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Biomedical subjects

C Ponticelli

Publications and source records attributed to C Ponticelli.

At least 145 records · Page 8Linked to original sources
PubMed1993

Idiopathic membranous nephropathy in the elderly.

In this retrospective non-randomized study we reviewed the outcome for 41 patients with membranous nephropathy older than 65 years at onset and followed for at least 1 year. Twelve of the patients never received any specific treatment (group A), 15 were treated with a 6-month course of methylprednisolone alternated to chlorambucil every other month (group B), and 14 received corticosteroids alone for 3-12 months (group C). At the end of a mean follow-up of 92 +/- 61 months in group A, 53 +/- 35 in group B, and 38 +/- 25 in group C there were significantly more remissions of nephrotic syndrome in group B than in group A (P = 0.035) or in group C (P = 0.010). Moreover patients in group B spent a significantly longer period without nephrotic syndrome than patients in group A (P = 0.000) and C (P = 0.000). Three patients in group A and one in group B died. During the follow-up six patients of group A, two of group B, and five of group C developed renal function deterioration. In patients followed for at least 5 years the mean plasma creatinine increased from a basal of 112 +/- 29 to 239 +/- 287 mumol/l at the 5th year in group A and from 113 +/- 14 to 124 +/- 30 mumol/l in group B. The mean urine protein excretion remained unchanged in group A (basal 4.6 +/- 2.3 versus 4.8 +/- 5.7 g/day at 5 years) while it decreased in group B (from a basal of 6.8 +/- 3.5 to 1.1 +/- 0.4 g/day at 5 years).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

Cyclosporin versus cyclophosphamide for patients with steroid-dependent and frequently relapsing idiopathic nephrotic syndrome: a multicentre randomized controlled trial.

OBJECTIVE: To compare the efficacy (maintenance of remission), safety and tolerability of cyclosporin (CsA) with those of cyclophosphamide in patients with steroid-dependent or frequently relapsing nephrotic syndrome (NS). DESIGN: Open, prospective, randomized, multicentre, controlled study for parallel groups, stratified for adults and children. The setting was in nephrological departments in Italy. SUBJECTS AND INTERVENTIONS: Seventy-three patients with steroid-sensitive idiopathic NS admitted to the study were randomly assigned to cyclophosphamide (2.5 mg/kg/day) for 8 weeks or CsA (5 mg/kg/day in adults, 6 mg/kg/day in children) for 9 months, tapered off by 25% every month until complete discontinuation at month 12. Seven patients lost to follow up were not considered in the analysis. The remaining 66 patients were followed up for 3-24 months after randomization. MAIN OUTCOME MEASURES: Relapse-free survival; number of N.S. relapses/patient/year; cumulative dose of prednisone/patient; laboratory investigations (kidney and liver functions, haematological parameters); incidence of adverse events. RESULTS: At month 9, 26 of 35 CsA-treated patients were still in complete remission and a further five patients were in partial remission; 18 of 28 cyclophosphamide-treated patients were in complete remission, and one in partial remission (P = NS). No difference between adults and children was seen with either treatment. The risk of relapse was similar between frequent relapsers (19 of 22) and steroid-dependent patients (8 of 14) given CsA, and those given cyclophosphamide (5 of 15 and 6 of 15). The mean number of relapses per year and the mean dose of prednisone per year were significantly less (P < 0.001) in both groups for the experimental year than for the year before randomization. At 2 years, 25% of the patients given CsA (50% adults and 20% children) and 63% of those given cyclophosphamide (40% adults and 68% children) had not had any relapse of NS. Tolerance to the two drugs was generally good. The CsA-related side-effects were mild and disappeared after drug discontinuation. CONCLUSIONS: This study shows that both treatments are effective and well tolerated; more patients given cyclophosphamide had stable remissions.

Adolescent↗
PubMed1993

Lupus membranous nephropathy: long-term outcome.

The follow-up of 42 patients affected by lupus membranous nephropathy (LMN) is reported and compared with that of 43 patients affected by diffuse proliferative lupus glomerulonephritis (DPGN), who were the object of a previous study. According to the WHO classification, the patients were subdivided into two groups: pure LMN (Va + Vb class) and LMN with superimposed proliferative lesions (Vc + Vd class). Antiphospholipid antibodies (APA) and lupus anticoagulant were tested in 23 subjects. All the patients were treated with corticosteroids, which were associated to cytotoxic drugs in 28 cases. Although a higher number of complete remissions was obtained in patients with pure LMN, the difference between the 2 groups was not significant (7/26 vs 1/16). At 10 years kidney survival was 93% in all LMN patients with no significant differences between the 2 groups. This 10-year kidney survival rate is very similar to that previously observed by us for DPGN (91%). The WHO histological classification and the chronicity index did not identify the patients who reach end-stage renal failure. Eight patients suffered from thrombotic manifestations which were the cause of death in two cases. Fourteen of the 20 patients studied presented echocardiographic abnormalities. A statistically significant association was found between the occurrence of cardiovascular complications and APA levels. The effectiveness of treatment in LMN remains controversial. We suggest, however, that adequate therapy may significantly improve the prognosis of lupus nephritis thus reducing the differences in the outcome of SLE patients having different histological WHO classes. Cardiovascular illness represents a frequent and severe late complication.

Adult↗
PubMed1992

Methylprednisolone plus chlorambucil as compared with methylprednisolone alone for the treatment of idiopathic membranous nephropathy. The Italian Idiopathic Membranous Nephropathy Treatment Study Group.

BACKGROUND AND METHODS: Treatment with methylprednisolone and chlorambucil may protect renal function and increase the chance of remission of the nephrotic syndrome in patients with idiopathic membranous nephropathy. To determine whether similar results might be obtained with methylprednisolone alone, we compared the effects of methylprednisolone and chlorambucil with those of methylprednisolone alone in 92 patients with the nephrotic syndrome caused by idiopathic membranous nephropathy. The patients were randomly assigned to receive either alternating one-month courses of methylprednisolone and then chlorambucil for a total of six months (group 1) or methylprednisolone alone for six months at the same cumulative dosage (group 2). RESULTS: Four of the 45 patients in group 1 (9 percent) and 1 of the 47 in group 2 (2 percent) stopped treatment because of side effects. At one, two, and three years, the percentage of patients who did not have the nephrotic syndrome was significantly higher in group 1 than in group 2. It was 58, 54, and 66 percent, respectively, in group 1, as compared with 26, 32, and 40 percent in group 2 (P = 0.002, 0.029, and 0.011). By year 4, the difference was no longer statistically significant: 62 percent of the patients in group 1 and 42 percent of those in group 2 did not have the nephrotic syndrome (P = 0.102). The patients in group 1 were in remission longer than those in group 2 (P = 0.008). CONCLUSIONS: In patients with the nephrotic syndrome caused by idiopathic membranous nephropathy, treatment with methylprednisolone and chlorambucil for six months induces an earlier remission of the nephrotic syndrome than methylprednisolone alone, but the difference may diminish with time.

Adolescent↗
PubMed1992

Treatment of the nephrotic syndrome with cyclosporin A.

The three main causes of primary nephrotic syndrome are minimal change nephropathy, focal glomerulosclerosis and membranous nephropathy. Corticosteroids obtain remission of proteinuria in most patients with minimal change nephropathy. Many patients, however, show either frequent relapses or steroid dependency. A short course of cyclophosphamide or chlorambucil can achieve stable remission in many of these patients but alkylating agents cannot be repeated, their toxicity being cumulative. Analyses of the available studies showed that some 80% of patients can be maintained in remission with cyclosporin A (CsA) but relapse occurs when the drug is stopped. Severe side effects are rare. In particular, the mean values of creatinine clearance did not deteriorate in cyclosporin-treated patients and repeat renal biopsy showed only mild changes in some patients. There is no definite treatment for focal glomerulosclerosis. An analysis of 10 clinical trials showed that some 17% of nephrotic patients may enter complete remission of proteinuria and another 13% may attain partial remission of the nephrotic syndrome with CsA. There is concern over the use of this drug since cases of irreversible renal dysfunction have been reported. However, retrospective reviews of the available studies showed that the mean serum creatinine levels did not modify if patients had normal renal function when given CsA. A 6-month course of methylprednisolone and chlorambucil may obtain remission of the nephrotic syndrome in some 60% of patients with membranous nephropathy. Some trials have shown that CsA may improve proteinuria and there is also some suggestion that the drug might protect against renal function deterioration. Thus, when given at correct doses, CsA may exert an anti-proteinuric effect without deteriorating renal function, suggesting that the drug may represent a further tool in treating the primary nephrotic syndrome.

Chlorambucil↗
PubMed1992

Acute tubular necrosis caused by gross hematuria in a patient with focal and segmental necrotizing glomerulonephritis.

We describe a patient with gross hematuria, severe renal failure and symptoms suggestive of systemic vasculitis. Renal biopsy showed very focal and segmental necrotizing glomerulonephritis without crescents. A few C3 deposits were seen by immunofluorescence. The tubular lesions, on the contrary, were very severe, consisting of tubular cell necrosis and ruptured tubular basement membrane, associated with large numbers of intraluminal erythrocytes and erythrocytic casts. After gross hematuria had cleared, renal function slowly recovered. Because of biopsy findings and clinical course, acute renal failure in this patient was considered to be due to the tubular lesions caused by gross hematuria.

Acute Kidney Injury↗
PubMed1992

Renal transplant recipients and chronic liver disease: statistical evaluation of predisposing factors.

278 azathioprine and methylprednisolone (AZA)-treated and 406 ciclosporin (CS) treated patients with a kidney graft functioning for more than 1 year were investigated for the presence of chronic liver disease (CLD), defined as an increase in transaminases of 1.5 times the upper normal limits for a period of at least 12 months. The prevalence of CLD was 36 and 27% in the two groups, respectively. The univariate analysis showed that male sex, alcohol abuse and HBsAg positivity correlated with CLD onset in the AZA group while blood transfusions, length of dialysis treatment, pretransplantation CLD, HBsAg positivity and ferritin levels over 800 ng/ml correlated with CLD onset in CS. The multivariate analysis identified male sex and HBsAg positivity in the AZA group and age over 18 years, high ferritin levels and HBsAg positivity in the CS group as risk factors predictive of CLD onset. Liver failure represented the 4th cause of death in the AZA group but 1 of the 2 most important causes of death in CS in the long term. However, these drawbacks were overcome by the overall low mortality rate in CS. Therefore, renal transplantation should not be refused to patients positive for HBsAg and/or with preexisting liver disease.

Adult↗
PubMed1992

Remissions and relapses in idiopathic membranous nephropathy.

To assess the significance of remissions and relapses in idiopathic nephrotic syndrome the outcome of 169 patients was reviewed of them III had either a complete or partial remission. The probability of obtaining a complete remission within 5 years was 44% for the whole group, being significantly higher (P = 0.015) for those patients who had been treated with steroids plus cytotoxic drugs. Of the 74 patients who had complete remission only two showed renal function deterioration over time. Relapse of non-nephrotic proteinuria occurred in 22 patients. Of these, 12 again entered complete remission spontaneously, which persisted in nine until the last observation. Relapse of nephrotic syndrome occurred in 42 of III patients. Six patients showed a moderate renal function deterioration. Of 27 untreated patients, 17 had again a partial or complete remission that persisted in 13 until the last observation. All the 15 patients submitted to treatment again entered remission, which persisted in nine of 11 patients given prednisolone and chlorambucil and only in one of four given steroids alone. In conclusion, (a) the development of complete remission is a good marker of an excellent renal outcome, (b) patients with relapse of non-nephrotic proteinuria usually carry a good prognosis, (c) about half of patients with relapse of nephrotic syndrome show a spontaneous remission, and (d) the chances of a stable remission may be increased by treatment with steroids and cytotoxic agents.

Adolescent↗
PubMed1992

Clinical status of patients after 10 years of lupus nephritis.

Little information is available about the clinical status and outcome of patients with a long history of lupus nephritis. We have reviewed the dossiers of 25 patients (23 women and two men) who have been monitored by our Unit for more than 10 years after the diagnosis of lupus nephritis. At presentation the mean age was 28.5 +/- 10.33 (SD) years, the mean plasma creatinine was 136.1 +/- 144.7 (SD) nmol/l, the mean proteinuria was 3.02 +/- 2.7 (SD) g/day. At initial renal biopsy 18 patients showed diffuse proliferative glomerulonephritis, six patients showed membranous glomerulonephritis and one showed focal proliferative glomerulonephritis. All patients but one were treated with corticosteroids and 18 were also given immunosuppressive agents. At the last observation (16 +/- 4.6 (SD) years after presentation), 19 patients have normal plasma creatinine (11 of them show proteinuria less than 0.2 g/day) and six patients show increased plasma creatinine (mean 203.3 +/- 61.9 (SD) mmol/l). Eleven patients have been without any treatment for 88 +/- 64 (SD) months. The incidence of lupus flare-ups fell significantly after the tenth year (0.31/patient/year between 0 and 10 versus 0.11 between years 11 and 27; p = 0.01). No case of pericarditis or cerebritis occurred after the tenth year. Only one case of cerebral thrombosis occurred before the tenth year, but ten severe atherosclerotic cardiovascular and cerebrovascular complications were seen after the tenth year (two cardiac infarcts, three angina pectoris, four cerebral thrombosis, one cerebral haemorrhage). Two cases of cancer (thyroid and lung) occurred after the tenth year. The professional rehabilitation was good in most patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Exit-site and tunnel infections in continuous ambulatory peritoneal dialysis patients.

One hundred two exit-site infections (ESI) were diagnosed in 63 of 163 (38.6%) patients, with an incidence of one episode every 23.7 patient-months in patients with a history of ESI, whereas in the overall continuous ambulatory peritoneal dialysis (CAPD) population the incidence was one episode every 48.7 patient-months. In diminishing order of frequency, the bacteria isolated were Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Escherichia coli. The probability of remaining free of ESI was 72% at 1 year and 45% at 5 years. The ESI that led to catheter removal were due to S aureus and gram-negative rods. In 13 (48%) of 27 S aureus ESI unresponsive to antibiotics and local care, deroofing and outer cuff shaving completely resolved the ESI. Despite this treatment, the catheters of the remaining 14 patients had to be removed because of peritonitis associated with the tunnel infection. In conclusion, ESI is a major cause of CAPD failure. In our series, shaving the cuff as a rescue treatment was effective for almost 50% of the patients with antibiotic-resistant S aureus ESI.

Bacterial Infections↗
PubMed1991

Utility of immunofluorescence of urine sediment for identifying patients with renal disease due to monoclonal gammopathies.

Immunofluorescence (IF) of urine sediment with antisera to light-chain immunoglobulins (LC) was used for patients with renal disease due to various monoclonal gammopathies. Urinary casts and/or masses from 20 of 27 patients (74%) of this group stained predominantly for one or another of the two LC, but from none of the 25 controls, who all had renal diseases other than monoclonal gammopathies. In all but one patient with monoclonal gammopathy the more intensely staining LC in the urine sediment was the same as that found in the paraprotein. For 68.7% of patients, the prevailing LC in urinary casts was the same as that prevailing in the casts of the renal biopsies. The sensitivity of IF of urine sediment for identifying patients with plasma cell dyscrasias was 74%, the specificity 100%, and the accuracy 86.5%. The positive predictive value was 100% and the negative predictive value was 78%. Globally, urine sediment IF was more sensitive than serum or urine electrophoresis (74% v 63% and 66.6%), but less than serum or urine immunoelectrophoresis (74% v 85%). In light-chain deposition disease, a disorder in which there are often no definite symptoms, urine sediment IF was more sensitive than both traditional methods. We conclude that IF of urine sediment is a useful test to identify patients with renal disease associated with monoclonal gammopathies.

Adult↗
PubMed1991

The impact of azathioprine and cyclosporine on long-term function in kidney transplantation.

To assess the impact of cyclosporine on long-term kidney function in transplant patients, we retrospectively analyzed 273 patients on azathioprine and 308 on CsA with graft functioning at 1 year. To balance the length of follow-ups, the observation of patients was cut at 5 years. Actual graft survival rate at 5 years was similar in Aza and CsA (88% vs. 90%). Multivariate analysis in Aza pts showed that proteinuria (P = 0.006) and hypertension at 1 year (P = 0.002) increased the probability of irreversible graft failure by 2.47 and 2.85, respectively. In CsA patients, proteinuria (P = 0.007) and plasma creatinine higher than 2.5 mg/dl (P = 0.006) increased the probability of graft failure by 5.12 and 6.48, respectively. In both Aza and CsA patients with a follow-up of at least 5 years, plasma creatinine levels were significantly worse at 5 years vs. 1 year (P = 0.004). The slopes of plasma creatinine values plotted vs time were not different between the two groups. Chronic graft dysfunction (CGD) was defined as a stable increase of plasma creatinine of at least 50% above stable values at 1 year. The probability of remaining without CGD at 5 years was 75% for CsA and 80% for Aza patients (P = N.S.). Multivariate analysis of factors influencing the development of CGD showed that hypertension (P = 0.003) and proteinuria at 1 year (P = 0.081) increased the probability of developing CGD by 2.19 and 1.76, respectively, in Aza, while in CsA patients proteinuria only (P = 0.063) increased the probability of developing CGD by 2.29. Graft survival at 5 years after development of CGD was 34% in Aza and 53% in CsA-treated patients. These data confirm that in the long-term CsA does not cause a higher prevalence of CGD and show that, in the presence of CGD, CsA has a superior protective effect than Aza.

Adult↗
PubMed1991

A randomized prospective trial comparing cyclosporine monotherapy with triple-drug therapy in renal transplantation.

In a prospective trial 151 recipients of renal transplants were randomly assigned to treatment with CsA alone (74 patients) and to low dose of AZA, prednisolone, and CsA (77 patients). At two years, graft survival was 84% for the monotherapy and 90% for the triple therapy. This difference was not statistically significant. The number of rejection episodes was similar in the two groups, but the severity of rejection was significantly worse among the patients on monotherapy. More kidneys were lost because of rejection (6 versus 3), and a higher number of methylprednisolone pulses was used for treating rejection (5.2 +/- 2.3 versus 4.3 +/- 2.9; P = 0.0077). CsA nephrotoxicity episodes were more frequent among patients on monotherapy (23 versus 7; P less than 0.02). Infectious episodes were equally distributed between the two groups. Creatinine clearance was poorer in the monotherapy-treated patients at the third month (42 +/- 16 ml/min versus 48 +/- 15 ml/min; P = 0.02), but no differences were observed between the two groups since the sixth month after transplantation. Many patients on monotherapy required changes in maintenance therapy. In fact, one patient was switched to conventional immunosuppression because of Cremophor-induced anaphylaxis. Another patient who developed Kaposi's sarcoma 4 months after surgery was switched to steroids alone. Excluding 5 patients who lost their grafts a few days after transplantation, only 30 of 74 patients (40%) could be kept without steroids. We conclude that both the therapeutic protocols can give good results in renal allotransplantation; however, monotherapy could create some problems in keeping the balance between drug toxicity and significant immunosuppression. On the contrary, triple therapy is easier to handle, especially in the early posttransplant period when the differential diagnosis between acute rejection and CsA-related nephrotoxicity can be difficult even for a skilled clinician.

Adult↗