . New Yo r k Me d ica l Co lle ge , Metropol i tan Hosp it al , New York, NY . Vo lume contract i on du rin g a standard 4 hour CHD treatment may stimul ate an increas e in PRA and a ff ec t BP. To test this premise , PRA was det ermined before(base lin e) and a f ter a standard 4 hr CHD treatment in 25 consec uti ve unse l ected CHD patients . Mean BP befo r e and after 4 hr of CHD was a lso noted. Wei ght change duri ng th e treatment was re corded. Aft er 4 hr of CHD all 25 pati e nts had a decrease in BP of 4.2 mmHg ; a mean l oss o f wei g ht of 3 . 62 I b ; and a mean increase o f PRA 2 .1 5 time s base line PRA. The mean baselin e PRA was 3 . 31 n g/ml / hr. Afte r 4hr of CHD the mean PRA was 7.11 n g /ml/h r. The mea n BP before and after 4 hr of CHD was 1 0 4. 9 and 100.7 mmHg res pect ively. 19 of 25 patients had a decrease in BP o f 8.6 mmHg wit h mean we i ght l o ss o f 3.11 lb .. Thi s was associated wi th a mea n inc re ase in PRA of 2 . 07 time s base l ine . 6 of 25 patient s had a mea n BP increase of 9.5 mmHg with mean we i g ht lo ss of 5.23 Ib and mean increase o f PR A 2.4 2 times the b aseli ne value . It i s co nclud ed that 4 hr of CHD i s associated with an increase in PR A at least twice baseline. With a greater i n creas e i n PRA , mean BP may also i ncrease paradox i ca lly at the end of 4 hr of CHD.

• A NINE YEAR RETROSPECTIVE REVIEW OF OUR EXPERIENCE WITH GERIATRIC ESRD PATIENTS (G-ESRD) IN NORTHWEST NORTH CAROLINA John Burkart, Britta Hylander, Carol Taylor, Vardaman Buckalew, Grethe Tell, Bowman Gray School of Medicine, Winston-Salem, North Carolina We reviewed 785 charts from all new ESRD patients (pts) starting dialysis at our unit during the years 1980-88. Of these, 235 (30%) were 65 or older. Causes of ESRD, age at initiation of dialysis, initial dialysis modality, length of time on that modality, reason for changing modality and causes of death were noted. Life table analysis was performed for those on CAPO and those on hemodialysis (HD) using Kaplan-Meier plots. Of the 235 pts, 35% initially chose CAPO while the remainder (65%) chose HD. The median duration of dialysis for the entire group was 8 months vs 9 months for those on CAPD and 8 months fig. 1 for those on HD. There .. was no statistically 1 significant difference 1M

I··.. U

in length of time on

! .. J

.

dialysis for CAPD vs HD \-~_ _~~~~---l using life table analysis (fig 1). The major causes of death were ca rd i ac (33%), sept i cemi a (13%), malignancy (7%) and withdraw from dialysis (5.5%). Of those on CAPO, 14 out of 86 changed modality. Only 1 of the 235 pts was transplanted. In summary at our center, G-ESRD represented a significant portion of all ESRD : There was no statistically Significant difference in life expectancy or median duration of dialysis between HD vs CAPO. The leading cause of death was cardiac.

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CNS Complications of OKT3 Treatment of Acute Renal Allograft Rejection. P. A. Bowen II MD and James J. Wynn MD,----Departments of Medicine and Surgery, Renal Transplant Program, Medical College of Georgia, Augusta GA 30912 34 patients(Pts) received OKT3 for acute rejection. Headache occurred in 26. 8 Pts had important CNS complications. 3 developed seizures. In 2, seizures were single, generalized tonic/clonic convulsions; 1 Pt developed status epilepticus requiring mechanical ventilation. In 2 of 3, CSF revealed a sterile pleiocytosis with normal protein and glucose values. CT and EEG disclosed no focal abnormalities. Seizures did not recur and all are currently seizure-free. 4 Pts developed acute confusion accompanied by paranoia, hallucinations & obtundation.1 had CSF findings of aseptic meningitis. Mental status cleared in 3 to 6 days despite continued OKT3. No Pt had a psychiatric history. Pt 8 had headache and meningismus, CSF was compatible with aseptic meningitis. 3 of the 34 were retreated; no CNS symptoms developed as a consequence. Clinical and laboratory data did not identify Pts prone to severe CNS effects. Rejection was reversed in 32 Pts (94%) receiving their first course of OKT3 . Retreatment was successful in 2 of 3 Pts. In this series mild symptoms were ubiquitous, with severe CNS toxicity seen in 8 of 34 Pts (23%) .

.. FACTORS AFFECTING RACIAL DIFFERENCES IN RENAL CADAVERIC ALLOGRAFT SURVIVAL. Donald E. Butkus*, Kent Kirchner* and Seshadri Raju, Dept. of Med •• Univ. of Mississippi Med. Ctr., Jackson, MS. Blacks (B) have poorer patient and renal graft survival than caucasians (C), espeCially those treated with conventional immunosuppression (CI) as opposed to cyclosporine (CS). To assess factors affecting outcome we evaluated 100 consecutive primary cadaveric transplant recipients (61B, 39C) 48 of whom received CI with prednisone (P) and azathioprine (A) and 52 of whom received CS in combination with P+A. Patients with delayed onset of renal function (OF) also received ATG until function was established. One year patient and graft survival were significantly related to race in CI. CS improved patient and graft outcome in B but graft survival remained less than C. One year graft function (ScR) was equivalent in Band C: 1 yr Survival: Patient (%) Graft (%) 1 yr-SCR C CI (n=14) 93 86 1.58 .29 CS (n=25) 96 92 2.15 .24 50 1.77.11 B CI (n=34) 85 CS (n=27) 100 82 2.44 .29 In Cr. but not CSt graft survival was significantly related to race, HLA match and identity of donor-recipient race, but not to age. etiology of ESRD, ABO group, Lewis Ag match, PRA at transplant, or DF. OF was more common in B with CI than in C (50% vs 14.3%); graft survival in B with OF was greater than with immediate function (71% vs 46%) probably secondary to ATG. Graft survival in B with CI is related to HLA match and donor-recipient racial identity; ATG partially, and CS more completely. abrogate the effects of these variables.

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

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o EFFECTS OF DECREASING OR STOPPING CYCLOSPORINE FOR FINANCIAL REASONS. Cannon V.

ERADICATION OF BLOOD STREAM INFECTION (BSI) CAUSED BY LONGTERM DOUBLE-LUMEN JUGULAR VEIN CATHETERS (DWVC) WHILE PRESERVING TIlE ACCESS SITE (A.S.) E. Carlisle,P.Blake,F.McCarthy,S.Vas,and R. Uldall Divisions of Nephrology and Microbiology, Toronto Hospital,

Curtis J, Julian B, Jones P, Deierhoi M, Barber H, Laskow D, Diethelm G: Univ of AL Medical Center, Birmingham, AL One year after kidney transplantation (TX) Medicare stops paying for cyclosporine (CYA). We defined three groups of patients (pts) with primary cad Txs. Group 1 (no financial resources) were tapered off CY A. Group 2 (severely restricted financial resources) were tapered to a low dose CYA (100150 mg/day) for financial reasons. Group 3, a control group, TXed between 1984 and 87 and remained on at least 200 mg/day CY A for 2 years. Groups 1 and 2 were selected only if it was clearly indicated in the medical record that CYA reduction was for financial reasons - none had therapeutic CY A blood levels after taper. We excluded pts tapered to CYA doses < 200 mg for therapeutic reasons, pts in other prospective studies, pts < 18 yrs old, and pts with previous TXs. Tapering to low or no CY A took 3-5 months and azathioprine and prednisone doses were increased. Neither group 1 nor 2 had rates of early AR greater than control. As expected, AR was rare (2%) after the first year in the control group. No graft was lost to AR in this group - two were lost to chronic rejection. In contrast, group 1 and 2 experienced a 21 % and 9% (respectively) frequency oflate AR. All ARs occurred between 1 and 9 weeks after CYA taper. AR was associated with . 2 gra f t t al'1 ure In pts'In group 1. Group # AR in Late Mean Follow Graft pts 1.) No CYA 2.) Low CYA 3.) Control

* p
34 22 83

first 6 months 6 9 45

AR serum Cr (after 1 year) (mg/dl) 7* 1.9+0.7 2 1.9+0.7 2 2.1+0.8

up since Tx (mas) 38+13 34+10 38+10

Toronto, Canada. Silastic DWVCs are

being

used

increasingly

for patients

(pts) on long-term hemodialysis (LTHD) who have especially difficult vascular access problems. I t has hitherto been accepted that when they cause BSI they should be removed and replaced under antibiotic cover (A.C.) by a new catheter in a different site. Since DWVCs are normally inserted surgically their removal usually

results in

permanent loss

of an A.S. Since Feb 1988 we have observed 10 episodes of BSI, without purulent skin exit site infection (SESI), in 7 pts on LTHD attributable to their DWVCs. Attempts were initially made in 4 of the 7 pts to eradicate the BSI with antibiotics alone. All recurred. In all cases the DWVC was removed under appropriate A. C., started at least 48 hrs previously, and replaced immediately by a new DWVC using a guide wire and the same track.

In

every case

the BSI was

eradicated and did not recur after follow-up periods of 2-14 months (mean 6 months). All these pts remain on LTHD with the same A. S. In 3 other pts with BSI and frankly purulent SESI, the DWVCs were removed and not rep laced. We conclude that in the absence of purulent SESI, DWVC-induced BSI can be eradicated by changing the catheter ~der A.C. over a guide wire, using the same A.S. This observation is

loss post

I year

important for the future of DWVCs in pts on LTHD.

2 0 2

compared to control.

Stopping CYA a year after TX for cost reasons is associated with a significantly increased frequency of AR. Remaining on low dose CYA (100 -150 mg/day) appears to lessen this risk.

•

SERUM TUMOR NECROSIS FACTOR ALPHA (TNFa) AND INTERLEUKIN lB (IL I-B) LEVELS IN HEMODIALYSIS (HD). Ralph J. Caruana, Steven A. Lobel, Mary S. Leffell, H. Thomas Campbell. Medical College of Georgia, Augusta, Georgia. The interleukin hypothesis proposes that cytokines contribute to uremic toxicity. We measured serum levels of TNFa and ILl-B by enzyme immunoassay before and during HD in 10 chronic HD patients (4 males, 6 females) with a mean age of 52 ± 17 years who had been on HD for 6.2 ± 5.0 years. Each patient was studied during 6 HD's employing 6 dialysate/dialyzer combinations (acetate and bicarbonate dialysates and cuprophane, cellulose acetate and polymethylmethacrylate membranes). Five patients had detectable pre-dialysis serum levels of TNFa (>40 ng/L) at least once and 2 had detectable levels prior to all HD (671 ± 174 and 621 ± 183 ng/L). Six patients had detectable pre-dialysis serum levels of ILl-B (>20 pg/ml) at least once and 2 had detectable levels prior to all HD (72.9 ± 14.2 and 95.4 ± 18.1 pg/ml). There was no consistent effect of HD on serum TNFa or IL l-B levels. One patient who had persistently elevated levels of both TNFa and ILl-B had carpal tunnel syndrome, severe osteopenia and progressive, unexplained cachexia. The other patient with persistently elevated levels of ILl-B had a chronic arthropathy suggestive of the recently described HD amyloid arthropathy. Serum levels of TNFa and ILl-B are persistently elevated in some patients and intermittently elevated in others. Further studies are required to determine whether serum cytokine levels have predictive clinical value in HD.

o

EVAIIllITICN OF a:MPL:IllN:E 'IO DIEl' AND REWIL FUtO'ICN QWIGES IN HID!I\RY GU:MERlICNEHIRl PATIENTS (QW). D.C. cattran for "t'm Olra±i.an GlCIlErul~tis

Sb.rly Grcql.

In J:hase 1 of a lllllti-antre druJ trial, 171 patients with pr:inmy glCIlErulcn¥ritis an:l. prote:iruria(P) ~ p1.acai en a restrict.Erl protein diet (:so.~jFg) an:l. m::nitorerl rrart:hly by =-ectErl c::reat:i.n.iIE cle:rran::e, mls/sec (OC), P, grrs/day, an:l. urina urea in nnoljday(U) as v.ell as by Iflysiciarn an:l. dieticians. Initial data, rrean cqa 43(19-73), male/female; 125/46, CC 1. 18±0.49 (80) , P 5.5±4.41(8O). Mijor cat:.eg:ries ~ llBli:lran:us 63; Fs:s 44; 19A 47. Cl:seI:vaticns are limited to 125 p:ttia1t:s folla.a:i > 6 m:nths(6.2-27). Rx:lr CXItpl:i.aroe, as defirB:l by U ~O% a1:ove assigrai ~O% of "t'm tine, ...as seEn in 24%. ~ relaticn:rup I:Jetv.em P an:l. OC by U ...as exam:ined (e.x'Cluiirg CXItplete ranissicns). N:J significant differexres ~ seEn in rates of ciJarl3e in fun:::t:.ic:n Gt1), in OC or P by diet:aIy protein ~ as defirB:l by u. U

<250 250-400 >400

# AOC(8O)

A.P(8O)

27 -.14( .26) 70 -.li( .23) 28 -.04(.16)

+.6(5) -.4(5) +.3(3.2)

oiffere.n:::JeS am:rgst U gro..p; by histol
19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS [] RISK FACTORS FOR PENTAMIDINE NEPHROTOXICITY IN AIDS PATIENTS. A.Chua*, J. Busse*, H. Alpert*, C.A. Vaamonde. VAMC, Jackson Memorial Hospital, and the Department of Medicine,University of Miami School of Medicine, Miami, FL. Nephrotoxicity (NTX) is the most common systemic adverse effect of iv pentamidine (P)therapy, with a reported range of 19-65%. We undertook a retrospective study of 33 consecutive AIDS patients (pts.) who had received iv P for at least 7 days,from Oct 1988, to Jan 1989. Particular attention was given to the role of risk factors: volume depletion, sepsis, preexisting renal dysfunction, other NTX agents (aminoglycosides, NSAIDs, radiocontrast). NTX was defined as a rise in serum creatinine (cr) >0.5 mg/dl from baseline. Average age was 37 yr (range 24-56). All pts. received 4 mgjKg/d of iv P for a mean of l3±1 (SE) days (range 7-22). Initial cr was 0.97±0.1 mg/dl, and NTX developed in 11(33%);it was mostly mild, with peak cr of 2.3±O.1 mg/dl, occurring after 10±1.7 days. Only 1 pt. had severe renal failure (cr >5 mg/dl).Hypoglycemia was noticed in 6 (18%). Comparison of pts with and without NTX revealed similar age,body weight, initial cr, and total dose of P. The risk of NTX was directly related to the number of risk factors present (r~0.93, p~O.02).There were no risk factors in 1/11 (9%) of pts with, and in 13/22 (59%)of those without NTX (X',p
DAILY, SLOW VEN0-VENOUS HEMODIALYSIS (SVVHD) FOR HEMODYNMlICALLY COt1PROMISED PATIENTS. Mario Corona and Rasib M. Raja. Albert Einstein Medical Center, Kraftsow Division of Nephrology, Philadelphia, Pennsylvania. CAVH and CAVHD are frequently used in critically ill pts. Hemodynamic compromise and inaccessible arterial system would make a veno-venous system ideal for these pts. We report on the use of SVVHD on 4 pts in whom all other forms of dialytic therapy could not be utilized. SVVHD was performed in a conventional ICU and by nursing personnel with no hemodialysis experience. The system used consisted of a roller pump with an integrated pressure monitor and an air detector with automatic clamp. QB was prefixed at 100 ml/min. Standard IV pumps were used for infusion of the dialysate, heparin, and replacement fluids. Vascular access was achieved by double lumen venous catheters. Pts I,ere dialyzed an average of 8 hrs a day. Apache II scores before SVVHD was 29+3. BUN before SVVHD was 131+10 and after: 79+21 fig/dl. The resul ts are: FILTER QDml/min UFml/min Ku KCrml/min CD 3500 16.7 6.5 22.3+1.3 21.1+1.6 CF 1511 33.3 8.5 36.8+5.0 34.3+5.4 COBE 300 33.3 6.7 38.5+2.8 35.1+4.0 All the pts achieved good metabolIc, nutritional and fluid control. There were no hypotensive episodes, arrhythmias or other complications. The ICU personnel accepted the procedure well. These data suggest that daily SVVHD is a simple, safe and effective way for metabolic control in hemodynamically unstable, critically ill pts. Ability to complete SVVHD during day shift enhances acceptance by ICU personnel. The need for arterial access is alleviated with SVVHD.

AS

[ ] EFFICACY OF THROMBOLYSIS OF THROMBOSED DIALYSIS ACCESSES WITH UROKINASE. Mark A H. Cohen, David A Kumpe, Marshall E. Hicks, Michael Hovan, and Janette Durham. Univ. of Colorado Health Science Center Depts of Medicine and Radiology, Denver, CO. Maintenance of vascular access remains a major problem in the management of patients on chronic hemodialysis. In order to determine the efficacy of thrombolysis we reviewed the records of 37 consecutive patients with thrombosed dialysis accesses treated with urokinase (UK) between 1986 and 1989, with followup until June 1989. Successful thrombolysis was defined as that sufficient to permit at least 1 subsequent dialysis via the access. A total of 67 infusions were performed. Fifty-seven were done on polytetrafluorethylene (PTFE) accesses, the remainder on arteriovenous fistulas (AVF). The mean age of the patients at the time of the procedure was 46.6yr +/- 2.1 (SE). Twenty-six (39%) of the procedures were performed on diabetics. Within 48h after the thrombosis patients underwent a fistulogram followed by direct infusion of UK into the access until there was clinical evidence of reestablishment of flow, significant bleeding, or the decision that the thrombosis would not lyse. The mean total dose of UK was 1,130,000 u +/-87,000 given over 15.2h +/- 1.3. Angioplasty was performed after 29 successful infusions. Patients who had at least partial lysis received systemic heparinization. Twelve (18%) attempts had to be stopped before thrombolysis because of extravasation through needle punctures. An additional 16 (24%) occlusions did not lyse. Thirty (45%) grafts were patent for at least 30d, 15 (22%) for at least 150d. PTFE grafts had a mean patency of 1OOd +(-23 and a median patency of 14d (range 0-756d). AVF had a mean patency of 84d +/-191, with a median patency of 5d (range 0-588d). Diabetics with a PTFE graft had a significantly lower patency rate than did nondiabetics (52d +/- 31 v. 132d +/- 31 , non-parametric test, p<.OOl). Eight patients had sufficient blood loss so as to require 1.75u +/-0.39 of packed rbc. We conclude that UK infusion provides an effective means of establishing short-term patency of thrombosed accesses, but does not reliably result in long-term patency. Thus, UK infusion may allow dialysis.to continue via the lysed access until a new access matures.

[] THE USE OF SUBCLAVIAN CATHETERS IN PEDIATRIC PATIENTS: A COMPARISON OF CUFFED VS UNCUFFED CATHETERS FOR EXTRACORPOREAL THERAPY. Robert J. Cunningham & Ben H. Brouhard. Cleveland Clinic Foundation, Dept. of Peds & Neph., Cleveland, Ohio Maintenance of vascular access in pediatric patients remains a major technical problem for long-term hemodialysis. This retrospective study compares the use of uncuffed subclavian catheters (n=22, in 12 pts.) with the cuffed catheters (n= 8, in 8 pts.) for dialysis/or plasmapheresis. Adequacy of blood flow, clotting of catheters, catheter infection rates & catheter survival rates were compared. None of the cuffed catheters had to be removed for technical problems with insufficient blood flow. In contrast, 11/12 of the un cuffed catheters were replaced because of poor blood flows, recirculation difficulties or clotting of the lumen. None of the 9 cuffed catheters became infected; 6/22 uncuffed catheters had documented infections; 5 of these infections resulted in sepsis requirin9 IV antibiotics. Catheter sorvival was also significantly different between the 2 groups. The longest use time for the cuffed catheters was 270 days; for the uncuffed, 96 days. Survival data are summarized in the table below: Catheter Survival/Cath Treatments/Cath Infect. (days) cuffed 160+87*(x+SD) 55+40* 2 12+10 5 uncuffed 28+21 Subclavian-vascular access is-an acceptable means for pediatric patients. However, cuffed catheters should be used exclusively, particularly if long-term access is required. *p < 0.01 cuffed vs uncuffed

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19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

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HIGH RELAPSE RATE WITH WEEKLY INTRAPERITONEAL VANCOMYCIN (V) FOR COAGULASE NEGATIVE STAPHYLOCOCCUS (CNS) CAPD PERITONITIS. Dou~lass T. Domoto, and Marilyn Weindel. St. Louis University Medical Center, Division of Nephrology, St. Louis, MO. A marked increase in peritonitis prompted a retrospective review of all incidences of peritonitis since 1986 in our CAPD program. During 1167 patient months, 148 episodes of peritonitis occurred in 39 of 68 patients. CNS was cultured 70 times. Sterile cultures occurred 28 times. Intraperitoneal V, 30 mg/kg in two doses, 1 week apart was used for 25 episodes (Bastasi, B. Nephron 45:283, 1987). Eleven episodes relapsed, defined as an episode of peritonitis within 30 days of the last dose of V, in which the same strain of staph, CNS or no growth was found on culture. Two of 11 relapses were due to failure of the patient to receive his second dose. Two patients had 2 successive relapses before cure. One had 4 successive relapses before cure. Eventual cure was achieved with Valone in 2 patients, 2. with V and streptokinase, 1 with V and rifampin and 1 required catheter removal. In 19 of 25 other cases of CNS peritonitis various other vancomycin protocols achieved cure with initial therapy. In 12 of 13 episodes of S. Aureus or other gram positive bacterial peritonitis, V was successful. We conclude that the 44% relapse rate with I.P. vancomycin 30 mg/kg in 2 doses is unsatisfactory for CNS peritonitis. A loading dose and continuous I.P. vancomycin may be a better protocol.

[J SUB-CUTANEOUS(s.c.} ERYTHROPOIE~N(EPO}:EFFICIENT AND MORE SO IN CAPD PATIENTS(pts}? M.DRATWA, F.Collar·t, R.Wens. Brugmann Hospital, Brussels, Belgium. Recombinant human EPO has proven its efficacy when given i.v. to HD pts. Thus, it seemed of interest both to look at the effect of s.c. administration of EPO and to search for any differences in its effectiveness between CAPD and HD pts. Six CAPD and 8 HD pts received s.c. EPO 50 U/kg body wt twice weekly for 8 weeks(w}. Both groups were comparable in terms of age (46.5 ± 3.4 vs 52.0 ± 9.2 years), duration of dialysis therapy (40 ± 10 vs 30 ± 12 months), ferritin (752 ± 547 vs 488 ± 161 ~ g / I), aluminum, folate and vito BI2 levels, and severity of anemia. All pts responded well and without side-effects but already at w 4, CAPD pts showed a significant increase in Hb, Hct and RBC count (p < .Ol) while in HD pts Hct only had changed (p < .05). Results are given as means ± SEM 6 Hb (g/dl) Hct (%) RBC (\0 /~l) CAPD HD CAPD HD CAPD HD wO 7.8±.2 7.8±.3 24.8±0.823.6±1.0 2.6±.12.6±.1 w4 9.7t.5 8.5±.2 30.2±1.725.9±0.5 3.2±.22.8±.1 w810.2±.59.4±.3 31.6±1.729.3±1.1 3.5±.23.2±.1 The rates of increase of Hb and R~C were significantly different between CAPD and HD pts (comparison of regression lines, F slopes: 5.695 and 6.015, respectively; p <.05) so that at w8 Hb and RBC count were higher in CAPD pts (p < .01). In conclusion, twice weekly s.c. EPO 50 U/kg (i.e. 2/3 of the usual i.v. dosage) is sufficient to elicit a satisfactory erythropoiesis in both HD and CAPD pts The latter seem to respond faster than the former for reasons not yet elucidated but among which the possible influence of HD-induced blood loss should be evaluated.

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CLINICAL EXPERIENCE WITH SHORT TIME HIGH FLUX HEMODIALYSIS. Francis Dumler, Karen Stalla*, Ravinder Mohini*, Gerard Zasuwa* and Nathan W Levin. Department of Medicine, Henry Ford Hospital and Greenfield Health Systems Corporation, Detroit, Michigan. We wish to report our clinical experience with short time high-flux (HFH) hemodialysis. After 6 months on conventional hemodialysis (CH) 45 patients (mean age: 45±13 yrs) were changed to HFH (F60 and F80 dialyzers). Dialysis prescriptions were targeted at a Kt/V of 1.2 for both modalities. Results are given as mean±SEM. Changing from CH to HFH decreased dialysis time (191±5 vs 147±5 min; P=O.OO1), while Kt/V (1.22±O.04 vs l.29±O.06) and per (1.l0±0.05 vs 1.l0±0.07 g/kg/d) remained constant. When compared to the CH period, after 6 mos. of HFH no changes occurred in pre dialysis BP (l48±2/84±1 vs 153±2/85±1 mm Hg), post dialysis BP (142±2/8o±1 vs 146±2/83±1 mm Hg), interdialytic weight gain (2.3±O.1 vs 2.3±O.1 Kg), BUN (74±2 vs 75±2 mg/dl), serum potassium (5.o±O.1 vs 5.1±O.1 mEq/l) or phosphate (6.o±O.2 vs 5.7±O.2 mg/dl). However, serum cholesterol (201±8 vs 185±9 mg/dl; P=O.Ol) and triglycerides (218±16 vs 180±9 mg/dl; P=O.OOI) were lower during HFH. When compared to CH, HFH decreased the frequency (%) of dialysis related hypotension (14.5 vs 10.0; P<0.05), vomiting (6.4 vs 1.6; P
[JRECURRENT IGA NEPHROPATHY IN RENAL TRANSPLANTATION: IMPLICATIONS FOR CHOICE OF DONOR SOURCE. Robert B. Dunmire*, H. Keith Johnson, Robert C. MacDonell, Jr., and Robert E. Richie. Vanderbilt and V.A. Medical Centers, Nashville, Tennessee. Several recent studies have suggested that the recurrence rate of IgA nephropathy is much higher in living related donor (LRD) transplants than in cadaveric transplants. We conducted a retrospectiv e analysis of the 1112 transplants performed at th e Vanderbilt and Nashville V.A. Medical Centers sinc e 1979. Twenty-nine transplants were identified among 24 patients who had IgA nephropath y as the cause oJ their initial renal f a ilure. Thirteen LRD transplants, 5 of whom were HLA identical, were followed for 3 to 99 months with a mean duration of 37.6 months. Sixteen cadaveric donor transpiants were followed for 1 to 116 months, mean of 37.9 months. Clinical circumstances dictated biopsy in 12 patients, 3 of whom were found to have recurr e nt disease. No patient treated with Cyclosporine had proven recurrence of disease. Three grafts were lost in the LRD group (23 %), 1 from recurrent IgA nephropathy and 2 from re j ection. One patient had biopsy evidence for recurrent nephritis at the time of graft loss from acute rejection. Four grafts were lost in the cadaveric group (25%), I from recurrent IgA nephropathy and 3 from rejection. Remaining graft function as determined by serum crea tinine and 1-125 iothalamate clearance favored the LRD group. We conclude th a t when IgA nephropath y is the cause of renal failure, graft loss from recurrent disease and long-term outcome are similar comparing LRD transplants and c adaveric transplants. This data supports the continued use of living related donors as a source for renal transplantation in patients with IgA nephrop a thy.

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS •

EVALUATION OF VARIOUS METHODS FOR CALCULATION OF KT fV. Russell Ellenberg. Barry B. Kirschbaum. Domenic A. Sica. Medical College of Virginia, Nephrology Division, Richmond, Virginia. Determining the adequacy of dialysis has been a goal since its Inception. The National Cooperative Dialysis Study provided guidelines from which a dimensionless value based on urea clearance was derived; KTIV. Since that time, four indirect methods for calculating KTIV have been popularized; the KtfVPCR Domain Map, a slide rule like device distributed by Baxter, (pre-BUN - post-BUN)/(pre-BUN + post-BUN)/2, and the natural log of pre-BUN/post-BUN. We sought to compare these various methods by evaluating 48 stable anuric dialysis patients based on a midweek dialysis. The palients were metabolically stable by routine clinical determinalions and none were overtly malnourshished. The Domain Map and the Baxter calculator provided essentially identical results (means 1.04 ± .25 vs 1.05 ± .26, p > .1). The two methods using predlalysis and postdialysis urea nitrogen determinations provided identical results (means .83 ± .16 vs .89 ± .21, P > .1). The Domain Map and Baxter calculator consistently provided higher values for KT fV than did the two methods using urea nitrogen determinations (p < .001). The sources of the variance were not completely identified by the present study however we did find a significant difference between the Baxter estimation of urea volume as compared to the calculated value (p < .01). The actual vs. manufacurer's clearance of urea is another obvious source of potential error. The implications of these findings not only include the medical aspects but perhaps have economical connotations. Further study is required to determine which method best represents adequacy 01 dialysis. .

ON-SITE DIALYSIS QUANTIFICATION USING THE REFLOTRON™. J. Fangman*,G. Ullrich, G. Sadewasser, M. Streicher, M. Flanigan, U of Iowa Hospitals & Clinics, Iowa City, IA Purpose: Determine the accuracy, reliability and cost of an automated, on-site technicianoperated urea nitrogen assay for urea kinetic modeling. M~thods: Dialysis was quantified using single-pool Urea Kinetic Modeling (UKM) , Direct Dialysis Quantification (DDQ) , and Urea Reduction Analysis (URA). Duplicate samples were assayed by the ReflotrontM and the clinical research laboratory. Cost analysis included the time required to obtain and process samples, cost of disposable supplies , and clinical laboratory fees. Results : 25 sets of dialysis were assessed. Blood and dialysate urea nitrogen measurements performed on the Reflotron™ correlated with clinical laboratory values (r2-0.99 and 0.96). Reflotron™ blood urea - 0.79 + 0.99 (Lab BUN) Reflotron™ dialysate urea - -0 . 21 + 1.00 (Lab dialysate UN) The cost of an assay using the Reflotron™ included a syringe and needed to obtain the 30~L blood sample, assay "kit" and 4 min . of technician time to obtain, assay, and record the results of each sample. Laboratory costs are those billed by the clinical laboratory plus the needle, sample tube, and nursing time for sample acquisition, labeling, and deposit at pick-up site. Total Cost Per Assay: Laboratory - $6.87 Reflotron™ - $2.58 Conclusions: 1. Accurate on-site dialysis quantification (UKM DDQ, URA) can be performed using the Reflotront M urea assay system. 2. The Reflotron™ can reduce the costs of kinetic modeling and dialysis quality assurance programs.

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ACUTE AND CHRONIC EFFECTS OF IATROGENICALLY INDUCED INCREASED RENAL PELVIC PRESSURE IN RABBITS. Majid Eshghi, Jose M. Hernandez, Muhammad Choudhury and Joseph C. Addoniz~o. Dept. of Urology, New York Medical College, Valhalla, NY We compared the acute and chronic effects of iatrogenically induced increased renal pelvic pressure in 35 New Zealand albino rabbits. The rabbits were divided into three main groups depending on the pressure; low (50-90 mm Hg), medium (100 mm Hg), high (up to 150 mm Hg) and separated into acute and chronic effects. Microscopic changes varied according to the exposed renal pelvic pressure. Moderate and high pressure kidneys showed cortical and medullay tubule dilatation, degeneration of renal pelvis epithelium, lymphatic dilatation, and an increase in Bowman's space. Our results reveal that after 8 weeks the kidneys show pathologic changes as a result of temporary increased renal pelvic pressure. The human kidney probably responds in a similar fashion.

• LONGITUDINAL SURVEY OF APOLIPOPROTEINS AND ATHEROGENIC RISK IN CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) PATIENTS, P.Fein, Y.Rao*, A. Antignani*, N.Mittman, P.Goldwasser*, MM Avram The Long Island College Hospital, Brooklyn, NY CAPD patients are said to have dyslipidemias distinct from those seen with hemodialysis. Dialysate glucose absorption and the continuous loss of various plasma constituents have been implicated. We investigated lipid and apolipoprotein (Apo) parameters over a two year period in 35 patients maintained on CAPD and correlated these values with clinical and biochemical informa tion. In a group of 10 patients followed for 24 month s and 25 patients followed for 12 months, HDL-C (p=.03) and HDL-C/Apo-I (p"::.Ol) were lower in whites than blacks and HDL-C was lower in men th an women (p=.08). Surprisingly, diabetic status did not affect lipid values. For the group as a whole, HDL-C (p=.Ol) and the atherogenicity risk ratio, Apo A-I/Apo B (p=.05) were inversely correlated, and an alternate risk ratio, total cholesterol (TC)/HDL-C (p=.06) positively correlated, with length of CAPD treatment. However, for individual patients, there were no significant changes in the values of TC, HDL-C, HDL-associated Apo A-I, LDL-associated Apo B, or the atherogenicity risk ratios, TC/HDL-C and Apo A-I/Apo B. There was also no change in the rela tive composition of HDL, as reflected by the ratio HDL-C/ Apo A- 1. These prospective results confirm our previous retrospective observations on the stable nature of lipids, apolipoproteins and atherogenicity risk ratio with CAPD treatment.

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19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

THE EFFECT OF PROSTAGLANDIN El ANALOG, MISOPROSTOLON CHRONIC CYClOSPORIN NEPHROTOXICITY. Eunice G. John, linda C. Fornell, Saipin Anutrakulchai, Olga Jonasson. Unlv. of Illinois, Chicago, Dept. of Pediatrics; Ohio State Univ., Dept. of Surgery. Cyclosporin(CSA) is used extensively in the treatment of organ transplantation. CSA produces renal dysfunction(RD) and hypertension(HTN) which in part has been attributed to changes in vasodilatory prostaglandins. The aim of the study was to investigate the possible ameliorating effect of misoprostol(MS), a prostaglandin El analog, on CSA induced RD and HTN. Two groups of rates were investigated: Group I(GI) received CSA by gavage (20mg/kgBW/day); Group II(GII) received CSA + MS (lOO~g/kg/day) by gavage over a period of 2 wks .• At the end of 2 wks., two to three 10 minute urine collections and midpoint blood samples were obtained to measure GFR (ml/min) (Iothalamate method) clearance of PAH (CPAHml/min), FENA (%), urine volume (uV/ml/min) and renal blood flow (ml/min) (microsphere method); blood pressure(BP) and heart rate(HR) were monitored continuously d~ring RF s,Fudies. Results are given as M±SD for each group P values <0.05 was considered signifi cant. In Group II, MS caused a significant increase in GFR, CPAH, RBF and RVR as compare~ to Group (GFR(GI) 1.76±0.85 Vs(GII) 4.37±0.95 ; RIlF(GI) 3.99±2 Vs(GII) 6.1±1.1*; RVR(GI) 41±21 Vs(GII) 13 ± 7.8*). In GI I, increase in UV and decrease in FENA was not significant compared to Group I. BP and HR were similar in both groups. In conclusion, MS prevented chronic CSA induced renal dysfunction but not hypertension.

FACTORS wHICH INFLUENCE THE USE OF CPR :1ND DIALYSIS THER.4PV: RESULTS OF A NATIONAL SURVEY. C. J. Foulks, J. Holley, and A. Moss, U of Texas Southwestern, U of Pittsburgh, and U of west Virginia, Dallas, Texas. Dialysis, like CPR, was initially developed for use in a small set of well-defined palient.s, usually younger and ,.-i th few co-morbid condi tions. Both CPR and dialysis are currently used in a multitude of patients with a wide variety of ages, diseases, and prognoses. we report the resul ts of a randomized national survey of internists (I) (n=40B, response rate 23'11) and nephrologists (N) (n=4B3, response rate 25'11) which examined factors affecting the decision to use CPR and dialysis (demographics, patient characteristics, and case presentations using a linear analogue scale). Half of all respondents believed that CPR should be offered only to those who might recover to functional status. 25% felt that all patients should undergo CPR and 25% felt that only tbose who might recover to their pre-arrest status should undergo CPR. Neurological disease was the single most important factor for both I and N on 1imi ting the use of dialysis and CPR (p=O. 02). N 1 imi ted the use of CPR based on age (p=O. 02) , however, age was not an importZ'lllt factor in determining the sui tahili ty of pa tients for dialysis. The requirement for cbronic dialysis was an important factor in limiting the use of CPR by I (p=0.02) and N as well (p=O. 02). Ife conclude that I and N limit the use of life-sa~'jng procedures in patients (based on neurologic status, age, and presence of a chronic disease (dialysis). Although the application of CPR and dialysis may seem to be unrestrained, I and N feel that these procedures should be limited .

RACIAL DIFFERENCES IN HLA ANTIGEN FREQUENCY IN PATIENTS WITH HYPERTENSIVE END STAGE RENAL DISEASE (H-ESRD). B Freedman, J Graves, M Callahan, E Heise, V Buckalew Jr, V Canzanello. Bowman Gray Sch of Med, Wake Forest Univ, Winston-Salem NC. The incidence of H-ESRD is increased in blacks compared to whites despite adjustment for prevalence of hypertension and blood pressure control. We analyzed HLA-A,B,and DR antigen phenotypes in patients with H-ESRD to determine if genetic differences could account for the racial variation in H-ESRD. Three hundred and sixty consecutive patients undergoing renal transplant evaluation at the NC Baptist Hosp from 1/77 to 6/89 were screened for HESRD based on 1) blood pressure )140/90 and/or use of antihypertensive drugs prior to development of renal insufficiency, and 2) exclusion of all other known causes of renal disease. The frequency of HLA-A,B and DR phenotypes in H-ESRD patients was compared with a race-matched, healthy kidney donor population (South Eastern Organ Procurement Foundation data base). Forty-two patients had H-ESRD (13 white and 29 black). For whites there was an increased frequency vs control of B18: 31% (4/13) vs 8% (323/4039) (P=.02, Fisher's exact test) and in blacks a decrease in Al :0% (0/29) vs 13% (61/467) (P=. 04). Interracial frequencies (corrected for intraracial variation) of A23 and A28 were increased by 15% (P<.05, Z normal distribution) and decreased by 24% (P<.03), respectively, in blacks with H-ESRD compared to whites with H-ESRD. Our results demonstrate intraracial and interracial differences in HLA antigen frequencies in the presence of H-ESRD. Pending larger analyses, we feel genetic factors controlling susceptibility to hypertension-induced renal disease may include loci in the major histocompatibility complex on chromosome 6.

WHAT IS THE BEST WAY TO MONITOR HEPARINIZATION IN CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT)?Robert Geronemus, Neil S. Schneider, Florida Medical Center, Lauderdale Lakes, Florida. Anticoagulation of patients on acute CRRT is an extremely delicate matter because of (l)the severity of illness of patients on CRRT and (2)the continuous nature of the therapy means that patients will be anticoagulated for days instead of hours as in intermittent dialysis. Ye have studied 9 patients with acute renal iailur9 treated with CRRT (mean age=72, we&n treDtm.nt time=99 hrs, mortality=56%). All patients were treated with CRRT in the form of continuous arteriovenous hemodialysis (CAVHD) with no blood pump; heparinization was by continuous infusion (0-1100 u/hr, mean rate=495 u/hr). Heparinization was monitored by activated clotting time(ACT) by both manual and automated (Hematec, Englewood, CO) methods; treatment decisions were made on the basis of the automated ACT. Results: For paired samples (n=216) automated ACT was 130.2±27.5, manual ACT was 160~46.8.Auto­ mated ACT was more reliable, manual ACTs varied by operator. When following ACT variation with time, in 26.5% of observations the two ACTs varied in opposite directions or one varied and the other did not. In 59.2% of observations, the manual ACT would have guided the therapy differently from the automated ACT leading to over- or under-anticoagulation. Conclusions:This study adds to the weight of previous data suggesting that automated ACT is more reliable than manual ACT. In a significant percentage of observations the two methods varied differently and would have led to different therapeutic decisions. In view of the necessity for precise anticoagulation in critically ill patients,these data suggest that automated ACT is mandatory for CRRT.

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS •

USE OF AMBULATORY BLOOD PRESSURE RECORDINGS FOR EARLY RECOGNITION OF HYPERTENSION IN TYPE DIABETES MELLITUS. K Gish-Herron', W Moore', A Chonko, M MacDougall, T Wiegmann. VAMC, Kansas City, MO and KU Med Ctr, Kansas City, KS. Hypertension is an important risk factor in the development of complications associated with diabetes mellitus (DM) and Diabetic Nephropathy. Early diagnosis and therapy are important in diminishing disease related morbidity. We recorded ambulatory blood pressure .every 20 min (SpaceLabs) in 25 patients with Type I DM who were not hypertensive based on measurement >130/85 mm Hg during outpatient clinic visits. Group characteristics (mean ± SE): Insulin 58 ± 3 IU/d; duration DM 11.2 ± 1.1 yr; age 32.3 ± 2.8 yr. Day (06:00 to 22:00 hrs) and night (22:00 to 06:00 hrs) measurements were analyzed sep-arately. We defined patients as hypertensive (HTN) when mean BP exceeded 130/85 mm Hg and at risk (risk) for readings > 130/85 more than 20% of the time. syst HTN RISK diast HTN RISK mm Hg N N mm Hg N N 24 Hr 132 ± 3 12 19 77 ± 2 7 13 Day' 133 ± 3* 13 20 78 ± 2* 8 13 Night 127 ± 3* 12 16 74 ± 2* 6 10 * ~ P < 0.05 for paired difference from 24 hour reading A significant number of Type I diabetic patients have hypertension that is not detected during regular clinic visits. We conclude that ambulatory BP recording can identify patients who have established hypertension and those at risk for hypertension.

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COLD KNIFE ENDOURETEROTOMY OF 40 STRICTURES: TECHNIQUE AND 3 YEARS FOLLOW-UP. Majid Eshghi, Jose Hernandez-Graulau,Muhammad Choudhury and Joseph C. Addonizio. Dept. of Urology, New York Medical College, Valhalla, NY. Forty strictures in 34 patients were managed with cold knife incision over a 3-year period. Three patients had multiple strictures managed in one session, and 3 patients required repeat inc~s~on. Strictures were in the distal (27), mid (10), and upper (3) ureter. Twenty-eight endoureterotomies were done with the straight and halfmoon knives, endoureterotomy scissors (10), straight catheter knife (4). Nine patients had a history of non-urologic surgery (26.4%), 13 with urologic surgery (38.2%). Post-operatively the patients were stented 4-6 weeks with 6-10 F stents. Our one-time incision was successful in 88% of cases and with repeat incision 97%. Cold knife incision of the ureter seems to be the procedure of choice for ureteral stricture.

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(D) ULTRASONOGRAPHY AND CAPTOPRIL (C) SCANNING AS SCREENING TESTS FOR TRANSPLANT RENAL ARTERY STENOSIS (TRAS). D. Glicklich, V.. A. Tellis, S.M. Greenstein, R. Schechner. Montefiore Medical Center, Bronx, N.Y. We reviewed our experience with Doppler and radionuclide scanning before and after captopril (25 mg) as noninvasive screening tests for TRAS. All 16 patients had recent onset severe HTN (diastolic > 110) not controlled on at least 3 drugs. After screening tests, all patients had selective renal angiography. No patient was felt to have HTN due to cyclosporine toxicity. Rejection was ruled out by renal biopsy. C scan was considered positive if uptake or excretion changed on visual inspection pre vs post C. D cri teria for TRAS: increased velocity of blood through the stenotic segment (> 6KHZ), decreased frequency and marked turbulence downstream from the stenosis. angio(+) angio(-) angio(+)angio(-) C scan(+) 9 0 D(+) 9 0 2 2 D(-) 5 1 C scan( -) sensitivity 9/14=66% sensitivity 9/11=82% specificity 1/1 specificity 2/2 false negative 2/11=18% false negative 5/14=34% Two patients with multiple renal arteries had negative C scans and D but then developed ARF on C therapy. Subsequent angiograms were positive. Conclusions: (1) D studies and C scanning may be useful to screen for TRAS although C scanning seems to be the more sensitive test. (2) Both screening procedures fail to detect some patients with TRAS. Patients with multiple renal arteries may present special diagnostic difficulties .

THE ROLE OF PERCUTANEOUS NEPHROLITHOTOMY AND ESWL IN THE MANAGEMENT OF CYSTINE NEPHROLITHIASIS. J. Hernandez-Graulau, J.C. Hulbert*. M. Eshghi, M. Choudhury and J.C. Addonizio. Dept. of Urology, New York Medical College, Valhalla, NY *University of Minnesota Hospital A review of medical records of 1,000 patients with renal calculi treated by extracorporeal shock wave techniques at the University of Minnesota Hospital and Clinic and at the New York Medical College between 1984 and 1988 disclosed that 10 patients were treated for cystinuria. The characteristics of the patient population; previous therapy; and the effectiveness of medical therapy, percutaneous stone removal, and ESWL were evaluated. Between 1984 and 1988, 8 men and 2 women (average age 34.2 years) with cystinuria were treated for obstructive or symptomatic renal calculi. Average follow-up was 2 and (;'J.e-half years. In all of these patients the serum creatinine level was less than 3mg/dl before treatment and the coagulation profiles were normal. All patients suspected of having cystinuria underwent a complete metabolic evaluation to confirm the diagnosis. We will present our results and experience with a series of 10 patients pith cystinuria and highlight the particular problems associated with the use of ESWL to treat these types of stone and our resultant emphasis on percutaneous techniques.

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19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

TREATMENT OF NEPHROLITHIASIS OF PATIENTS WITH TRAUMATIC SPINAL' CORD LESIONS BY PERCUTANEOUS NEPHROLITHOTOMY AND ULTRASONIC LITHOTRIPSY: EFFICACY AND COMPLICATIONS. J. Hernandez-Graulau, J.C. Hulbert*, M. Eshghi, M. Choudhury and J.C. Addonizio. Dept. of Urology, New York Medical College, Valhalla, NY *University of Minnesota Hospital and Clinic We reviewed 30 patients who were spinal cord injured and underwent percutaneous nephrolithotomy and ultrasonic lithotripsy from 1981 to 1988. We evaluated for the success rate of stone removal and the incidence of operative complications. There were 17 quadraplegic and 13 paraplegic patients of which 25 were males and 5 females. Of the 51 renal units 13 had staghorn calculi, 15. had pelvic and caliceal stones, 11 had multiple caliceal stones, 7 had more than 2.5 cm pelvic stones and 5 had l~ss than 2.5 cm stones of which 4 were located in the upper ureter and one in the renal pelvis. Our results showed that 8 out of 9 renal units (88.8%) followed for one year were free of stones. Thirty-four out of 42 renai units (80.1%) followed from 2 to 6 years remain stone free. A to'tai of 73 procedures were performed on 51 renal units. Major complications included one nephrectomy and one hydrothorax in 2 out of 73 procedures 2.7%). Minor complications included fever (more than 101.4F) in 63% (19 out of 30 patients), retained stones in 10% (5 out of 51 renal units operated upon), dislodged nephrostomy tube in 1.9% (1 out of 51 renal units). and anemia requiring transfusion in 7% (5 out of 73 procedures). Percutaneous nephrolithotripsy has proven to be a safe and effective procedure in these patients.

EFFECTS OF NURSE PRACTITIONER EDUCATION AND MANAGEMENT OF CHILDREN WITH NEPHROTIC SYNDROME. Elizabeth Heywood, Edward Ruley, Glenn Bock. Children's Nat'l Med. Ctr., Dep't of Nephrology, Washington, DC. Over the past several years, a Pediatric Nurse Practitioner (PNP) has had primary patient care and educational responsibilities for children with nephrotic syndrome (NS) in our program. This approach places a heavy emphasis on patient/parent education about pathophysiology, natural history, disease manifestations, medication usage, etc. We compared clinical course and cost effectiveness during the 36 month period following onset of the NS in those children treated prior to the PNP program (PrePNP) and those treated subsequently (PostPNP) . There were 14 PrePNP and 20 PostPNP patients. Age of NS onset and M:F did not differ between groups (4.9±2.8 yr, 64% male PrePNP; 4.9 ±2.9 yr, 60% male PostPNP). The mean periods of followup were 25.9 ±2.8 mo and 17.1 ± 12.6 mo for the Pre and Post groups, respectively. The frequency of relapses/mo followup was 0.20 ±0.11 for the Pre group and 0.23 ± 0.25 for the Post group (p=NS). The PostPNP group made significantly more telephone calls (11.6 ± 13.2 calls/yr vs 5.04 ± 7.44 calls/yr, p=.015) and had fewer hospital days (1.56 ± 3.84 days/yr vs 8.04 ± 13.2 days/yr, p=.004). While the number of clinic visits were not significantly different, patients in the PostPNP group had fewer clinic visits with lab tests (1.2 ± 0.84/yr vs 3.12 ± 2.16./yr, p<.003). We conclude that quality care of children with nephrotic syndrome can be cost-effectively delivered using clinical expertise and education delivered by the PNP.

LABORATORY INVESTIGATION OF RENAL PELVIC PRESSURE (RPP) DURING URETERAL DILATATION AND URETEROSCOPY. M. Eshghi, J. Hernandez-Graulau, M. Choudhu.ry and J.C. Addonizio. Dept. of Urology, New York Medical College, Valhalla, NY This investigation was designed to measure the RPP during ureteral dilatation and ureteroscopy, to assess the effect of continuous bladder drainage and renal pelvic decompression with a ureteral catheter on RPP, and to determine the maximum RPP and "rupture" pressure in 13 minipigs weighing 50-65 pounds (26 renal units and 10 freshly harvested kidneys). These minipigs are the ideal animal model in view of their marked anatomic and physiologic similarities to the adult human urinary tract. A modified technique in retrogra de renal puncture to insert a nephros tomy tube wa s performed which was connected to a transducer and digital monitor for continuous RPP recording. Four mode s of ureteral dilatation (bougie, Teflon, balloon or hydraulic) were performed while recording RPP. Rigid ureteropyeloscopy was performed using variabl~ inflow irrigant pressure to evaluate its ef fect on RPP. RPP after 5 minutes of balloon ureteral dilatation wa s 39mmHg while the maximum RPP during hydraulic intramural dilatation (150-200mm Hg pressure, 200-400cc/min flow) >Jas 60mmHg. RPP during rigid ureteroscopy is related directly to the irrigant height above the kidney or to the se t pressure on the hydraulic pump plus the "scope effect:" 20-2SmmHg (the mechanical pressure of the scope in the ureter without flow). Continuous bladder drainage with a small catheter during ureteroscopy lower RPP by 20-25mmHg.

R FAILURE OF THE DERMAPORT CATHETER (DC) AS AN ACCESS DEVICE IN CAPD. W.H. Hines,* D.R. Smego.* and R.E. Longnecker, Stamford Hosp. Stamford, Ct. The DC is a new polyurethene peritoneal access device for CAPD constructed with a subdermal flange which is intended to aid healing and prevent exit site and tunnel infection. We studied all pts i n a single dialysis center who had CAPD catheters inserted over a 1 yr period. 9 pts received 10 DCs and 9 pts received 12 Tenckhoff catheters (TC). Some pts received both types of catheter.

DC TC

total II at end mos of stud~ 63.2 0 100.2 8

rate/pt mo exit infection eeritonitis leak 3.6 2.2 ~ 20.0 5.7 100.2

There was a dramatic increase in the number of infections. especially of the exit s ite, with DC as opposed to TC. Catheter survival time is l ess for DC than TC. which is magnified by the fact th a t 8 of 12 TC placed during the study period remained until the present time. whereas 0 of 9 DC are c urrently in place. 9/10 DC were removed for infec tious complications of the device (8 catheters) or dialysis dissection into the abdominal wall (1 catheter); 1 DC was indwelling at the time of death from other causes. Of the 4 TC removed, 3 were for infectious complications and 1 was for a switch to hemodialysis. We conc lude that the DC has an inordinatel y high rate of infectious complications and a low catheter survival rate as compared to TC. The data suggests that the DC as currently manufactured is an inferior device to the TC.

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS • PLASMACYTIC INTERSTITIAL NEPHRITIS (PIN) IN A HIV+ PATIENT. Jennie Hom,* Rocco C. Venuto, Brian M. Murray, Dept. of Medicine, SUNY at Buffalo, Buffalo, New York. A 36 y.o. female with a history of I.V. drug and alcohol abuse, HIV and hepatitis B Ag+ was admitted in 1/89 with a creatinine of 6.6 mg/dl (0.8 in 10/88). She had hepatosplenomegaly, cervical adenopathy. Evaluation revealed anemia, ESR 139, nephrotic-range proteinuria, reversed T4/T8 ratio, polyclonal increase in IgG, and a CT scan showed para-aortic adenopathy and bilaterally enlarged kidneys. Renal biopsy revealed a few sclerosed glomeruli with mild mesangial hypercellularity of the remainder and massive infiltration of the interstitium with mononuclear leukocytes, mostly of the plasma cell series. There was no indication that the infiltrate represented a lymphoma or myeloma. The patient was begun on Prednisone 60 mg/ day and her renal function improved remarkably. Date 1/22 1/24 1/27 1/29 1/31 2/2 2/4 2/6 3/16 Creat. 6.6 7.3 6.8 6.5 6.0 5.3 4.0 3.8 1.5 Pred. 60 60 60 60 50 40 30 Most previous reports of ARC/AIDS nephropathy have focused on the presence of focal glomerulosclerosis with little attention paid to the interstitium. In this case, PIN appeared to be the predominant lesion causing renal failure and also proved to be reversible with steroid therapy. A druginduced nephritis is unlikely for no medication could be incriminated in the time period involved and there wa s no evidence of peripheral or renal parenchymal eosinophilia. This hitherto unrecognized and treatable form of renal failure in a HIV+ patient emphasizes the need for renal biopsy in defining the spectrum of renal disease in HIV+ patients.

THE EFFECT OF CALCIUM CHANNEL BLOCKERS ON THE CYCLOSPORINE (CSA) DOSE REQUIREMENT IN RENAL TRANSPLANT RECIPIENTS. R.L. Howard*. J . I. Shapiro. S. Babcock, L. Chan. Dept. Med .• Univ Colorado Sch. Med .• Denver. CO. Thirteen patients found to be hypertensive following renal transplantatlOn were treated with either a calcium channel blocker or other antihypertensive therapy for control of blood pressure. Immunosuppression was either with CSA and prednisone alone or CSA, azathioprine and prednisone. Patients had weekly or biweekly CSA whole blood levels measured by radioimmunoassay drawn approximately 12 hours after their last dose. Patients treated with CSA alone had their CSA dosage adjusted to maintain their CSA level between 400 and 900 ng/ml between 1 and 6 months following transp lantat ion. Pat ients treated with CSA, azathioprine and prednisone had the i r CSA I eve I adj usted to between 100 and 400 ng/ml during this same time period. CSA levels were higher in verapamil treated patients and slightly lower in nifedipine treated patients as compared to controls (817±63 and 409±54 vs 556±38 P9/ ml, P<0.01 and P<0.05). The dose of CSA administered was significantly lower in the verapamil treated patients and higher in the nifedipine treated patients than controls (4.0±0.5 and 6.9±O.5 vs 5.7±O.2 mg/kg. P<0.01 and P<0.05). Normalizing the whole blood CSA level for the dose of CSA, the verapamil treated patients had a much greater and the nifedipine treated patients a somewhat lower value than control patients (203±14 and 56±5 vs 98±7 gil, both P<0.01). These data suggest that verapamil treatment results in significantly higher levels of CSA whereas nifediplne therapy may actually result in lower CSA levels for a given dose of CSA than seen in patients not exposed to these drugs.

A11

PHOSPHATE (Pi) REMOVAL BY HEMODIALYSIS: COMPARISON OF TERUMO TAF-lO AND BAXTER HT-lOO HOLLOW FIBER DIALYZERS. S. Hou, C. Ellman, Z. Griffin, J. Hu, J. Zhao, and~urdeau, . Michael Reese Hosp. and University of Chicago, Chicago, Illinois. An important therapeutic goal in uremic patients is prevention of Pi retention and hyperphosphatemia, Because of the problems with intestinal Pi binders , there is renewed interest in increasing Pi removal by hemodialysis. One approach (that used in the HT-lOO dialyzer) has been to chemically modify the cellulose dialysis membrane to increase the permeabilit y to Pi' To evaluate the HT-lOO dialyzer, we studied 8 stable hemodialysis patients during two dialysiS treatments, each following one day without dialysis. The treatments were identicalt except that the TAF-lO was used in one and the HT-lOO in the other. Plasma [Pi) was measured predialysis, and all dialys ate was collected volumetrically and analyzed for Pi' Total Pi removal and dialysis membrane Pi permeability were calculated for each treatment. Predialysis plasma [Pi) was similar for the two treatments, 6.4l±0.48 (TAF-lO) vs 6.30±0.60 (HT-lOO) mg/dl. Although the membrane Pi permeability (em per hour) of the HT-lOO, 0.79±0.01, was significantly (P<0.025) higher than that of the TAF10, 0.73±0.02, total Pi removal durin~ 4h was not greater, 1105±83 vs 1078±64 mg, respectively. In conclusion, although the HT-lOO dialyzer membrane is more permeable to Pi than the TAF-lO, the differen ce is small and does not effect a clinically significant increase in Pi removal during a standard hemodialysis treatment. tBlood and dialysate flows = 300 and 500 ml/min, respectively; dialysate composition (in mEq/L) Na 140, K 2, Ca 3.5, HC03 35 and D-glucose = 200 mg/dl

•

LINE!\R
C. !M!§ am Barry L. Wllshaw. Brmy lhiversity Sdlool of Medicine, DEpt of Pediatrics. Atlanta, Georgia. Line:u: gr~ rates were analyzed in perliatric transplant redpioots (age <17 yrs, graft functioo >12 IlD) in order to ide1tify factors that influence height velocity am catc:lHJp gr~. Sixty-five patie'lts were studied (32.±18 IlDS posttransplant) , 43 with noma! am 22 with Slt:noma! pcsttransplant gr~, with r~ to age, geOOer, pret:ransplant sOOrt stature, dialysis IlDdality, prineI}' diagnosis, osteOOystrq:hy, living-related graft (IRl'), IRlltiple grafts, (p) steroid am rEnal. functioo (W). N:>ma! gr~ ~ associated with better W (p< .0005), sOOrt stature (P<.02), (p) (P<.01) am IRI' (P<.05). N:> other significa1t variables were idaltifiEd. '!he relatiooSlip betwes1 noma! gr~ am IRI' or (p) W3S depeldent 00 W (P<.OO5), but that of noma! gr~ am sOOrt stature ~ no depeldent 00 W, IRI' or (p) (p>.25). SJpranoma! gr~ velocity ocx:urrEd IlDre cammly with sOOrt stature (P<.05), (p) (P<.01) am sOOrt stature + (P) (P< .01). PiIal3 38 patioots with sOOrt stature Wlo were foll~ 33 .±.18 rrmths posttransplant, ooly 3 have attained noma! height for age. Ccnclusioo: N:>ma! gr~ ~ highly depeldent 00 W, am 00 sOOrt stature to a lesser degree. catdHJp gr~ ~ IlDre oamm in sOOrt stature treated with (P). Rnetheless, noma! height ~ not achieved in IrCSt patioots with sOOrt stature despite noma! W, (P) am catdHJp gr~. lanaI(]

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

A12

[] CYCLOSPORINE TREATMENT DECREASES GLOMERULAR ULTRAFILTRATION COEFFICIENT . Michael D. Jameson*, Virginia J. Savin, Ram Sharma*, Helen B. Lovell*, Dennis A. Diederich. Univ. of Kansas Medical Center, Kansas City, Kansas Cyclosporine (CSA) administration to patients produces reversible impairment in glomerular filtration rate (GFR). To examine potential glomerular contribution to decreased GFR, we studied filtration by glomeruli isolated from adult male Wistar Kyoto rats (250 g) injected subcutaneously with saline or CSA (30 mg/kg/day) for 14-21 days. Mean serum creatinine was 0.68 vs 0 . 96 mg/dl for saline and CSA rats, respectively (p < 0 . 005). Glomeruli were isolated and filtration induced by an albumin oncotic gradient and ultrafiltration coefficient, Kf , was calculated from the initial rate of increase in glomerular volume. Capillary hydraulic conductivity, Lp, was calculated as Kdarea where area was estimated empirically from average glomerular diameter. Both Kf and Lp were markedly diminished in CSA treated rats compared to controls. Glomerular volume, nl Saline (5) 2.4±0.2 CSA (5) 2.l±0.1 Mean ± SEM. (N) -

Kf

nl/min'mmHg

#

. . THE MODIFICATION OF HLA MATCHING UPON CADAVERIC GRAFT SURVIVAL BY IMMUNOSUPPRESSANT PROTOCOL. H. Keith Johnson, Robert C. MacDonell, Jr. ,. Wayne Green, and Robert E. Richie. Vanderbilt and V.A. Medical Centers, Nashville, Tennessee. The impact of HLA compatibility upon graft survival following cadaveric renal transplantation continues to be a source of considerable debate. An additional variable of interest and possible impact is the choice of immunosuppressant protocol. We decided to examine the effect of three immunosuppressant protocols that we have utilized in our transplant program upon the results with different degrees of HLA-AB matching. Three time periods were examihed: Period I, 1974-1976, during which time immunosuppression was with Imuran and Prednisone; Period II, 1981-1983, during which time Imuran, Prednisone and rabbit anti-thymocyte serum (ATS) were used; and Period Ill, 1985-1987, when Imuran, Prednisone, ATS and Cyclosporine formed the immunosuppressive protocol. During each period, 1 and 3 year graft survivals for different degrees of HLA-AB matches were examined. The results were as follows.

Lp

~l/min 'mmHg' cm 2

8 . 6±0.7 3.4±0.2 4.2±0 . 2** 1.8±0.l** rats . ** p < 0.001, t-test.

These results demonstrate a marked effect of CSA on the glomerular filtration barrier with decreased Kf and Lp that persist in vitro and are independent of perfusion. Thus, altered capillary function as well as altered vascular reactivity may contribute to renal dysfunction during CSA therapy .

.. TREATMENT OF HYPERCHOLESTEROLEMIA WITH LOVASTATIN (LOV) IN RENAL TRANSPLANT RECIPIENTS (RTR), Warren L. Kupin, K. K. Venkat, Heung K. Oh, Karen Stalla and Martin Mozes. Henry Ford Hospital, Detroit, MI. LOV, an HMG CoA reductase inhibitor, has recently become available for the treatment of hypercholesterolemia. Rhabdomyolysis with the risk of acute renal failure has been associated with LOV use in cyclosporine (CSA)-treated heart transplant recipients. We report our experience with the long-term use of LOV in 17 CSA-treated and 11 conventionally immunosuppressed RTR with serum cholesterol concentrations> 300 mg/dl. Mean follow-up after initiation of LOV was 11±16 months in the CSA and 13±4 months in the conventionally treated group, respectively. 18 patients required 20 mg/day; 8 - 40 mg/day and 1 - 60 mg/day. Results (pre - at initiation of LOV; post - at most recent visit): Serum Serum Serum CPK cholesterol creatinine (lU/L) (mg/dl) (mg/dl) CSA 2,O±0,? 378±81* 78±43 pre 250±49 95±68 2.1±0.6 post conventional 60±23 pre 320±39* 1. 3±0. 3 52±31 post 256±38 1. 3±0. 4 *p < 0.05, pre vs post The LDL/HDL ratios decreased in LOV treated pts (4.2±1.1 pre vs 2.7±1.2 post p< 0.5). There have been no episodes of overt rhabdomydlysis and no changes in liver function or CSA levels with the use of LOV. We conclude that LOV can be used safely and effectively in CSA and conventionally treated RTR with significant hypercholesterolemia.

4AB 3AB 2AB

Period II 3 yr

Period I 3 yr

1 yr

68% 54% 49%

84% 76% 73%

1 yr

79% 69% 65%

73% 60% 57%

Period III 3 yr

1 yr

96% 89% 81%

93% 81 % 74%

We conclude from this data that HLA-AB matching continues to affect graft survival with each of the immunosuppressant protocols studied and that none of these protocols was capable of obliterating this effect of matching.

CLINICAL USE OF UREA KINETIC MODELING (UKM) IN HEMODIALYSIS (HD). Katharina Kurunsaari, Ralph J. Caruana, Barbara O. Lightfoot, Jennie Klein. Medical College of Georgia, Augusta, Georgia. UKM was performed 3 times in 41 chronic HD patients over a 9 month period. Clinical goals included maintenance of KT/V>1.06, normalized protein catabolic rate (NPCR) >1 gm/kg/day and prevention of uremic symptoms. Dialyzers were not re-used and no dialyzers haVing a urea clearance > 210 ml/min at Qb of 300 ml/min and Qb of 500 ml/min were used. Additional data recorded included midweek BUN, residual urea clearance, dialysis time (Td), Qb and KT/V delivered ~ predicted KT/V (D/P %). Intensive dietary counseling was employed and close attention given to maintaining prescribed Qb, Td, needle placement and vascular access quality. Results 1st UKM 2nd UKM 3rd UKM Midweek BUN (mg/dl) 54 ± 13 59 ± 19 70 ± 21 Td (minutes 229 ± 38 236 ± 36 222 ± 38 Qb (ml/min) 283 ± 39 298 ± 29 305 ± 33 KT/V 1.10±.3l 1.26 ± .28 1.35 ± .51 NPCR(G/kg/day) 0.72±.28 0.94 ± .24 0.96 ± .26 D/P % 85 ± 15 93 ± 19 99 ± 15 Correlations (r) KT/V vs NPCR 0.56 0.31 0.52 BUN vs KT/V 0.02 -0.10 0.09 BUN vs NPCR .76 .83 .78 Conclusions: KT/V can be augmented by increasing Qb and improving D/P without increasing Td. Poor NPCR is amenable to dietary counseling and is only modestly related to KT/V. Midweek BUN has no predicative value for KT/V but is a powerful predictor of NPCR in chronic HD patients receiving standard therapy.

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS •

• A LA CARTE HEMODIALYSIS: A PRACTICAL APPROACH . Alfred Lefebvre*, Marie-Odile Frydman*, Claude Roux and Henri E. KUntziger. Centre d'Hemodialyse du Bessin, Aura, Paris, Fr.ance. Ideal a la carte dialysis should be based on dialysate (D) individualized for every patient. Approaches are : stock different D concentrates, change concentrate during dialysis, alter concentrate dilution through a variable proportioning equipment. With this device however D concentration of Na, (Na) D, or of Bicarbonate (Bic) D cannot be changed without changing concentrations of other D ions. In vitro varying (Na) D from 131 to 151 mM (x) increases significantly D ions (y), Cl y = 1.2 x-59; K : y = 0.01 x + 0.2 ; Ca : y = 0.01 x - 0.4 ; acetate: y = 0.01 x - 0.3 (N=5). Varying (Bic) D from 30 to 40 mM (x) decreases significantly D ions (y), C1 : y = - 1.1 x + 155 ; K : y = - 0.02 x + 3 ; Ca : y = - 0.02 x + 2 ; acetate: y = - 0.01 x + 2 (N=4). These variations might be clinically relevant. In 15 patients postdialysis blood Ca increased from 2.85 +/- 0.15 to 3.1 +/- 0.15 mM (mean +/- SD, P < 0.001), when (Na) D was increased from 140 to 145 mM. To specifically modulate (Na) D, or (Bic) D, without changing other ions D concentration, the following device has been built: a double pump is incorporated into the terminal dialysis pathway, NaCl (or NaHC03) is infused into D at prescribed rate and the same volume is withdrawn at the same time to respect the prescribed ultrafiltration rate. This device may be operated manually, but is to be included into a computerized dialysis delivery system. It has many advantages, tailor (Na) D or (Bic) D to specific patients' needs without changing co~ centration of other D ions, stocking many concentrates, changing D concentrate during procedure .

INTESTINAL IRRIGATION FOR REPLACING RENAL EXCRETORY FUNCTION: FACTORS EFFECTING SOLUTE AND WATER CLEARANCE IN DOG JEJUNUM. Eugene D. Kwon, Harold P. Schedl, James F. Donovan, William J. Lawton, and Richard D. Williams, Univ. of Iowa Hosp. and Clinics, Dept. of Urol., Iowa City, IA. Intestinal irrigation has previously been shown to provide substantial clearance (CL) of urea and water, however, clearances were inadequate for long-term management of chronic renal insufficiency. Factors effecting movement of solute and water in previous studies were poorly defined. To optimize attainable clearances while determining the feasibility of substituting conventional forms of dialytic therapy with intestinal irrigation, we studied effects of irrigant rate, osmolality, temp., and chemical augmentation of mucosal permeability on solute (Na, K, Cl, Urea, and creatinine (CR)) and water movement in 90 cm in situ segments of dog jejunum. Solute CL increased with increasing rate. Effluent volume was augmented 120% and solute CL (Na, K, CR, urea) doubled when lumenal osmolality was increased from 300 to 1200 mOsm/kg. Urea CL was strongly dependent upon irrigant temp. and peak clearances (10.1+/0.5ml/min) were achieved with hyperthermic (39 0 ) irrigation. Sodium deoxycholate-induced increases in mucosal permeability led to augmented CL of uric acid, phosphate, and CR. To date, CR CL rates of 3.0 ml/min have been achieved. We conclude CL of solutes (including urea and CR) and water approach that necessary for treatment of chronic renal insufficiency when factors pertaining to irrigation are critically selected. The optimal irrigant composition and flow rate to chronically support uremic dogs is currently under investigation.

COMPREHENSIVE OUTPATIENT METABOLIC TESTING OF PATIENTS WITH RECURRENT KIDNEY STONES Stephen W. Leslie, M.D., Lorain, Ohio (Presentation to be made by Dr. Leslie) Our new comprehensive metabolic testing program for patients with recurrent kidney stone disease is presented. This protocol can be expected to detect and identify specific biochemical abnormalities and high risk factors which contribute to new stone formation. The program includes: l:Brief clinical history questionnaire. 2:Serum testing of 1,25 Vit.D, N-terminal PTH, magnesium and an SMA-20. 3:24 hour urine values of calcium, citrate,- oxalate, magnesium, phosphate, uric acid, sulfate and cystinuria screening. 4: Correction factors for body weight and urine volume. 5: Simplified data reporting with all ~esults categorized into "High, Medium or Low Risk". 6: Provides guide for data interpretation -and possible therapeutic options. We recommend treatment selection based on likelihood of patient compliance and lack of long-term side effects. 7: Rechecks at regular intervals to evaluate continued efficacy of therapy. 8: A complete Calcium Loading Test for selected pat ients. 9: Pat ient instructions educational materials and laboratory protocols. Patients with recurrent stones willing to make permanent changes in lifestyle, diet or take daily' medication Lu prevent stones are ideal test subjects. This program uniquely combines hardto-find comprehensive testing with data analysis and treatment suggestions.

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•

TRYPTERYGIUM WllFORDII, A CHINESE HERBAL MEDICINE WITH POTENT IMMUNOSUPPRESSIVE PROPERTIES. X.W. Li*, Matthew Weir, and Steve Shen. Univ. of Maryland Hosp., Div. of Nephrology, Baltimore, MD. Radix Tripterygium Wilfordii (TW) is a chinese herbal medication known to be effective in the treatment of various immunologic disorders in man. The purpose of this report is to report the inhibitory properties of TW. TW at concentrations of 2.4,1.2 and 0.6 ug/ml inhibited human peripheral blood mononuclear cell (PBMC) responses to both phytohemagglutinin (%inhibition: 89.8, 76.3, and 35.1, respectively (R» and concanava lin A (% inhibition: 89.3, 47.3, and 9.9,R) in a concentrationdependent fashion (CDF) when added prior to mitogen. Trypan blue exclusion by the PBMC at the end of three day culture periods demonstrated no cytotoxicity. TW inhibited alloantigen-induced responses of PBMC in mixed lymphocyte cultures in a CDF with concentrations of TW of 2.4,1.2,0.6: % inhibition = 93.1, 91.6,73.9, R. TW inhibited the responsiveness of the IL- 2 dependent helper T cell clone (CTLL-2) to 10 U/ml recombinant Il-2 in a 24 hour assay when added just prior to the Il-2 in a CDF (% inhibition = 68.6, 59.7, 35.5, R). The generation of cytotoxic T cells (CTL) was significant Iy inh ibited by TW with 81 % and 70% inhibition, R, with concentrations of 2.4 and 0.6 ug/ml (at killer: target ratios of 25: I). No inhibitory effect of TW was noted on CTl effector function or natural killer cell activity during four hour microcytotoxicity assays. TW inhibited in vivo delayed type hypersensitivity in mice induced by oxazolone in a CDF: 15 mg/kg/day, 23.2%; 30 mg/kg/day, 25.3%; and 60 mg/kg/day, 40.4%, R, while the control inhibition was 21.2% by 25 mg/kg/day cyclosporine. TW may be an important new immunosuppressive agent for possible use in organ transp Ian tat ion.

A14

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

• PAGE Kidney: A Rare Co!rplication of Renal Biopsy. '!homas McCune, William stone, Julie Breyer, Vanderbilt university SChool of Medicine, Nashville, Tennessee, U.S.A. Small subcapsular hematomas are a COll1IOCln oamplication of renal biopsies (10-20%) and generally have few clinical consequences. We now refOrt the developnent of a subcapsular hematoma surrourrling the entire kidney which led to an acute loss of renal function and new onset hypertension, post-renal biopsy. A 33 y/o white male with a history of increasing creatinine over 4 years, microscopic and macroscopic hematuria, and nonnephrotic proteinuria was biopsied. Renal biopsy was without incident and revealed 19A nephropathy. 24 hours post-biopsy, the patient was noted to have an increase in creatinine (2.7->3.8), decreased PCIT (38->33), and new onset hypertension. MRI, abdaninal cr, and ultrasourrl revealed a subcapsular and perirenal hematoma consistent with a PAGE kidney. Blood supply to the kidney was intact. 'Ihree rocmths post-biopsy the patient remains with a stable decrement in his renal function and continued poorly controlled hypertension. PAGE kidney has been described primarily following blunt trauma and is associated with new onset hypertension, often requiring neIfu"ectomy. '!his is the first description of a PAGE kidney following a renal biopsy in a patient with urrlerlying renal insufficiency leading to, not only new onset hypertension, but a decrement in renal function.

COMPARATIVE COSTS OF CONTINUOUS ARTERIOVENOUS HEMOFILTRATION (CAVH) AND DIALYSIS (CAVHD) VERSUS INTERMITTENT HEMODIALYSIS (HD) IN TREATMENT OF ACUTE RENAL FAILURE (ARF). (Introduced by Robert W. Steiner), Ravindra L. Mehta*, Denise Turner*, Linda Montalbano* and Edgar R. Black*. University of Rochester, Dept. Medicine, Rochester, NY.

PRODUCING AN EDUCATIONAL VIDEO FOR THE HOME DIALYSIS PROGRAM. Alma Melendez, Joseph S. Madej and Cosme Cruz. Henry Ford Hospital, Division of Nephrology & Hypertension, Detroit, Michigan. Teaching patients and medical personnel is the most important endeavor in a home dialysis program. Instructional videos facilitate and enhance this task, but finding appropriate and current material on film can be a tedious and frustrating effort. Thus, producing your own educational video may be ideal. First, decide on your objective. Will the video relate information or will it instruct a step-by-step procedure? Next, update the information in a generic way. The language must be plain and concise. Consider your audience's education, job experience and/or language barriers. The knowledge of your audience will affect the pacing of action and sequencing of information bits as they are presented on video. Differentiate between the "need to know" and "nice to know". Remember, a 10-15 minute video is long enough! Anything longer would lose the audience's interest. Then write the script. Correlate what needs to be filmed to the verbiage. Be specific and get as much footage as possible, excess footage is never a problem when editing. Printed handouts to accompany the video is a good idea. In conclusion, decide on a topic, identify your audience, concentrate on "need to know" and write your script detailing the action. Now get a good videographer and go for it!

• REVERSIBLE ACUTE RENAL INSUFFICIENCY FOLLOWING SIMULTANEOUS BILATERAL ESWL. Marc Meiser, M.D., Ray H. Littleton, M.D. Joseph C. Cerny, M.D. Henry Ford Hospital Detroit, MI Extracorporea I shock wave Ii thotr i psy (ESWL) is known to produce morphologic, enzymatic, and functional changes in the kidney. The patient undergoing simultaneou s b i I at.era I s hock wave therapy is potentially at an increased risk for such changes. We reviewed our series of 70 patients who underwent 74 treatments of simultaneous bilateral ESWL. Four patients with normal rena I function and an average stone burden per kidney of 18 mm had a greater than two fold increase in their preoperative serum creatinine. Three of these patients had uni lateral obstruction, the fourth was unobstructed. AI I patients returned to their baseline creatinine within 10 days. We conclude that simultaneous bilateral ESWL is generally safe, effective, and well tolerated. As in unilateral therapy results and complications are related to stone burden. A reversible acute renal insufficiency occurs as a result of shock wave therapy.• Prevention of this can be achieved with preoperative hydration and intraoperative use of Lasix, and/or Mannitol.

CAVH and CAVHD are increasingly utilized to treat ARF in critically ill patients in the ICU. We analyzed the relative cost of CAVH/CAVHD vs acute HD in 15 ARF patients who required dialytic support in the surgical ICU (SICU) from Nov. 87-June 88. There were 62 HD treatments in 11 patients, 12 days of CAVH in 3 patients and 12 days of CAVHD in 1 patient. Cost information was obtained for each patient by using time log methods to determine actual time spent on each procedure and using actual cost figures (not charges) for each supply item. Cost (SEI1) n

Supplies

Dia1. IQJ Nursing Nursing Time Time

Physieian Time

Tech Time

Total Cost/

Day

HD 6254.4(5.7) 42.9(0.7) 3.3(3) 66.4(11.2) 11.3(0.1) 178.6(36) CAVH 1297.1(25.6) 8.9(1.8) 38.2(3) 121.8(30.1) 2.5(0.8) 268.6(56) CAVHD 12 120.2(16.2) 6.3(1.6) 40.9(4) 65.8(10.9) 1.3(0.7) 234.3(25)

Mean cost (SEM) for HD (minimum 3 hrs/$178.6) was lower (p<0.05) than CAVH/CAVHD ($268.6/234.3) mainly because of more costly hemofilters and sterile dialysate for CAVHD and inc~eased physiCian time for CAVH. ICU nursing costs increased for continuous therapy but were balanced by reduced HD nursing time. Contin-uous therapy was better tolerated, achieved better fluid balance (CAVH 60%, HD 32%) and allowed more adequate nutritional replacement (CAVH 66%, HD 43%). Our data provides new information on the relative costs of these procedures. Although currently more expensive, continuous therapies provide better physiological renal replacement and will likely prove to be more cost effective in treating ARF in critically ill patients .

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

A15

RECOVERY OF RENAL FUNCTION IN TWO PATIENTS WITH RENAL CHOLESTEROL EMBOLISM AR Morton, JM Roscoe and CC Williams. Division of Nephrology, The Wellesley Hospital, Toronto, Ontario, Canada. Acute renal failure due to cholesterol embolisation is the most dramatic presentation of atheromatous renal disease. The onset is abrupt and renal functional recovery is uncommon. We report two patients with systemic cholesterol embolisation and "end stage renal disease" who recovered renal function while on continuous ambulatory peritoneal dialysis (CAPD). A 54 year old black man with a short history of transient cerebral ischaemic attacks developed a an acute systemic illness with livideo reticularis, amaurosis fugax and acute oliguric renal failure (creatinine 819Ilmol/l). Cholesterol crystal emboli were identified on fundoscopy. He was commenced on peritoneal dialysis and discharged home on CAPD. He remained well, and II months after the acute episode his serum creatinine had fallen to 260llmol/I (creatinine'Clearance 20ml/min). Dialysis was discontinued. Six months later he was well with a serum creatinine of 2651lmol/l. A 63 year old white woman developed a left cerebral hemisphere infarct, digital gangrene and acute oliguric renal failure following cardiac catheterisation for unstable angina. Serum creatinine was 600llmol/l. She was commenced on intermittent peritoneal dialysis and later CAPD. Twelve months later her serum creatinine had fallen to 1581lmol/l (creatinine clearance 25ml/min). Dialysis was discontinued and 2 months later she was well with a serum creatinine of 300llmol/l. These cases indicate that late renal functional recovery is possible following cholesterol embolisation.

• EVALUATION OF A SILICONE CATHETER WITH DACRON CUFF AS A LONG-TERM VASCULAR ACCESS FOR HEMODIALYSIS. A. Moss, C. Vasilakis, J. Holley, C. Foulks, K. Pillai, D. McDowell. West Virginia University Health Sciences' Ctr, Morgantown, WV. We reviewed our experience with a dual lumen silicone catheter with a Dacron cuff(C) as a long-term vascular access in hemodialysis patients to assess the adequacy of C function and the complications of its use. One hundred fiftythree catheters placed in 125 patients between 1984 and 1988 provided a cumulative experience of 59.2 patient-years. Mean patient age was 58.5 years and 47% were diabetics. Catheters were used a mean of 4.6 months (range 1 to 28). The average blood flow rate achieved was 244 ml/min (range 180 to 350) with a mean recirculation of 6.6%. Thirty-three C exit-site infections occurred at a rate of 0.56/pt-yr and 88% resolved with antibiotics. C-related bacteremia occurred 14 times at a r~te of 0.24/pt-yr. C exit-site infections developed in 24% of diabetics vs 8.6% of non-diabetics (p=0.02). Clotting caused lumen occlusion in 72 C (47%), occurred an average of 9% of treatments (range 1 to 40) and resolved with urokinase instillation 82% of the time. Streptokinase infusions were used in 29 C (19%) when urokinase therapy failed and declotted C 96% of the time. Thirteen C (8.5%) were removed for infectious complications, 2 (1.3%) for thrombotic complications and 5 (3.3%) for mechanical problems. We conclude that C can be used for long-term vascular access, and that its infectious complication rate is acceptably low, especially in non-diabetics. Thrombotic complications are the main disadvantage to its use and occur in a minority of patients .

THE ROLE OF URODYNAMIC MEASUREMENTS IN ORDER TO AVOID KIDNEY FAILURE IN PATIENTS WITH SPINA BIFIDA. Ch. Munch, F. Kuhne, K. Mohring, G. Staehler Dept. of Urology, University of Heidelberg, FRG. For patients with neurogenic bladder dysfunction urodynamic controls to verify the situation of the lower urinary tract are still no standard. Therefore most patients will be seen by urologists only when complications occur. Material and Methods: In the past four years 1500 pat. were investigated by videocystometry. 79 of these suffered from a meningomyelocele. The mean age at first urodynamic investigation was 17.5 y. Results: The neurogenic bladder dysfunction was classified as follows:26 cases with supranuclear, 43 cases with mixed and 20 cases infranuclear lesions. Voiding habits: 50 pat. voided by the use of abdominal pressure, 16 pat. used suprapubic triggering, 5 pat. did self-catheterisation and 8 patients had a suprapubic catheter. In 22 pat. we found a physiological urinary tract, 28 pat. had diverticula or a vesico-ureteral reflux of I" to II". In 22 pat. monitored IV· to V· reflux. 7 pat. had developed kidney failure. Besides pharmacological treatment in 26 cases a surgical intervention was nessecary (12x sphincterotomy, 8x antirefluxive operations, 2x ileum conduits, 1 kidney transplantation). Conclusions: At the time of their first urodynamic examination (17.5 y) 37% of spina bifida pat. had severe lesions of the urinary tract or had development kidney failure. This fact points out that the urodynamic-urological evaluation of patients with spina bifida has to occur as soon as it becomes clear that physiological voiding patterns cannot be achieved by the small child.

. . COMPLETE SERO CONVERSION AFTER INTRADERMAL(ID) RECOMBINANT HBS VACCINE IN HD PATIENTS. Keiji Ono, & Seizaburo Kashiwagi*. Ono Geka Clinic & Dept. of General Med. Kyushu Univ. Faculty of Medicine, Fukuoka, Japan. This study was undertaken to elucidate whether the poor sero conversion rate in immune deficient HD patients could be enhanced by multiple ID inoculation of recombinant HBs vaccine(rHBs-v). Group I (13 pts) received 5 ~g ID rHBs-v, every 2 weeks; Group 11(14 pts) was given 5 doses of 2.5 ~g ID rHBs-v every 2 weeks and the inoculation rate then doubled to every week. Group 111(8 pts) was immunized by 10 ~g rHBs-v 1M 5 times every 4 weeks, then 5 llg ID every 2 weeks until sero conversion. As expected, the response to 1M injection was poor and only 37.5% of patients developed anti-HBs at a titer of 10 mIU/ml or more by the 16th week. This poor response was significantly imporved by changing the route of the injection to ID. The time of sero conversion was markedly earlier and the rate of response was higher in patients immunized by 5 ~g ID every 2 weeks. The slow response in Group II was improved by doubling the inoculation. Sero conversion was finally obtained in 100% of patients by multiple ID immunization 26 weeks after the initial vaccine dose. This is the first study to accomplish complete sero conversion in HD patients against HBs-v. However, the anti-HBs titers were lower in all patients than in healthy subjects and declined in some patients after discontinuation of immunization. We feel that the ID route remains a more useful and cheaper method of obtaining prophylaXis against HBs in high risk HD patients, but it would seem prudent to monitor these patients serially to assess the persistance of anti-HBs in serum and give a booster dose when required.

A16

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

URINARY ACID EXCRETION IN CHRONIC RENAL FAILURE PATIENTS. Kiyoshi Ozawa,* Takuo Sasaoka,* Sei Sasaki, and Fumiaki Marumo. Dept.of Nephrol., Yokosuka Kyousai Hosp., Yokosuka, Second Int. Med., Tokyo Med. and Dent. Univ., Tokyo. Quantitative measurement of urinary acid excretion in large numbers of chronic renal failure patients has not been made. Urinary excretion of ammonium (NH4), titrable acid (TA), net acid (NA), and unmeasurable anion (UA, which indicates the amount of acid produced in the body) were measured in 6 normal subjects and in 40 patients with renal disease (serum Cr: 0.8 to 17.2mg/dl, 69 samples in all). The subjects were divided into two groups: group A had Ccr~ 40ml/min(n=36); group B had Ccr<40ml/min (n=33). In group A, Ccr was significantly correlated with NH4 (r=0.83), NA(r=0.62), and UA (r=0.71), but not with TA (r=0.25). In group B, no relation was observed between Ccr and these parameters. NH4 excretion was linearly decreased in proportion to Ccr until 40ml/min, and no further decrease was observed. The value of UA minus NA (UA-NA), which reflects the extent of acid accumulation in the body, was 0.4 i 22.8(mean+SD) in group A and 8.0i12.6mEq/day in group No significant correlation was observed between urinary NH4 excretion and urine pH, blood pH, and blood HC03 in neither group. These data suggest that in chronic renal failure, 1)decreased urinary acid excretion is mostly due to decreased NH4 excretion, reflecting decreased nephron mass, 2) TA excretion is preserved until the end of renal failure, and 3) a small amount of alkali supplementation in dosages estimated by UA-NA is required when Ccr becomes less than 40 ml/min.

B:

SIMULTANEOUS ULTRAFILTRATION AND DIALYSIS (UF-HD): A NEW TECHNIQUE THAT IMPOVES TOLERANCE TO FLUID REMOVAL. Giovanni E~Q!~!!~, NicoLa Tessitore, Giovanni Faccini, and Giuseppe Maschio. University of Verona, Dpt of NephroLogy. Verona. ItaLy. Asymptomatic dehydrations up to 3 L/h may be achieved by HF-HD, in which fLuid removaL during diaLysis is excLusiveLy accompLished by the uLtrafiLter preceding the hemodiaLyzer. We studied 7 patients (4 F, 3 1'1) randomLy submitted to UF-HD and to a conventionaL hemodiaLysis session (c-HD). A fixed diaLysate composition (Na 142 mEq/L) and a fixed weight Loss (2.1 Kg in 90 min) were maintained in aLL cases. We evaLuated sodium concentraticn profiLes of pLasma water, uLtrafiLtrate and diaLysis fLuids, and pLasma voLume variations, and caLcuLated net sodium mass baLance and pLasma refil Ling rate. No significant differences were found in bLood pressure and pLasma voLume. However, an earLy increase in pLasma water sodium concentration was observed during UF-HD (150.6,152.7,153.8, 153.6 mEq/L at 0, 30,60,90 min), whiLe a Late rise was seen during c-HD (151.2,151.4,152.1,153.6 mEql L). Net sodium mass baLance was Less negative during HF-HD (-213 mEq) than during c-HD (-252 mEq) (pc 0.01), with a sodium-water mass removaL ratio of 101 vs 120 mEq/L. These findings demonstrate that the separation of convective from diffusive transport of sodium aLLows a better sodium transfer from diaLysate to pLasma and suggest that this mechamism may underLie the toLerance to high-rate dehydation with the UF-HD treatment.

THE DEVELOPMENT OF ANTI -OKT3 ANTIBODIES (AB ) IN CHILDREN

(C)

AFTER RENAL TRANSPLANT

(T).

JoAnn

Bruce Kaiser*, Stephen Dunn*, Martin Polinsky*, Seth Schulman*, Sharon Bartosh*, Jorge Baluarte. St. Chri"stopher's Hospital for Children, Temple Univ. Sch. of Med., Phila., Pa. Muromonab - CD3 (Orthoclone OKT3®) (OKT3) is an effective antirejection therapy for adults and C receiving all types of Ts. A major drawback has been the developnent of Anti-OKT3 (Anti-Murine) AB. The developnent of Anti-OKT3 AB is variable but in adult studies approximately 30% of patients develop AB. In order to study AB formation in C, we evaluated 15 C treated with 16 courses of OKT3 for steroid resistant rejection. Mean age was 10.4 ±? 5 yrs; 9 were male; 5 were first T, 9 were second, 2 were third. All C recei ved ei ther low dose cyclosporine or azathioprine during OKT3 therapy. C received 3 ng/m2 /dose of OKT3 with 14 receiving 10-14 doses and 1 receiving 28 doses in 2 courses for a single T. OKT3 was used for early acute rejection in 13 C at 15 ±15 days post T and in 2 C for acute rejection occurring after medicine noncompliance at 351 and 158 days post T. OKT3 was successful in reversing rejection in 13 of 15 C. The developnent of anti--{)KT3 AB was evaluated at 3 to 12 weeks post OKT3. There was no detectable AB in 8 C (53%), 5 developed low titers (1:100), 1 moderate" titers ( 1 : 1 ,000) and 1 high titers (1: 10, 000), the child who received 2 courses. In the 7 C developing anti--{)KT3 AB, titers were repeated after 6 months and were negative in all except the one wi th the high titers. The developnent of OKT3 AB may be more cOllDllOn in C but titers are low and decrease with time which may indicate that subsequent reuse is possible. "~almer*,

.TRANSABDOMINAL NEPHRECTOMY IN LIVING RELATED DONORS, TECHNIQUE, ADVANTAGES AND ASSESSMENT OF RENAL FUNCTIONAL RESERVE. James Peabody, M.D., Joseph C. Cerny, M.D. Henry Ford Hospital. Detroit, MI Transabdom ina I nephrectomy has been performed in 141 consecutive kidney donors in the past 15 years, utilizing a standard sub-costa l i n c i si 0 n and mob i i i z a t ion of the colon. The technique allows a) superior access to a nd mobil i zat i on of the rena I vessels b) minimal renal handling, i.e. "no touch" c) complete mobil ization of the infer ior vena cava as necessary, a Ilowi ng a cuff of cava to be taken routinely with the renal vein on the right, and in sei"ected cases on the I eft as we I I d) assessment harvest and transplantation of kidneys with multiple arteries e) preservation of renal pelvic and ureteral bl00d supply, and f) rapid rehabilitation. Renal functional reserve was evaluated in 42 of the donors who had undergone nephrectomy from 2 to 8 years previously. No clinically Significant impairment of renal function (24 hr. Ccr.) was found. All pati ents who had undergone un i nephrectomy remained normotensive and none demonstrated hypediltration proteinuria.

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

.. HYPERCHlOREMIC METABOLIC ACIDOSIS IN ADVANCED RENAL FAILURE. Beth Piraino, Susan Ray, J.B. Puschett, Univ of pittsburgh, Pgh., PA. We have previously found hyperchloremic metabolic acidosis to be a common pattern in patients with advanced CRF. We studied acid excretion in 12 such patients under the usual conditions of Rx including 60 Gm protein diet, CaC0 3 therapy (2 Gm q d) and Al binders. Mean creatinine clearance was 11 * 1 (SE) ml/min •.f. Serum Cl 110 * 1 mEq/l, tC0 2 18 ± 1 mEq/l, Ca+ 8.1 * 0.3 mg/dl, P0 4- 4.1 * 0.3 mg/dl, "del ta" 12 * 1 mEq/l, arterial pH 7.33 ± 0.01. Acid excretion values (mEq/d) were compared to those of normal subjects (n=12, obtained from literature): UNH~V

*

CRF pts. 11 1 normals 35 * 3 p val ue <0.001

UTAV

UHC0 3V

20 ± 2 30 * 3 0.02

0.7 ± 0.1 30 * 3 1.2 ± 0.6 63 ± 6 <0.001 0.4

Adjusted for GFR, the values in the CRF patients were 104 ± 11 mEq/d (UNH V/100ml GFR), 184 *'14 mEq/d (UTAV/100 ml GFR), 7 * 2 (UHCOJV/100 ml GFR) and 281 ± 19 mEq/d (UH+V /100ml GFR). Urine pH was 5.4 or less in all but 1 patient (UpH 5.6, ApH 7.24). Fractional excretion of bicarbonate (after bicarbonate Rx to raise tC0 2 to normal) was 7% * 2, range 1-19%. Tm bicarbonate was 24 * 1 mEq/l. We conclude that in patients with CRF and hyperchloremic acidosis both ammonium and titratable acid excretion are impaired and the hyperchloremic acidosis is not the result simply of a "bicarbonate leak". The functioning nephrons hyper-secrete acid.

4

. . IMMUNOGENETICS, IMMUNOHISTOLOGY AND BLOOD PRESSURE AS DETERMINANTS OF PROGRESSION IN IgAGLOMERULONEPHRITIS (IgA-G~) M. Ramba~sek, R. Waldgerr , E. Junger, G. Krupp, M. Gretz, A. Demaine , E. Ritz. ~ept. Int. Med+ and Pathol. University Heidelberg and Mjnnheim , Heidelberg, FRG; KingS-College LondonfUK We examined actuarial survival (Kaplan-Maier) of 186 patients with biopsy proven IgA-GN and correlated renal outcome with restriction fragment length polymorphism (RFLP) of the switch region (S«'l) of IgAl and S}l of IgM and of the constant region of immunoglobulins IgG and IgG 2 3 (C)'2' C )'3)' We examined also correlation between renal· outcome and immunoglobuline deposition pattern (capillary wall vs purely mesangial deposits) and the following parameters: gender, age at biopsy, proteinuria and blood pressure. Patients homozygous for the 7.4 kb allel of S-l'l had adverse renal prognosis compared to heterozygous patients (p < 0,001 log-rank test). Polymorphisms of gene regions upstream (5') of S.(l' 1. e. S)l and C)'3 as well as gene regions downstream (3'),1. e. C)'2 and D14Sl showed no correlation to renal prognosis. Extension of immunoglobuline deposits to capillary walls, presence of heavy proteinuria, male sex, advanced age and hypertension at biopsy were associated with a significantly higher probability of developing endstage renal failure. We conclude that clinical, immunohistological data and immunogenetic markers are related to renal functional prognosis. These findings indicate that in IgA-GN RFLP-polymorphisms of the IgAl switch region are not only altered in frequency but also associated with more adverse renal prognosis.

A17

[]CADAVERIC RENAL TRANSPLANTATION (CAD RTX) WITH CYCLOSPORINE IN THE ELDERLY. John D. Pirsch, Michael J. Armbrust, Anthony M. D'Alessandro, Munci Kalayoglu, Hans W. S~llinger, Folkert O. Belzer. University of Wisconsin Hospital, Depts. of Medicine and Surgery, Madison, Wisconsin. Patients over 60 comprise a large segment of the dialysis population, yet relatively few undergo transplantation. Fifty-five CAD RTX were performed in 53 patients 60 years of age or older under a quadruple immunosuppression protocol (34 primary, 2 retransplants). The mean age was 62.6 years (range ~73). Thirty-six patients were males and 19 females, with 87% having undergone dialysis. Twenty-nine percent of patients had a history of coronary artery disease. The most common indication was chronic GN, followed by hypertension and po lycystic kidney disease. Six patients were diabetic. Of the 55 patients transplanted, 78% have functioning grafts after a mean follow-up of 24 months (range 2~9). Graft loss included 7 to rejection, 2 from primary nonfunction, and 3 from patient death. Rejection episodes occurred in 24 patients and 79% were successfully reversed. Infection and cardiac events were the most frequent medical complications. Twenty-five patients developed serious infection (12 with CMV) and 2 patients died of opportunistic infection. Nine patients had cardiac events and 1 patient died of sudden death. Surgical complications were less frequent, with 6 patients necessitating reoperation (4 lymphocele, 1 hematoma, 1 urine leak). Recipients over age 60 years have a 3-year patient and graft survival of 90% and 77%, respectively, with a mean serum creatinine of 1.5+0.4 mg/dl. Conclusion: Cadaveric renal transplantation with cyclosporine immunosuppression is a safe and effective therapeutic modality that is no longer contraindicated in the elderly patient .

• TRANSPLANTATION OF EN-BLOC PAIRED PEDIATRIC KIDNEYS INTO ADULT RECIPIENTS. Lloyd E. Ratner, M. Wayne Flye, Washington Univ., SI. Louis, Missouri. Pediatric kidneys recovered from cadaveric donors less than 4 years of age are frequently not used for renal transplantation in adults but are discarded due to small size and possible increased complications. Over a 14 month period from 7/87 - 9/88, 5 adult recipients (mean age 39.2 years) received aorta/vena cava en-bloc paired pediatric renal allografts. Donor age ranged from 23-43 months (mean age 38 mo.), and mean donor weight was 15.1 kg. All patients received azathioprine, prednisone, and cyclosporine (CS) for immunosuppression. CS was not begun until the 5th post-op day, after a randomized 7 day course of OKTI or ALG. All patients have functioning allografts with a mean follow-up of 16.4 mo. (10-24 mo.) and an average serum One of the paired creatinine of 1.6 (range 1.3-1.9). pediatric kidneys failed in 3 patients by radioisotope scanning in the early post-operative period (POD 1, 12, and 20). Two patients underwent a transplant nephrectomy of the infarcted kidney without complication. The third patient remained asymptomatic, except for a transient rise in serum creatinine. No urologic complications were encountered. In the 1 patient who has developed severe hypertension a work-up, including renal artery arteriogram, has failed to reveal its etiology. Two patients have been successfully treated with steroids for mild rejection, confirmed histologically by percutaneous biopsy, which is easily performed under ultrasonic guidance. Conclusion: The use of en-bloc paired pediatric kidneys from donors less than 4 years old for adult recipients results in excellent long-term results. The en-bloc pair of kidneys allows a larger arterial and venous anastomosis with higher blood flow and twice as much function in!! renal mass.

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

A18

PREVALENCE OF SKELETAL LESIONS FROM B m 2 AMYLOIDOSIS IN A DIALYSIS POPULATION Rieden, K., Ritz, E., Barth, H.-P., Bommer, J.; Dept. Radiology and Internal Medicine, Ruperto Carol a University, Heidelberg, FRG

B m type amyloidosis has recently emer2 ged aS the single most important challenge to longterm hemodialysis. Data on cumulative incidence and prevalence by systematical annual X-ray survey in longterm hemodialysis (HD) patients scarce. We analyzed findings in 90 HD patients (60 male, 30 female, age 25-77 years) with a median duration of HD of 7 years (1-20 years). All patients had been dialyzed using regenerated cellulose; after mean duration of 5 years of HD, 19 patients had been switched to polysulfone. At last analysis, 2 pat. had destructive spondylarthropathy (managed conservatively) and 27 (=30%) had periarticular cysts. Cysts were first documented during 2nd year of HD and continued to increase in prevalence and number to the 17th year of HD (lly 52%; 17y 65%) at a mean of 1.B locations (range 1-5): acetabular 35%, carpal 23%, humoral 23%, femoral neck 20%. 2 patients had femoral neck fractures and required .. endoprothesis. 70% of patients with peria~ticular cysts complained of arthralgia. No differences in cyst prevalence was found between underlying renal diseases or types of membranes currently used.

D TEN

YEARS EXPERIENCE WITH CONTINUOUS AMBULATORY PERITONEA~ DIALYSIS (CAPO) .Q Rotellar,J Black *,TP Officer* ,TA Rakowski, WF Mosher MR Alijani,v Garagusi , WP Argy, JF Winchester. Georgetown university Medical Center. Washington DC. No published series of 10 years experience with CAPO exists. Up to January 1989 we trained 171 patients on CAPO & 17 on continuous cyclic peritoneal dialysis (CCPD) (95 m, 86 f, mean age 47, range 18-84 yr). Over 10 yr we gained 5,068 patient months I" ::-:::'f~~ experience. Life table analysis gave ''''&"" patient survivals ; " ° '''''''''&:.;:.. of 60% & 31% at 5 & &:...:& 10 yr resp. In contrast diabetics '!-,--:--~c---;---'~---, had a survival of 32% at 5 yr. Technique survival was 62% & 40% at 5 & 10 yr resp. Major complications were 499 episodes of peritonitis (ave. 1.2 episodes/pt yr) , 304 exit site infections (ave. 0.7 cases/pt yr), 22 hernias, 5 bowel perforations, 1 hydrothorax and 3 sclerosing encapsulating peritonitis. 49 peritoneal catheters were changed. Patient and technique survival have proved better than that reported in the 1988 National CAPO Registry (51% & 48% resp., at 4 yr) despite similar rates for peritonitis and exit site infections.

I" ~ i" "

0-0"""

0-0-0

." "0"

lIDOVUDINE (AlT) IN THE TREATMENT OF HIV-ASSOCIATED NEPHROPATHY (HIV-N). N.F. Rossi~ D. Bhathena, L. Crane, and R. Kauffmann. Wayne State U., Depts. of Med., Physiol., and Peds., Detroit, MI. HIV-N follows a fulminant and progressive course with a dismal prognosis. Maintenance hemodialysis is not effective in prolonging life. Therapies to mitigate renal deterioration have not yet been reported. We report a 30-year-old patient with AIDS-related complex (ARC) referred for evaluation of proteinuria and rapidly rising creatinine (Cr). He had a 10.5-kg weight loss over 6 months, but was asymptomatic. He denied use of illicit drugs. Ateno101 and 10pid were his only medications. BP was 160/100; he had generalized adenopathy. The BUN was 50 and Cr 8.1 mg/dL. Serum albumin was 2.1 g/dL, cholesterol 233 mg/dL, and urinary protein 4.1 g/d. ELISA and Western blot studies were positive for HIV. T4/T8 ratio was 0.40. Serology and viral screens were negative. Renal ultrasound and scan showed bilateral normal sized kidneys with poor but equal perfusion. The renal biopsy displayed focal glomerulosclerosis involving most glomeruli, extensive interstitial fibrosis and ectatic tubules containing casts. IgM and C3 deposits were prominent in glomerular segments. 'Tubu10reticu1ar structures were demonstrated in glomerular endothelial cells. He was begun on AlT 200 mg every 4 hours, a 95 gram protein diet, and ateno10l. The steep slope of the l/Cr ratio stabilized from the inception of AlT treatment. Kinetics of the AlT revealed a peak plasma AlT concentration of 836 ng/mL with an elimination he1f-1ife of 47.8 minutes. Advancing renal failure with histology typical for HIV-N may improve with AlT. The response to AlT is consistent with a viral etiology.

TOBRAMYCIN ABSORPTION FROM DIALYSATE FROM INFECTED AND NON-INFECTED PATIENTS UNDERGOING CAPD. J. Rubin Univ. of MS Med. Ctr. Dept. of Med., Jackson MS. Tobramycin absorption from the peritoneal cavity was evaluated among patients undergoing CAPD during episodes of peritonitis and when non-infected. Six patients in each group were studied. Mass transfer rates (MTC (ml/min)) were calculated for non-infected (C) and peritonitis (P) periods. The mean MTC for C was 6.5 + 2.1 (sd) ml/min and for P was 18.5 + 8~2 (sd) ml/min (P
61 14

57 14

52 13

48 12

45 12

39 12

P X' % 72 19 sd

20

77

63 14

60 12

43 12

37 17

28 10

Although peritonitis increased the rate of uptake from the peritoneal cavity the changes are clinically trivial (39% vs 28% tobramycin). Blood levels should be monitored.

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

II LIPOPROTEIN

GLOMERULOPATHY IN JAPAN. Takao Saito, Shin-ichi Oikawa , Hiroshi Sato, Kaoru Yoshinaga and Hiroshi Sakaguchi. Dept. of Int.Med. Tohoku Univ., Sendai, & Dept. of Pathol., Keio Univ., Tokyo, Japan. Renal lesions characterized by glomerular lipoprotein thrombi, reported as lipoprotein glomerulopathy by us(Am J Kidney Dis 13:148, 1989), have been recognized in 8 patients (male:female=6:2) in Japan. Two familial cases were included in them. Ages of patients at onset were r anged from 7 to 57 years. They had no physical abnormalities related to hyperlipidemia. Laboratory studies gave no abnormal values indicating liver dysfunction, diabetes mellitus or hematological diseases. Urinary protein was ranged from 1.6 to 109/day, and serum protein from 4.0 to 6.5g/dl. In lipid profiles, type III hyperlipoproteinemia was suggested by the chemical indices of Hazzard or Fredrickson. Plasma apo E markedly increased(lO to 19m9/dl). Apo E isoform in 5 patients showed E2/3 in 4 and E4/4 in one, and denied familial type III. But this result suggested that the disease could be related to other abnormal apo E metabolism because no examined patients had standard phenotype E3/3. Light microscopy showed marked dilatation of the glomerular capillaries, where sudan-positive thrombi were filled. Mild mesangial proliferation was observed. There was no foam cell in the glomeruli or the interstitium. On electron microscopy, capillary lumina were occupied by numerous small granular deposits. Three patients suffered from chronic renal failure throughout the clinical course, and one of them received renal transplantation. But transplanted kidney showed the same histology as his own. These findings may confirm a new inherited disease different from previously known nephropathies with abnormal lipid metabolism.

II IMPAIRED PULSATILITY AND BIOPOTENCY OF LUTEO-

TROPIC HORMONE (LH) SECRETION IN ADOLESCENTS WITH CHRONIC RENAL FAILURE (CRF).F. Schaefer, ~ SchArer, R. Mitchell, C. Seidel, W.R. Robertson. Dept. Pediatrics, University of Heidelberg, FRG, Dept. Biochemistry, Hope Hospital, Salford, UK. Delay in pubertal development is common in pediatric pts with CRF. We tested the hypothesis that disturbed pulsatile secretion and/or biopotency of LH is involved. Imunoreactive (i) and bioactive (b) plasma LH were measured at 15 min intervals from 8 PM to 7 AM in 47 CRF pts aged 11-23 yrs (8 conservative treatment " CT, 10 hemodia lys is = HD, 29 transp lants " 1). A11 stages of puberty were represented. iLH was determined by RIA and bLH by a mouse Leydig cell assay. Data were analyzed by Pulsar and cluster computer programmes. The number of iLH pulses per profile was lower in HD (2.0±1.6) than in CT (3.4±2.0) or T Rts (4.0±2.1 ,p <0.05). In T but not in HD pts the peak frequencies rose with advancing puberty as observed in healthy adolescents. The raHo bLH/iLH was decreased during all modes of therapy and did not rise significantly during Maturation. In T pts it was inversely related to the steroid dose (p <0.02). The data suggest that in adolescents with CRF LH secretion is tonic rather than pulsatile and that this is related to delayed sexual maturation. In T pts the pulsatile pattern of LH secretion is partially restored but biopotency of LH remains suppressed, probably by interference with enzymatic processing at the gonadotroph level.

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STABILITY OF MORBIDITY PATTERNS AND PRESCRIPTION DELIVERY DURING HIGH EFFICIENCY DIALYSIS. Stephen Sandroni, Bonnie Powell, and Neeru Arora. University Medical Center, . Jacksonville, Florida. Concern exists that unavoidable deviation from prescribed dialysis regimens occurs frequently, and that over time patients on shorter treatments will end up dangerously underdialyzed. We previously reported a pattern of compressed but not increased morbidity in patients switched from conventional to high efficiency dialysis (Sandroni and Dillman, Kidney Int 33:237, 1988). We now report the retrospective analysis of a six month experience of 63 patients who have received at least one year of high efficiency dialysis, three years after conversion of our center to such a program. Higher blood pump speeds, larger needles, bicarbonate bath, and high efficiency membranes with ultrafiltration monitoring are the essentials of our program; prescription is modified based on review of clinical and laboratory parameters. Mean treatment length for this period was 2 hours 48 minutes, decreased from 3 hours during our initial experience. The interdialytic weight gain was 3.5 kg. Mean days of hospitalization was 4.5. Requirement for saline infusion for symptomatic hypotension was unchanged from our earlier experience, at one infusion per three treatments. Mean KT/V was 1.1, with corresponding mean PCR of l.lg/kg/day. No special interventions or staffing patterns were implemented during the study period. We observed stable acute morbidity patterns and no deterioration of prescription delivery during this period of high efficiency dialysis provided by a staff with three years experience.

[] QUANTITATIVE BONE HISTOHORPHOHETRY IN OXALOSISSERIAL BIOPSY ANALYSIS. Jgn ~ Scheinman, Hichael Fallon*, and John Hahan. Duke Univ. Hed. etr., Dept of Pediatrics, Durham, NC Eleven patients with renal transplants (Tx) for primary hyperoxaluria had bone biopsies at Tx and at 1-4 years follow-up. Tx in infants (5), children (3) and adults (3), included both sucessful (7) and poor (4) clinical outcomes. Host patients (7/11) had oxalate granulomas at Tx, with increased bone turnover (9/11) manifested as increased osteoclastic surface and moderately increased osteoid matrix. This increased turnover persisted (but diminished toward normal) in successful Tx, locally increased adjacent to oxalate granulomas. Turnover was dramatically increased with poor outcomes. Osteomalacia (OH) ,massively increased osteoid with decreased mineralization, was seen in 1 adult at Tx, later normalized, and transiently at 5 mos in 1 successful Tx. OH was dramatic with increased fibrotic surface in 2 infants with poorly functioning grafts at 2 years. An older child, at 4 years, 2 years on agressive dialysis after rejection, had reasonably preserved morphology except for increasing granuloma size. After 3 successful years, 2/2 biopsies were almost normal. Growth after successful Tx was only mildly decreased. These observations delineated the distinctive bone lesions of oxalosis, their reversibility, and allowed recognition of complicating osteomalacia or osteodystrophy. Bone biopsy can help to fine-tune the extremely delicate balance of bone development in a disease whose treatment itself perturbs this balance.

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19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

COGNITIVE BEHAVIOR THERAPY IN FLUID NON-COMPLIANCE PATIENTS ON CHRONIC HEMODIALYSIS. Mark Schneider Nand K. Wadhwa, Ronald Friend, and Paul Whitaker, S.U.N.Y., STONY BROOK, NEW YORK. Fluid non-compliance remains a difficult widespread problem in chronic hemodialysis (HD) patients. Previous study done at this institution revealed that reactions to situations involving negative emotions (e.g. anxiety, anger) and social pressure were significantly related to difficulty in resisting drinking fluids. The present study was undertaken to modify above conditions implicating in fluid non-compliance using cognitive behavior therapy (CBT) sessions. CBT consisted of monitoring, stimulus control, contracting and relapse prevention. Twenty-four end stage renal disease patients on chronic HD were studied. All these patients were fluid non-compliant and were randomly assigned to control (n=9) and CBT (n=l) groups. Interdialytic weight gain was "measured over 24 HD treatments pre CBT, 24 during and 36 post CBT. Eight weekly CBT group sessions were administered to the treatment group. One patient died in the control group and 8 patients dropped out in the treatment group. Results are summarized below: Mean Interdialytic Weight Gain (lbs.) Pre CBT During Follow-Up Control (n=8) 7.28 6.31* 6.78 Treatment (n=7) 7.94 7.11* 7.17* Drop Out (n=8) 7.13 7.39 7.94 *P<0.05 (Paired "t" test - comparing with pre values) The patients in the treatment group reported feeling subjectively better. Data suggest that CBT may help to reduce fluid intake in HD patients.

D IMMUNE

RESPONSE TO MEASLES-MUMPS-RUBELIA (fVlIIIR) VACCINE IN INFANTS IN CHRONIC RENAL FAILURE ON

DIALYSIS. Se1;!LJ.. Schulman*, Adamadia Deforest*, Ani ta R. Gessner*, Bruce A. Kaiser*, Martin S. Polinsky*, H. Jorge Baluarte. Dept of Pediatrics, Terrple Univ School of Medicine, Philadelphia, PA Recently, infant dialysis and transplantation have been increasing in frequency. We studied illll!Rlne responses to the fVlIIIR vaccine in 10 infants on dialysis. Six females and 4 males were placed on dialysis (8 peritoneal dialysis, 1 hemodialysis, 1 both) at 11.6+4.6 (x+SD) months of age. Etiologies of their renal failure include obstructive uropathy (4), infantile polycystic kidney disease (2), hemolytic - uremic syndrome ( 2), and hypo-dysplastic kidneys (2). After starting dialysis, all infants received .5cc of fVlIIIR vaccine (Merck, Sharp & Dohme) at 19.O:t6.0 (range 15-33) months of age. fVlIIIR IgG were obtained within 6 months post vaccination in 9 infants and at 17 months post vaccination in the other infant. Vaccine responses were measured by ELISA (Measlestat, Mumpstat, Rubestat, Whittaker Bioproducts) . Seroconversion was considered as any positive response. Our results show that 8/10 infants responded with positive measles antibodies, 8/10 with positive rubella antibodies and only 5/10 with positive mumps antibodies. This ccrnpares wi th seroconversion rates of ~ 95% for measles, mumps, and rubella when measured by hemagglutination-inhibition assays in healthy infants. All infants responded to at least 1 antigen but only 3 responded to all 3. Our data suggest that infants on dialysis may not respond uniformly to standard doses of fVlIIIR vaccine therefore warranting testing and possibly reimmunization prior to transplantation.

ALTITUDE EFFECTS ON ANEMIA OF CHRONIC DIALYSIS PATIENTS. Wagner J. Schorr, Donna Swartzengruber, Karen Bell, Denver, CO, John L. Bengfort, Colorado Springs, CO, Paul Kovnat, Santa ·Fe, NM, Arnold Israelite, Portland, OR. In 1863 the first report of increased blood count related to high altitude was published. "Hypoxic stimulation of erythropoiesis" was reported in 1950 and the hormonal nature of this was reported in 1953. Published data indicates that the average hematocrit of dialysis patients is in the low to mid-twenties. Experience in the high altitude dialysis centers indicated a higher average level would be expected. We elected to study established patients on 3 time a week dialysis using similar dialysis modality. All patients have been on dialysis for two years as of December of 1988, with the last 3 months of 1988 used as baseline data. Patients were not transfused, all had kidneys and were not on androgens. No relationship between altitude and anemia was discernible. City Santa Fe Colorado Spgs Denver Portland

Altitude 6900 6000 5280 300

Hct. 30.5 29.2 30.8 32.2

The use of EPO has been associated with increased rates of hypertension, seizures, access clotting and worsened levels of BUN, creatinine and potassium. Our review of hematocrits and these complications from a level of 20 to 50 showed no change in incidence of these problems. Increased hematocrit was associated with decreased dialyzer reuse.

DTERMINAL COMPLEMENT PATHWAY ACTIVATION IN CHRONIC HEMODIALYSIS PATIENTS.J.E.Sherlock B.R.Adelsberg,P.R.Morrow,W.P.Colp,and J.D. Tamerius,Nassau County Medical Center,E. Meadow,NY,Long Island Kidney Institute, Freeport,NY and Cytotech Inc.San Diego,CA. C'fragments SC5b-9 and Bb were measured in 45 chronic hemodialysis(HD) patients at 0,15,30,60 and 120 minutes on blood in(A)and blood out(V)during HD on cuprophan hollow fiber (cuhf) (n=13), cuprophan plate (cup) (n=17), cellulose acetate (ca) (n=8) and polyacrylonitrile plate (pan) (n=7) dialyzers. A significant (p(,O. 03) V-A increase in Bb occurred within 30 min on cuhf,cup and ca but not on pan.A significant (P(O.Ol)increase in A occurred at 120 min in cuhf and cup but not in ca and pan. Highest levels with ca were 1/3 cuhf and cup. This confirms patterns of alternate pathway activation noted by other measurements. Mean predialysis SC5b-9 levels were increased and not statistically different among dialyzer groups or in different disease states. Predialysis levels were increased in 32/45 pts. A significant (p(O.Ol)V-A increase was noted only with cuhf,but A was increased at 120 min in both cuhf (p(O. 001) and cup (p(O. 05). Neither ca nor pan showed significant changes during HD. Thus terminal pathway activation is present in HD pts pre HD regardless of dialyzer membrane.Increases during HD occur only with membranes activating the alternate pathway. HD pts are at risk of chronic membrane damage as well as acute anyphylotoxic effects of c' activation.

19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

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• THE MALE GENITAL TRACT IN AIDS. Maria M. Shevchuk, Moacyr M. da Silva, Noel A. Armenakas, John A. Fracchia, New York, N.Y. Since it was first reported in 1981, AIDS has been associated with a multitude of systemic infections and neoplasms. Little, however, has been reported on the urological manifestations of this disease. In this study we examined 80 AIDS autopsies, from 1982-1988, to assess the histopathologic involvement in the male genital tract. In general, the testes were characterized by marked spermatogenic arrest, germ cell degeneration, peritubal fibrosis and Leydig cell depletion. Prostate tissue showed significant concretions, and in three specimens there was periProstatic venous thrOl'lbosis. Analysis of specific opportunistic infections disclosed: a) 11 cases of systemic toxoplasmosis, of which two (18.2%) involved the testes, b) 48 cases of systemic cytomegalovirus of which four involved the prostate and one the testes (10.4%), c) 27 cases of systemic candidiasis of which one (3.7%) involved the prostatic urethra. Seven tumors were identified in this series. Three" of these were unrelated to AIDS, including one Sertoli cell adenoma and two Stage A prostate carcinomas. The AIDS related tumors, included: a) 28 generalized Kaposi's sarcomas of which one (3.6%) involved the testes, b) 6 lymphomas of which two involved both testes and prostate (33.3%). Finally, in one of the specimens, the initial presentation of AIDS was primary immmunoblastic testicular lymphoma. With the rising incidence of AIDS, medical practitioners will be increasingly involved in the care of these patients. Therefore, the importance of familiarity with genitourinary manifestations of this disease should not be underestimated.

• Significance of Asymptomatic Bacteriuria in Spinal Cord Injury Patients on Condom Catheter Jose R. Sotolongo, Jr., Fifty-six male spinal cord-injured patients on condom drainage were studied prospectively within six months of their injuries for a period of 5 years. Low bladder pressures (filling maximum 35 cm. water, voiding maximum 70 cm. water) were ascertained with video-urodynamics and external sphincterotomy when necessary for detrusorsphincter dyssynergia. Yearly upper tract imaging, serum creatinines, and urine cultures were obtained. All patients had colonized urine (asymptomatic) during the entire study period. No patient sustained deterioration of the urinary tract on imaging or by serum creatinine determinations during the study period of 5 years. We conclude that asymptomatic bacteriuria is of no consequenc~ to the integrity of the upper urinary tract when low pressures are operant.

OF 1\CQUlRED RENAL CYSTIC DISFASE (ARCD). Spiegel, D.M., YUffi-Ko, J.L., Brandt, T.D., Grant, T.H. Michael Reese Hospital & Univ. of Chicago, Chicago, IL. The percentage of ESRD patients with ARCD correlates with length of time on dialysis and has been reported to be as low as 30"/0 to as high as 95%. Spontaneous hanorrhage and renal cell carcinana have also been reported. However, the natural history of ARCD has not previOUSly been reported. Between 1981 and 1984, renal ultrasounds were obtained on most dlronic dialysis patients at Michael Reese Hospital (n=45). In 1989, nine patients were still on chronic dialysis (7 HD, 2 CAPD) and available for follow-up ultrasounds. Nine patients had renal transplants. Of these, two were available for follow-up exams. The other patients had died (20), had undergone bilateral ne[ttrectomies (3), or had no baseline ultrasound (4). The Table shows the change in number and size of cysts over the stilly period for patients maintained on dialysis (9) or transplanted (2). NUMBER OF CYSTS Transplant pts. Dialrsis pts. new old new Cyst Size (an) old 7 3 6 0 < 0.6 57 3 6 14 0.6 - 1.0 15 4 2 1.1 - 1.5 7 0 3 5 1.6 - 2.0 2 0 5 10 >2.0 15 15 95 'lbtal 27 One HD patient developed a spontaneous hanorrhage requiring blood transfusion. Another HD patient developed and died fran renal cell carcinana. Both patients had CT scans performed 1 year earlier for unrelated reasons that showed only ARCD. In this patient populatim, the incidence of spontaneous hemorrhage and carcinana was .02 per patient year. In surrrnary, the number of cysts increased more than 3 fold in patients maintained on dialysis, while the size distribution remained relatively unchanged. In contrast, cyst number remained constant in patients with successful renal transplants.

. . LACK OF RESPONSIVENESS OF 1-25 (OH 2 ) CHOLECALCIFEROL (1-25D ) TO SERUM PHOSPHATE (PO ) OR PARATHYROID HO~ONE (PTH) IN RENAL TRANS~LANT RECIPIENTS (RTR'S). R. Steiner, S. Manolagas,* M. Ziegler,* and L. Deftos,* University of California at San Diego Medical Center, San Diego, California, and R.L.Roudebush VA Hospital, Indianapolis, Indiana. 1-25D levels have been reported to fluctuate 3 markedly in stable nonazotemic RTR's and have been held to be inappropriately low for the low serum P0 which often prevails. Utilizing an assay 4 sensitive to both 1-25D and dihydrotachysterol 3 (DHT) (normal=33.8±1.2 pg/ml), we studied (Part A) 22 RTR's (creatinine 1.4±O.1 mg/dL; PO 3.0±0.2 mg/dL[range 1.8-4.3 mg/dL; normal 3.0-~.0 mg/dL]), 14 of whom (FEP0 0.60±0.10) required P0 4 replace4 ment (2.1±O.4 gm/day). In Part B 10 similar RTR's were studied serially both on and off oral 1-25D 3 or DHT. Significant reciprocal relationships were obtained between Ca++ and PTH and between PTH and both P0 and FEP0 4 (previously reported) in 4 both Part A and Part B. However, no relationship was suggested by multivariate analysis between 125 D3 levels and any of these parameters or creatinine clearance in Part A or in Part B (either on or off therapy). In Part B on standard oral doses of 1-25 D3 or DHT, levels rose then fell to control when therapy ceased (control 36±5 pg/ml vs 55±4 pg/ml with therapy [p(.05]vs 32.4 pg/ml after therapy [p<0.05]). In conclusion, in RTR's (1) neither serum PO nor PTH could be demonstrated to affect 1-25D ~2) 3 the assay for 1-25D did detect changes in levels associated with orai therapy (3) 1-25D levels did 3 not fluctuate appreciably (4) 1-25D levels were 3 inappropriately low for the level of hypophos-

•

NA'IURAL HISl'ORY

nh~rpmi;::!_

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19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

. . EFFECT OF THROMBOXANE INHIBITION AND PROSTACYCLIN (PGI 2 ) ON FUNCTION OF REJECTING RENAL ALLOGRAFTS IN RATS. H.B.Steinhauer,*H.Rohde,*R.Rohrbach, P. Schollmeyer,* (intr.by T.F .Luscher) .Univ.of Freiburg Depts. of Medicine & Pathology, Freiburg, F.R.G. Acute renal allograft rejection is associated with increased production and renal excretion of thromboxane(TX). Because of its vasoconstrictive activity TX may contribute to impaired allograft function in acute rejection. In the present study the effect of the TX synthetase inhibitor CGS 13080 (10 mg/kg/day i.p.), or the TX receptor antagonist BM 13505 (10 mg/kg/day i.p.), and of PGI 2 (Flolan R, 5 ng/kg/min i.v.) were investigated in a rat transplantation model. Allograft biopsies were performed on day 3 and 6 after transplantation(TP), clearance rates(CR) of inulin and PAH were studied on day 2 and 5 after TP, urinary excretion of TXB 2 and PGE 2 were determined daily. Chronic administration of CGS 13080 resulted in a reduced renal TXB 2 excretion (p
% chanse % change + 54 * + 72 * + 21 * + 17 * pt.3 + 0.4 + 6 + 19 * + 15 * - 2.4 pt.4 + 14 * + 43 * + 13 * - 2.0 pt.5 + 42 * + 5 + 3 * = p less than 0.01 compared to basal value Our study confirm that EPO induced increase in Ht up to 33% does not affect dialysis efficiency. It shows that an increase in BUN during EPO is not always associated with an increase in PI(increase in PCR,no change in PCR/PI) ,but may also be the r~ suIt of an increased protein catabolism(increased PCR/PI),expecially in those patients in which are duction in dry body weight is necessary to control blood pressure.

TREHALASE (TR) ACTIVITY OF THE SEDIMENTABLE FRACTION OF URINE AS A USEFUL1 MARKER FOR TUBULAR INJURY *Etsuko Sugawara, *K, Miyagawa, *A. Fukumura, *A. Fukatsu, S. Matsuo, and *N. Sakamoto

from The Chubu Rousai Hosp., and from The 3rd Dept. Int. Med., Nagoya Univ., Nagoya, Japan

Many enzymatic activities were detected in urine. Among them NAG, y-GTP, and TR are used clinically as markers for tubular injury, but in proteinuric state, the correlation between enzymatic activity and tubular damage is not clear, probably because these enzymes, which exist in plasma, leak into urine. To find more usefull indicators for tubular injury, we first centrifused urine at l,800g for 15 min to remove sediments and separated the sedimentable fraction (SED) from supernatant (SUP) by ultracentrifugation for 1 hr at 100,OOOg. Enzymatic activities of both fractions for NAG and y-GTP were measured spectrophotometrically and for TR by the method of Carnie et al. Next we tested the reactivity of both fractions with sheep anti-human brush border (BB) vesicle antibody by immunodot blot assay to check the relative amount of BB in each fraction. 56% of y-GTP and 70% of TR activities were found in SED while 11% of NAG activity was detected in this fraction. Dot blot assay showed anti-BB antibody reacted strongly with SED and only weakly with SUP but not with human serum, suggesting that most of BB components belonged to SED. From these results the activity of TR, which is known to be localized in proximal tubular BB, in SED is more reliable marker for tubular injury than that of other enzymes in SED or than enzyme activities of whole urine.

• LIVING-RELATED RENAL TRANSPLANTATION WITHOUT MAINTENANCE CORTICOSTEROIDS IN 2-HAPLOTYPE MATCHED RECIPIENTS. Venkat KK, Kupin W, Oh HK, Mozes M. Henry Ford Hospital, Detroit, MI. Maintenance steroid administration is associated with a significant incidence of morbidity in renal transplant reCipients. We report our experience of renal transplantation in the absence of maintenance corticosteroids in 2 haplotype matched living-related transplant recipients (LRTR). Initial therapy consisted of oral Cyclosporine (CSA) (10 mg/kg/d), Azathioprine (AlA) (1.5 mg/kg/d) and 3 consecutive daily intravenous boluses of methylprednisolone (250 mg/d). Thereafter, only CSA and AlA were continued as maintenance therapy. Results: Number of pts 6 Male/Female 3/3 Average age (yrs) 39+10 Type I diabetic recipients 13% Mean period of follow up (months) 5.4+4.9 Mean serum creatinine (mg/dl) at the most recent visit 1. 5+0.2 No rejection episodes or infectious complications have developed in this group. We conclude that corticosteroid therapy may not be required in 2 haplotype matched LRTR receiving CSA and AlA as maintenance immunosuppression. Longterm follow-up of these patients will be necessary to determine if this protocol decreases the morbidity associated with chronic corticosteroid administration.

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19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS COMPARISON OF GLUCOSE (GLC) ABSORPTION AND LIPID ABNORMALITIES IN CONTINUOUS AMBULATORY (CAPO) AND CONTINUOUS CYCLIC (CCPD) PERITONEAL DIALYSIS. Richard A. Ward and Donna Riley. Dept. Medicine, University of Louisville, Louisville, Kentucky. Glc absorbed from the dialysate is thought to play a role in lipid abnormalities seen in patients treated by peritoneal dialysis. CAPO and CCPD differ in the number dialysate exchanges and dwell time. Accordingly, we hypothesized that glc absorption and the extent of lipid abnormalities might differ between the two therapies. To test our hypothesis, we measured glc loss from the dialysate over 24 hrs in 5 patients treated with CAPO and 5 treated with CCPD. Two measurements were made on each patient. Plasma lipid parameters (triglycerides, cholesterol, HDL, LDL, VLDL) , glc and insulin, and the composition of the diet were determined simultaneously. Total glc instilled per day was significantly greater for CCPD (340 ± 72g) than for CAPO (164 ± 72g). However, the amount of glc absorbed did not differ (97 ± 43g vs 109 ± 66g for CCPD and CAPO, respectively). Dialysate glc provided 20% of the patients' total energy intake. As shown by the data in the table, the lipid status of the two CAPO CCPD Chol (mg/dl) 247 ± 46 236 ± 55 Trig (mg/dl) 145 ± 44 212 ± 106 HDL (mg/dl) 56 ± 15 43 ± 13 162 ± 35 150 ± 64 LDL (mg/dl) VLDL (mg/dl) 29 ± 9 42 ± 21 groups did not differ. Our data demonstrate that the choice of CAPO or CCPD has no influence on the amount of glc absorbed from the dialysate and both therapies appear to be associated with an equal degree of hyperlipidemia.

[JINCREASING TOTAL DWELL VOLUME INCREASES SOLUTE CLEARANCE DURING TIDAL PERITONEAL DIALYSIS (TPD) IN THE ANEPHRIC MICROPIG. S. K. Webster. Baxter Hea1thcare Corporation, Round Lake, Illinois. TPD is a form of automated peritoneal dialysis (APD) in which, following the initial fill, the peritoneum is partially drained and refilled until the final drain. The purpose of this study was to evaluate the efficacy of TPD and determine the effects of increasing total dwell volume (TDV) and decreasing total dwell time (TDT) on peritoneal clearance (C1) of solutes. Anephric micropigs were maintained on an APD regimen for two weeks. For successive 5 day periods, exchange times and patterns were modified by using TPD (~ volume exchanges) as compared to APD (full volume exchanges), increaSing TDV by decreaSing the time between eXChanges, and decreaSing TDT by further decreaSing the time between exchanges.

CHANGES IN PLASMA POTASSIUM (K) ASSOCIATED WITH ELECTROCONVULSIVE THERAPY (ECT) IN END STAGE RENAL DISEASE (ESRD) PATIENTS. John E. Whalen, Dubuque, Iowa. Depression is frequently associated with ESRD. ECT is an accepted method of treatment for depression. Cellular leak of K was postulated considering the use of succinylcholine and the seizure sustained with ECT. Two diabetic patients with ESRD were monitored for changes in K after receiving ECT for refractory depression. K was obtained before and immediately after ECT and at 15 minute intervals for the subsequent 60 minutes. Acid base status and vital signs were monitored. Each patient had eight ECTs studied. K immediately increased post ECT .7 mEq/L and 0.5 mEq/L respectively. Fifteen minutes after ECT in patient #1, the mean increase in potassium was 0.8 mEq/L and in patient #2, the mean increase was 0.2 mEq/L. Over the hour post ECT, K remained elevated in patient #1 and returned to baseline in patient #2. The rise in K varied greatly from treatment to treatment with each individual. The variation in potassium ranged from a low of 0.4 mEq/L to a high of 1.3 mEq/L at 15 minutes in patient #1 over 8 ECTs. Individual potassium variation in patient #2 was varied from a high of .8 mEq/L to no change from baseline. No acid base changes were identified. In conclusion, ECT in ESRD patients causes a temporary rise in plasma potassium. There is marked variation in K response from individual to individual as well as with each ECT. ' No clinical consequences of the changes in K were observed.

[J

GROUP 1 APD 2 TPD 3 tTDV 4 +TDT 5 +TDV * p<0.05

TDT DWELL (hr) TIME (min) 12 120 12 65 12 51 38 9 9 49 as compared to

TDV (L)

Cl UREA (L/day)

5.6±0.2 4.2±0.1 5.8±0.2 4.2±0.3 6.8±0.2 4.8±0:3 6.9±0.2 4.9±0.2* 5.5±0.1 3.8±0.0 groups I, 2, and 5

C1 CREAT (L/day) 3.0±0.2 3.3±0.2 3.8±0.3 4.4±0.4* 2.9±0.1

These results demonstrate that increasing TDV while keeping TDT constant results in a significant increase in solute C1 using the method of TPD exchanges in spite of a decrease in total dwell time from 12 to 9 hours. Tidal Peritoneal Dialysis is shown to be an effective dialysis modality in thi s "high permeability" model.

EXTRACORPOREAL TREATMENT OF HYPERCHOLESTEROLEMIA (HyChol) WITH MONOCLONAL ANTIBODIES (MoA) AGAINST LOW DENSITY LIPOPROTEIN (LDL). RL Wingar!!, W. Wong, RM Hakim, Nephrology Division, Vanderbilt Medical Center, Nashville, TN and DuPont Co., Glenolden, PA. Severe HyChol is a well known risk factor for progressive atherosclerosis and coronary artery disease. In homozygous HyChol patients, HMG CoA reductase inhibitor medications such as Lovastatin are generally ineffective. We studied 2 patients with homozygous familial HyChol who had undergone coronary artery bypasses at age 16 and age 30 respectively, using an extracorporeal system for cholesterol removal. Pre-treatment cholesterol concentration was >500mg/dL. The system consists of 2 columns of MoA against LDL bound to sepharose (DuPont Co., Glenolden, PA) and a regeneration instrument (Excorim KB, Sweden) for continuous, on-line plasma processing. The patients were plasmaphel'esed using a conventional continuous plasmapheresis system and their plasma perfused over one of the columns. An alternating cycle of column adsorptionregeneration continues throughout the treatment. One and a half plasma volumes (4.7±0.18L) were treated each time over 3 hours. There was an exponential decrease of cholesterol concentration, and % pretreatment Chol was 67.6±3.6 after one hour and 51.4±4.4 after 2~ hours. There was no reduction in HDL concentration. The average total amount of Chol removed was 4.1±0.68 grams. The amount of HDL removed was below detection limit. The rate of Chol rebound was also measured, and again showed an exponential increase, with % increase over post-treatment of 35.8±9.4, 61.5±10.0, 76.3±12.6 and 81.2±13.3 at 2, 4, 6 and 7 day interval following depletion. The rate of rebound was not affected by the presence or absence of medication. We conclude that this type of treatment is effective and specific for the treatment of HyChol in homozygous patients.

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19TH ANNUAL SCIENTIFIC MEETING ABSTRACTS

IgA NEPHROPATHY (lgAN): FOLLOW-UP OF CHILDREN AND ADULTS FROM KENTUCKY. Robert J Wyatt, Bruce A. Julian, Susan Y. Woodford', Dept. of Pediatrics, University of Tennessee, Memphis and Dept. of Medicine, University of Alabama, Birmingham. We previously reported clinical features and predicted kidney survival on Jan. 1, 1984 for 80 patients (pts) with IgAN (Am J Kidney Dis 6: 192-200, 1984). The purpose of this report is to re-examine the outcome for these 80 pts on Jan. 1, 1989. Pts were designated adult (Apts) or pediatric (Ppts) based upon age at biopsy (~18 or < 18 yrs). Of 56 Apts (37 male, 19 female), 14 (13 male, 1 female) or 25% reached end stage renal disease (ESRD) by 1984. By 1989,21 (19 male, 2 female) or 38% of Apts had ESRD and 7 had chronic renal insufficiency (CRI) defined by serum creatinine concentration persistently ~1.5 mg/dl. Thus, only 50% of Apts had normal renal function (NRF) in 1989. Two Apts (1 male, 1 female) with NRF in 1984 had CRI by 1989 and one male with NRF in 1984 had ESRD by 1989. Twelve (43%) of Apts with ESRD or CRI presented with macroscopic hematuria (MH). Thirteen (46%) of Apts with NRF presented with MH. 'None of 24 Ppts (18 male, 6 female) had ESRD or CRI in 1984. Two Ppts (1 male, 1 female) presenting with MH had ESRD and two male pts had CRI by 1989. Thus, 17% of Ppts now have progressive disease. Kidney survival predicted from apparent onset by Kaplan-Meier curves for Apts at 10 yrs was 83% in 1984 and 77% in 1989 and at 20 yrs was 43% in 1984 and 40% in 1989. Predicted kidney survival at age 40 was 73% in 1984 and 65% in 1989. Thus, with longer follow-up, the poor prognosis predicted in 1984 for a significant proportion of Apts is confirmed. Furthermore, the prognosis for pts diagnosed as children worsens after they become adults.

TAKAYASU's ARrERITIS (TA) AL'ID affiONIC RENAL FAILURE

(CRF) REQUIRING DIALYSIS. M. YUDIS, R. SIROTA, H.

STEIN, E. SNIPES, Department of Medicine, Abington Merrorial Hospital, Abington, PA 19001 TA is a chronic inflammatory arteriopathy causing obliterative large vessal disease including the aorta and its main branches. We have recently seen a 44 year old wanan with a 20 year history who cEVeloped end stage renal disease (ESRD) as a result of bilateral renal artery stenosis(RAS.) The patient(K.W.) first developed ischemic symptans in the upper extremities in her 20' s. Angiography revealed stenosis of the left subclavianartery and stenosis of the right axillary artery. Bilateral renal artery stenosis was derronstrated. She had a right nephrectomy for severe atrophy to control hypertension (H'lN). M..lltiple left renal artery angioplasties were performed. Her complications included occipital infarction, seizures,aortic regurgitation, congestive heart failure, and perforated gastric ulcer. Progressive renal failure necessitated hEmXlialysis (HO.) Despite left renal artery aorta-renal bypass graft, she remained in CRF. COrticosteroids had been used earlier during her course. The case indicates TA can cause ESRD because of its involvement of the renal arteries. Despite aggressive efforts to repair the RAS by angioplasty and later with bypass grafts, ESRD ensued. HO access is difficult in the upper extremities due to occlusive disease of the axillary orsubclavian arteries. Permanent venous catheter access was used. In surrmary, TA can cause severe HTN, RAS, ESRD, requiring maintenance HD. Every effort to prevent CRF should be made including the use of the corticosteroids' vascular reconstruction and consideration of the use of Azathioprine and Cyclophosphamide.