cluded that our patient had nephrotic range proteinuria,. In patients with chronic ... Nephrotic syndrome secondary to chronic to have left-sided congenital ...
922 8. Sievers TM, Rossi SJ, Ghobrial RM, Arriola E, Nishimura P, Kawano M, Holt CD. Mycophenolate mofetil. Pharmacotherapy 1997; 17: 1178–1197 9. Smith KG, Walker RG, Becker GJ, Leydon JA, Catton MG, Isbel NM. Suppression of the humoral immune response by mycophenolate mofetil. Nephrol Dial Transplant 1998; 13: 160–164 10. Derry CJ, Ross CN, Lombardy G et al. Analysis of T cell responses to autoantigen in Goodpasture’s disease. Clin Exp Immunol 1995; 100: 262–268
Massive proteinuria in a patient with chronic pyelonephritis Sir, In patients with chronic pyelonephritis (CPN ), protein loss is usually less than 1 g/24 h. Proteinuria exceeding 5 g/day [1] has been observed to occur especially in patients with CPN and vesico-ureteral reflux [2,3], coexistent diabetic nephropathy [4] or primary glomerulonephritis [5]. We present a patient with unilateral CPN complicated by severe proteinuria resulting from transudation of tissue fluid out of the chronically infected kidney. A 65-year-old Caucasian female had been treated 3 weeks before admission for urinary tract infection. She was known to have left-sided congenital duplication of the pelvi-caliceal system, complicated by renal stone formation during adolescence. During admission she had recurrent bouts of fever. The latter ultimately was explained by CPN. Laboratory data revealed ESR 115 mm/h, Hb 5.8 mmol/l, MCV 90 fl, leukocyte count 7.2×10/with a normal differential count. Serum creatinine level was 105 mmol/l, CPK 7 mmol/l and albumin 20 g/l. Urinalysis manifested leukocytes >20/hpf and a non-selective proteinuria of 4.5–7 g/day. Creatinine clearance was 64 ml/min. Serum-protein-electrophoresis revealed an albumin fraction of 34.8%, a-1-fraction 7.5%, a2-fraction 18.3%, b-fraction 15.2% and c-fraction 24.2%. Urine-protein-electrophoresis revealed an albumin fraction of 30.7%, a-1-fraction 7.9%, a-2-fraction 10.4%, b-fraction 8.0% and c-fraction 43.0% (albumin5globulin ratio of 1.43 and 0.71 in serum and urine respectively). Urine cultures yielded mixed bacterial growth, namely b-haemolytic streptococcus >105 CFU/ml and Staphylococcus aureus >105 CFU/ml, which were considered colonization.
Fig. 1. Proteinuria and serum creatinine levels before and after nephrectomy.
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To exclude an underlying primary renal disease, a right kidney biopsy was performed. On light microscopy less than 1% of the glomeruli were sclerosed, the rest being completely normal. Immunofluorescence and electron microscopy findings were also normal. Gallium scan revealed accumulation of tracer in the left kidney, with a functional excretory capacity of 20% on the renogram. We concluded that our patient had CPN complicated by nephrotic range proteinura based on transudation of tissue fluid out of the persistently infected kidney. Left-sided nephrectomy was performed, sclerosis was found in less than 4% and the remaining glomeruli were normal. The patient had full clinical recovery and proteinuria fell to 0.5 g/day within 5 days after surgery. Two years later, proteinuria had remained low and her renal function was stable (Figure 1). Based on macroscopic and histological findings, we concluded that our patient had nephrotic range proteinuria, most probably secondary to transudation of proteins from an intractable infected kidney rather than primary glomerular or interstitial disease. Department of Internal Medicine Academic Hospital Vrije Universiteit Amsterdam The Netherlands
Muhammed Hadithi Reinold O. B. Gans Pieter M. ter Wee
1. Brod J. Chronic pyelonephritis. Lancet 1956; i: 973–981 2. Salomon D, Smith EC. Nephrotic syndrome secondary to chronic pyelonephritis and ureterovesical reflux. J Urol 1976; 115: 108–109 3. Torres VE, Velosa JA, Holley KE, Kelalis PP, Stickler GB, Kurtz SB. The progression of vesico-ureteral reflux nephropathy. Ann Intern Med 1980; 93: 776–784 4. Kleeman CR, Hewitt WL, Guze LB. Pyelonephritis. Medicine 1971; 39: 3–116 5. Bronomo L, Schena FP. Patterns of proteinuria in chronic pyelonephritis, the pseudo glomerular pattern. Clin Chim Acta 1969; 23: 295–303
The patient with over 100 relapses of minimal change nephrotic syndrome: prolonged complete remission after chlorambucil treatment Sir, Minimal change disease accounts for more than 80% of the cases of idiopathic nephrotic syndrome in children. Several studies have demonstrated that more than 90% of patients show a complete disappearance of proteinuria after 6–12 weeks of steroid treatment [1]. However, a considerable proportion of patients, reaching more than 75% in some series, experiences relapses of nephrotic syndrome [2]; cyclophosphamide or chlorambucil treatment, usually administered for 6–12 weeks, leads to prolonged steroid-free remission in most children with frequently relapsing minimal change disease [3,4]. Here we report the exceptional clinical course of a patient that experienced more than 100 steroidsensitive relapses of minimal change nephrotic syndrome. Case. A 41-year-old man was admitted to our hospital because of severe headache and blurred vision. Evaluation on admission disclosed a blood pressure of 220/130 mmHg; the patient was alert but aphasic. Funduscopic examination showed a grade II hypertensive retinopathy. A computed tomographic scan of the brain revealed a left temporal intracerebral haemorrhage. Blood pressure was normalized with i.v. sodium nitroprusside and oral captopril. Laboratory data, obtained at admission were as follows: haematocrit 48%, haemoglobin 15.9 g/dl, leukocyte count 9559/mm3,
