RESUMEN
BACKGROUND: There is not enough epidemiologic data of biopsy proven renal diseases. This is the first report of clinicopathologic correlations over a period of 20 years from central Balkan country-Serbia. METHODS: A retrospective review of reports of 2 362 native renal biopsies performed on patients at the leading nephrology unit in Serbia from 1987 to 2006 was undertaken. Patients were divided in two groups according to age: younger (<60 years old) and older (>or=60 years old). RESULTS: The annual incidence of renal biopsies increased from 3.9 p.m.p./year in 1987 to 12.5 p.m.p/year in 2006. The most common clinical syndrome as an indication for renal biopsy was nephrotic syndrome (NS) (53.6%). Membranous nephropathy was the most frequent cause of NS (21.6%). Primary glomerulonephritis (PGN) accounted for about two thirds of all performed biopsies. Non-IgA mesangioproliferative GN was the most frequent primary GN accounting for almost 25% of all PGN in our whole population, while the prevalence of IgA nephropathy was only 12%. Lupus nephritis was the most frequent secondary glomerulonephritis (75.6%). CONCLUSIONS: This report represents epidemiological overview on biopsy proven renal disease coming from one specific Balkan country, which was under economic sanctions for almost half the studied period. We are hoping that this register will be the basis for developing not only a national register but also a register that will encompass all Balkan countries.
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Enfermedades Renales/epidemiología , Enfermedades Renales/patología , Sistema de Registros , Adolescente , Adulto , Distribución por Edad , Anciano , Biopsia/estadística & datos numéricos , Estudios de Cohortes , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Serbia/epidemiología , Distribución por Sexo , Adulto JovenRESUMEN
Lack of cadaveric organs for transplantation resulted in increased number of living related kidney donors examinations and consequent transplantations in our Department. Donor procedure, selection, drop-outs and final results for living related donors (LRD) were retrospectively analyzed in this paper. Between 1987 and 1994 202 potential LRD were examined. Most of them were females (59%) and about 30% were older than 60 years. The family relation between LRD and recipients were: parents (95%), siblings (3%), grandmother/grandfather (1.5%) and uncle (0.5%). Potential LRD were informed on risks, advantages and procedure of living donor transplantation. After primary information 26% of potential LRD gave up further examinations. Following immunological and clinical evaluations 48% of LRD actually donated a kidney. The other 26% were excluded during the selection procedure. High immunological risks including ABO incompatibility, HLA mismatches and positive cross match test were the reasons for drop outs of 35 potential LRD (17%). Five more donors were excluded for medical reasons: one because of low creatinine clearance and four because of neoplasms, discovered during examination (kidney, laryngeal, lung). Fourteen transplantation were not realized due to different recipient reasons: 5 of them had clinical contraindications, two died and in 7 cadaveric kidney transplantations were performed. Mild hypertension, coronary disease and diabetes mellitus type 2 were presented in 5 LRD accepted for transplantation. Five more had to be operated before donation (abdominal or urological operation). Early complications after donor nephrectomy were acute renal failure, stress ulcus, pleuropneumonia in three and thromboflebitis in two donors. In conclusion, although kidney transplantation from LRD is highly successful, careful examination during selection procedure is indispensable.
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Trasplante de Riñón , Donadores Vivos , Nefrectomía/efectos adversos , Adulto , Familia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
The study carried out was at the Department of Nephrology, Military Medical Academy, over the period from 1996 to 2001. Different types of lupus nephritis were documented in 42 patients and were treated with standard therapeutic protocols (corticosteroids, the pulse dose of cyclophosphamide + corticosteroids) and cyclosporine in the target serum concentration of 100-120 ng/ml along with pronisone of 15-20 mg per day. The different degree of damaged renal function was observed. Renal biopsy was performed in 13 patients and in one patient rebiopsy was done. Twenty one patients were treated only with corticosteroids (remission in 23.8% of cases), with cyclophosphamide + corticosteroids 33 patients (remission in 42.4% of cases) and cyclosporine + corticosteroids 12 patients (remission in 91.7% of cases). The pulse therapy with cyclophosphamide in combination with corticosteroids, and cyclosporine in combination with lower doses of corticosteroids was statistically more successful in comparison with corticosteroids monotherapy (p < 0.01). Remission was found in 73.8% of patients, terminal renal weakness was observed in 7 patients, and fatal outcome in 4 patients. We recommend the pulse therapy of cyclophosphamide in combination with corticosteroids in the treatment of severe clinical forms of lupus nephritis, and in refractive forms cyclosporine in combination with low doses of corticosteroids.
Asunto(s)
Ciclosporina/administración & dosificación , Glucocorticoides/administración & dosificación , Inmunosupresores/administración & dosificación , Nefritis Lúpica/tratamiento farmacológico , Adulto , Quimioterapia Combinada , Femenino , Humanos , Masculino , Quimioterapia por PulsoRESUMEN
INTRODUCTION: Immunosuppressive drugs, particularly cyclophosphamide, are widely accepted as the treatment of choice for severe, proliferative lupus nephritis. However, there is no consensus with regard to: 1) the dose required for achieving control of disease activity; 2) duration of cyclophosphamide therapy after the achievement of treatment response; 3) treatment of lupus nephritis relapses [1-5]. In the Institute of Rheumatology, Belgrade, two regimens of intravenous cyclophosphamide have been introduced in the treatment of lupus nephritis patients years ago. The first has comprised the so called "small pulses" that have been used since 1985, and the second has been standard protocol with high doses of cyclophosphamide, accepted in 1990. Results of these follow-up studies were published previously [6-8]. AIM: The aim of this study was to compare the efficacy of two regimens of intravenous pulse cyclophosphamide in the treatment of patients with severe lupus nephritis. METHODS: We analyzed the results of two follow-up studies comprising patients with lupus nephritis, treated with cyclophosphamide: 1) 41 females treated with "small pulses", consisting of 400 mg of cyclophosphamide weekly at treatment onset, followed by the same dose fortnightly for the next three months, and finally on monthly basis for several months or years; 2) 33 patients (29 females and 4 males) treated with standard protocol consisting of "induction phase" with 6 monthly pulses of high doses (0.5-0.75 g/m2 body surface), followed by "maintenance phase" with quarterly pulses for additional 1-2 years. The evaluation of long-term treatment effects was based on remission/response rate [9], number of patients with renal failure, end-stage renal disease and death outcome. RESULTS: Groups of patients were quite comparable with respect to their demographic and clinical data (Table 1). The only difference was much higher frequency of renal biopsy in "high dose" cyclophosphamide pulse (85% versus 32%), confirming the presence of proliferative lupus nephritis. Cummulative dose of cyclophosphamide and treatment duration were not significantly different between treatment groups. At the end of the follow-up, distributions of favorable (remission/response) and unfavorable outcome was similar (p = 0.831; Mann-Whitney U test), as well as dynamics of remission achieving (p = 0.068; Log-rank test), cummulative renal survival (p = 0.129; Log-rank test) and patient survival (p = 0.577; Log-rank test). DISCUSSION: Similar efficacy of two different cyclophosphamide regimens in our patients with lupus nephritis was not surprising considering that cummulative cyclophosphamide doses and treatment duration were similar obtaining similar control of disease. During induction phase of treatment, patients on small pulses have received even higher cummulative dose of cyclophosphamide. Aggressive immunosuppressive treatment with cyclophosphamide has significantly ameliorated the outcome of lupus nephritis. In different studies, rate of assessed clinical response is 60-80 [13-17]. Significant proportion (42%) of patients who achieved partial remission, as well as complete remission, developed flare of renal disease several months after the end of the treatment, necessitating restarting of pulse cyclophosphamide therapy. The results of our study were in accordance with those results, especially with results of Mosca et al. [18] who have applied the duration of treatment similar to ours in high pulse regimen. CONCLUSION: Treatment response did not differ between two different cyclophosphamide regimens (small pulses and standard high doses protocol), but standard protocol seemed to be more comfortable for patients. We recommend standard protocol for patients with biopsy proved proliferative lupus nephritis as a gold treatment standard. However, sustained remission of proliferative lupus nephritis is a goal that still remains to be achieved.