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Spontaneous Relapse of Naproxen-Related Nephrotic Syndrome
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOVASCULAR SURGERY
The authors performed ureterorenoscopy for large distal ureteral stones and smaller stones that had been in the lower ureter for longer than 6 weeks. Persistent upper ureteral stones can be disintegrated with the ureteroscope or extracted with the Dormia loop. If the ureteral orifice calibrates to less than 12 Ch. the authors do not hesitate to enlarge the ureteral opening with an endoscopic scissors. Balloon catheters frequently are used to block the upward migration of floating stones. Longer intervals of ultrasonic use are associated with ureteral damage and the authors attempt to keep exposure time to less than 30 seconds. In a review of 84 patients subjected to ureterorenoscopy only 9 required subsequent open ureterolithotomy. In 7 patients ureterorenoscopy simply was not possible because of a difficult angle. No vesicoureteral reflux resulted from ureteral meatotomy. The authors recommend the technique. G. F. S. 8 figures, 2 tables, 9 references
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOV ASCULAR SURGERY Safety and Efficacy of W a.rfarin Started Early After Submassive Venous Thrombosis or Pulmonary Embolism A. GALLUS, J. JACKAMAN, J. TILLETT, W. MILLS AND A. WYCHERLEY, Departments of Hematology and Nuclear Med-
icine, Flinders Medical Centre, Bedford Park, South Australia Lancet, 2: 1293-1296 (Dec. 6) 1986 A total of 266 patients with clinically submassive venous thromboembolism was treated with 2 anticoagulant regimens that differ in the timing of warfarin therapy. In 127 patients (group L) warfarin was started after 7 days of continuous intravenous heparin infusion, while in 139 (group S) warfarin was started within 3 days (average 1 day) of starting heparin. The incidence of recurrent symptomatic venous thromboembolism during the hospital stay was 4. 7 per cent in group L and 3.6 per cent in group S. The rate of symptomless new perfusion defects was 8.5 per cent in group L and 3.9 per cent in group S. During routine 125iodine-fibrinogen leg scanning of the patients who presented with distal thrombosis in the calf, popliteal and distal femoral veins asymptomatic proximal extension was noted in 3.6 per cent in group S but none in group 1. The incidence of major or minor bleeding, and the inpatient mortality rate were similar in both groups. The outpatient followup of both groups (average 29 months) showed similar mortality and symptomatic recurrence rates during and after warfarin treatment. This study suggests that short-term heparin treatment with early warfarin treatment for venous thromboembolism is effective and safe in most patients. It is cost-effective and shortened significantly the average hospital stay to 3.9 days. F. T. A. 4 tables, 22 references
Spontaneous Relapse of Naproxen-Related Nephrotic Syndrome M. SCHWARTZMAN AND V. D'AGATI, Nephrology Section, Department of Internal Medicine, Mary Imogene Bassett Hospital, Cooperstown, New York, and Department of Pathology,
227
Columbia University, College of Physicians and Surgeons, New York, New York Amer. J. Med., 82: 329-332 (Feb.) 1987 Many nonsteroidal anti-inflammatory drugs have been associated with the nephrotic syndrome and varying degrees of renal insufficiency. Prompt remission of the nephrotic syndrome has been reported after the drug has been discontinued. The authors report a case of a naproxen-related nephrotic syndrome with complete remission following discontinuation of the drug but with relapse 14 weeks later in the absence of re-exposure to a nonsteroidal anti-inflammatory drug. The biopsy findings were consistent with minimal change disease associated with mild to moderate arterionephrosclerosis without evidence of active interstitial nephritis. The pathogenic relationship between these 2 episodes of the nephrotic syn drome remains uncertain. The authors suggest that the glomerular alterations in nonsteroidal anti-inflammatory drug nephropathy may be responses to enhanced leukotriene production or altered T-lymphocyte reactivity induced by relative prostaglandin E deficiency, or they may be pharmacological or physiological interactions with the immune system of the patient rather than a hypersensitivity reaction. F. T. A. 2 figures, 24 references
Circulating and Tissue Angiotensin Systems D. J. CAMPBELL, Laboratory of Molecular Endocrinology, Massachusetts General Hospital, Boston, Massachusetts J. Clin. Invest., 79: 1-6 (Jan.) 1987
The prevailing view has been that the circulating reninangiotensin system primarily is an endocrine system designed for the general mediation, through the systemic circulation, of the effects of renin on angiotensin production in plasma. Recent studies suggest that the existence of local angiotensin generating systems (brain, kidney, adrenal, testis and arterial wall) that operate wholly or in part is independent of the circulating renin -angiotensin system. The circulating renin-angiotensin system, particularly the renin secretion by the kidney, provides a rapid and efficient homeostatic response to acute changes in blood pressure, and fluid and electrolyte status, while tissue angiotensin systems may provide a more tonic and, specifically, local influence in tissues in which they exist, such as the regulation of vascular tone or renal, cardiac, adrenal or intestinal function. Some reports state that the hypotensive actions of renin inhibitors and converting enzyme inhibitors may be owing at least partly to inhibition of local tissue angiotensin systems. The author concludes that the major site of angiotensin production is not in blood but in tissue, resulting from the action of plasma-derived renin on plasma-derived angiotensinogen together with the interaction of locally synthesized components. The tissue angiotensin production and the regulation of its production to a greater or lesser extent may be independent of the circulating renin-angiotensin system. However, further studies are necessary on the mechanisms and regulation of angiotensin production in vivo, in individual tissues and within the multiple compartments of each tissue, as well as the development of methodology able to measure the concentration of angiotensin II at the local receptor level if the functional and pathogenic significance of local tissue angiotensin systems is to be established. F. T. A. 1 figure, 111 references
The authors performed ureterorenoscopy for large distal ureteral stones and smaller stones that had been in the lower ureter for longer than 6 weeks. Persistent upper ureteral stones can be disintegrated with the ureteroscope or extracted with the Dormia loop. If the ureteral orifice calibrates to less than 12 Ch. the authors do not hesitate to enlarge the ureteral opening with an endoscopic scissors. Balloon catheters frequently are used to block the upward migration of floating stones. Longer intervals of ultrasonic use are associated with ureteral damage and the authors attempt to keep exposure time to less than 30 seconds. In a review of 84 patients subjected to ureterorenoscopy only 9 required subsequent open ureterolithotomy. In 7 patients ureterorenoscopy simply was not possible because of a difficult angle. No vesicoureteral reflux resulted from ureteral meatotomy. The authors recommend the technique. G. F. S. 8 figures, 2 tables, 9 references
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOV ASCULAR SURGERY Safety and Efficacy of W a.rfarin Started Early After Submassive Venous Thrombosis or Pulmonary Embolism A. GALLUS, J. JACKAMAN, J. TILLETT, W. MILLS AND A. WYCHERLEY, Departments of Hematology and Nuclear Med-
icine, Flinders Medical Centre, Bedford Park, South Australia Lancet, 2: 1293-1296 (Dec. 6) 1986 A total of 266 patients with clinically submassive venous thromboembolism was treated with 2 anticoagulant regimens that differ in the timing of warfarin therapy. In 127 patients (group L) warfarin was started after 7 days of continuous intravenous heparin infusion, while in 139 (group S) warfarin was started within 3 days (average 1 day) of starting heparin. The incidence of recurrent symptomatic venous thromboembolism during the hospital stay was 4. 7 per cent in group L and 3.6 per cent in group S. The rate of symptomless new perfusion defects was 8.5 per cent in group L and 3.9 per cent in group S. During routine 125iodine-fibrinogen leg scanning of the patients who presented with distal thrombosis in the calf, popliteal and distal femoral veins asymptomatic proximal extension was noted in 3.6 per cent in group S but none in group 1. The incidence of major or minor bleeding, and the inpatient mortality rate were similar in both groups. The outpatient followup of both groups (average 29 months) showed similar mortality and symptomatic recurrence rates during and after warfarin treatment. This study suggests that short-term heparin treatment with early warfarin treatment for venous thromboembolism is effective and safe in most patients. It is cost-effective and shortened significantly the average hospital stay to 3.9 days. F. T. A. 4 tables, 22 references
Spontaneous Relapse of Naproxen-Related Nephrotic Syndrome M. SCHWARTZMAN AND V. D'AGATI, Nephrology Section, Department of Internal Medicine, Mary Imogene Bassett Hospital, Cooperstown, New York, and Department of Pathology,
227
Columbia University, College of Physicians and Surgeons, New York, New York Amer. J. Med., 82: 329-332 (Feb.) 1987 Many nonsteroidal anti-inflammatory drugs have been associated with the nephrotic syndrome and varying degrees of renal insufficiency. Prompt remission of the nephrotic syndrome has been reported after the drug has been discontinued. The authors report a case of a naproxen-related nephrotic syndrome with complete remission following discontinuation of the drug but with relapse 14 weeks later in the absence of re-exposure to a nonsteroidal anti-inflammatory drug. The biopsy findings were consistent with minimal change disease associated with mild to moderate arterionephrosclerosis without evidence of active interstitial nephritis. The pathogenic relationship between these 2 episodes of the nephrotic syn drome remains uncertain. The authors suggest that the glomerular alterations in nonsteroidal anti-inflammatory drug nephropathy may be responses to enhanced leukotriene production or altered T-lymphocyte reactivity induced by relative prostaglandin E deficiency, or they may be pharmacological or physiological interactions with the immune system of the patient rather than a hypersensitivity reaction. F. T. A. 2 figures, 24 references
Circulating and Tissue Angiotensin Systems D. J. CAMPBELL, Laboratory of Molecular Endocrinology, Massachusetts General Hospital, Boston, Massachusetts J. Clin. Invest., 79: 1-6 (Jan.) 1987
The prevailing view has been that the circulating reninangiotensin system primarily is an endocrine system designed for the general mediation, through the systemic circulation, of the effects of renin on angiotensin production in plasma. Recent studies suggest that the existence of local angiotensin generating systems (brain, kidney, adrenal, testis and arterial wall) that operate wholly or in part is independent of the circulating renin -angiotensin system. The circulating renin-angiotensin system, particularly the renin secretion by the kidney, provides a rapid and efficient homeostatic response to acute changes in blood pressure, and fluid and electrolyte status, while tissue angiotensin systems may provide a more tonic and, specifically, local influence in tissues in which they exist, such as the regulation of vascular tone or renal, cardiac, adrenal or intestinal function. Some reports state that the hypotensive actions of renin inhibitors and converting enzyme inhibitors may be owing at least partly to inhibition of local tissue angiotensin systems. The author concludes that the major site of angiotensin production is not in blood but in tissue, resulting from the action of plasma-derived renin on plasma-derived angiotensinogen together with the interaction of locally synthesized components. The tissue angiotensin production and the regulation of its production to a greater or lesser extent may be independent of the circulating renin-angiotensin system. However, further studies are necessary on the mechanisms and regulation of angiotensin production in vivo, in individual tissues and within the multiple compartments of each tissue, as well as the development of methodology able to measure the concentration of angiotensin II at the local receptor level if the functional and pathogenic significance of local tissue angiotensin systems is to be established. F. T. A. 1 figure, 111 references