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Race and Kidney Disease: Role of Social and Environmental Factors. Journal of the National Medical Association. 94(8 Supplement): 28S-38S. August 2002.

Numerous studies have documented the presence of racial disparities among Americans in health outcomes with respect to cardiovascular disease, infant mortality, cancer, and kidney disease. With regard to kidney diseases, these disparities are more dramatic. African, Hispanic, and Native Americans have the highest risks of end stage renal disease (ESRD). The incidence of ESRD is four times higher in African Americans than in whites. This article considers the role of social and environmental factors in this disparity. Diseases causing chronic kidney failure, such as diabetes mellitus, hypertension (high blood pressure), systemic lupus erythematosus (SLE), and HIV associated kidney disease, are particularly prevalent among African-American patients. In addition to the higher prevalence, the morbidity (complications and related illness) associated with kidney complications of these diseases appears worse in African American patients. African Americans also have worse outcomes and a relatively reduced access to kidney transplantation (the best therapy for ESRD). The authors note that it is highly likely that social and environmental factors play a very significant role in the persistence of these disparities. A detailed understanding of these socioeconomic and environmental factors will be critical in formulating rational public health strategies to redress these disparities.

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Advances in the Treatment of Lupus Nephritis. In: Coggins, C.H.; Hancock, E.W., Eds. Annual Review of Medicine: Selected Topics in the Clinical Sciences, Volume 45. Palo Alto, CA: Annual Reviews Inc. 2001. p. 63-78.

Systemic lupus erythematosus (SLE) is an autoimmune disease that leads to the formation and deposition of immune complexes throughout the body, which are pathogenic (causing disease) for SLE. Different forms of glomerulonephritis (inflammation of the filtering units of the kidney) can occur in patients with SLE and can contribute significantly to the associated morbidity (illness and complications) and, ultimately, mortality (death) from the disease. Over the past two decades, there have been significant strides in the understanding of the disease and in treatments that attempt to control the formation and deposition of anti-DNA auto-antibodies and immune complexes, as well as the subsequent inflammatory cascade mediated through various cellular and humoral pathways leading to progressive renal (kidney) damage and end stage renal disease (ESRD). This article reviews the current understanding of the pathogenesis and treatment of lupus nephritis in its various stages and discusses the experimental and human data regarding some of the potential newer forms of therapy. The authors discuss data regarding the use of steroids, azathioprine, cyclophosphamide, cyclosporine A, mycophenolate mofetil, gammaglobulin, plasmapheresis, LJP 394, flaxseed oil, bindarit, anti-CD-40 ligand, and CRLA41g. The authors conclude that the long term morbidity and mortality for patients with lupus nephritis (LN) has improved markedly over the past two decades. This is due in part to the addition of newer adjunctive therapies to control blood pressure and intraglomerular pressure, reduce proteinuria (protein in the urine), and manage hyperlipidemia (high levels of fats in the blood). 89 references.

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Glomerulonephritis Recurrence in the Renal Graft. JASN. Journal of the American Society of Nephrology. 12(2): 394-402. February 2001.

Although kidney transplantation may return renal (kidney) function to the recipient, it does not necessarily remove the cause of the recipient's original kidney disease. Glomerulonephritis is the cause of renal failure for 20 to 40 percent of those who receive a transplant; for these recipients, the threat of recurrent disease is very real. This article discusses recurrent glomerulonephritis. The author first reviews the epidemiology of recurrence in a general sense, then addresses recurrence of specific forms of the disease. The incidence of recurrence and recurrence leading to graft failure is examined, and risk factors for disease recurrence are assessed. Where available, data on the pathogenesis and management of recurrent glomerulonephritis is also presented. The typical features of recurrent glomerulonephritis are those of nephritis involving the native kidney, including proteinuria (protein in the urine), hematuria (blood in the urine), and deterioration in renal function. When the diagnosis of recurrence is suspected, renal biopsy is essential. The author discusses IgA nephropathy and Henoch Schonlein purpura; antineutrophil cytoplasmic antibody associated vasculitis, Wegener's granulomatosis, microscopic polyangiitis, and idiopathic necrotizing crescentic glomerulonephritis; anti GBM disease; hemolytic uremic syndrome (HUS); focal and segmental glomerulosclerosis; membranous glomerulonephritis; mesangiocapillary glomerulonephritis; lupus nephritis; systemic sclerosis and scleroderma; and fibrillary glomerulonephritis and immunotactoid glomerulonephritis. Strong data have emerged on patterns of recurrence, risk factors for recurrence, and the implications for patient and graft outcomes after recurrence of the most common glomerulopathies. However, data available on recurrence of the less common nephropathies are inadequate and make treatment and prevention more difficult. 1 figure. 1 table. 60 references.

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Goodpasture Syndrome: Pathophysiology, Diagnosis, and Management. Nephrology Nursing Journal. 28(3): 305-310. June 2001.

Goodpasture syndrome is an autoimmune disease characterized by glomerulonephritis (inflammation of the capillary loops in the glomeruli of the kidney), pulmonary hemorrhage (bleeding in the lungs), and autoantibodies to the glomerular and alveolar basement membranes. This article reviews the pathophysiology, diagnosis, and management of patients with Goodpasture syndrome. The cause of the condition is unknown and, if left untreated, Goodpasture syndrome usually is fatal. Early diagnosis and prompt initiation of therapy can decrease disease progression and increase the patient's chance of survival. Differential diagnosis includes Wegener's granulomatosis, Henoch Schonlein purpura, lupus nephritis, and polyarteritis nodosa. Diagnostic tests include chest x rays, urinalysis, renal (kidney) biopsy, and lung biopsy. Treatment modalities remain controversial and vary among practitioners. Currently, treatment is focused on plasmapheresis and immunosuppression. The goals for treatment are to remove circulating antibodies, stop further production of antibodies, and remove any antigens that stimulate antibody formation. Plasmapheresis, or therapeutic plasma exchange (TPE), is an extracorporeal (outside the body) process that decreases large molecular weight substances in the blood; as this removal is taking place, a replacement fluid is used to maintain hemodynamic stability. The replacement fluid used for patients with Goodpasture syndrome is albumin (protein). Complications of TPE can include hypotension (low blood pressure), citrate metabolic alkalosis, respiratory distress, and allergic reaction. Renal transplantation provides a good option for these patients, particularly if other therapies first reduce or eliminate autoantibody production before transplantation is undertaken. 1 table. 27 references.

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Renal Disease in the Inner City. Seminars in Nephrology. 21(4): 334-345. July 2001.

For various ethnic and socioeconomic reasons, the pattern of renal (kidney) disease in the inner city displays distinctive features. This article covers the evolution and present status of hypertension and nephrology (study and medicine of the kidney) in the inner city as seen by the authors over several decades. Hypertension (high blood pressure) is frequent, often intractable, and generally conditioned by salt sensitivity and a high sodium intake. Chronic hypertensive nephrosclerosis, found predominantly in African Americans, comprises marked cardiomegaly (increased heart size), renal shrinkage, and hypertensive retinopathy (eye disease). While hypertension has been overdiagnosed in the past, it actually accounts for less than 20 percent of end stage renal disease (ESRD) in African Amerians. Malignant hypertension, less frequent nowadays, may cause renal shutdown, which is reversible in a few cases; the heart and kidneys are often of normal size. Idiopathic focal segmental glomerulosclerosis (scarring in the filtering parts of the kidney) is the most common cause of the primary nephrotic syndrome in blacks, but its incidence has also been rising in whites and Hispanics; it does not respond well to treatment, and almost one half of the patients develop ESRD within 10 years. Systemic lupus erythematosus is also more common in African Americans, in whom the severe proliferative forms of lupus nephritis (kidney infection associated with lupus) pursue a more deadly course: one half of such patients develop ESRD in 5 years. Cocaine, the use of which has assumed epidemic proportions, may cause accelerated hypertension, acute renal failure from rhabdomyolysis (a disease of skeletal muscle), and progression of preexisting renal disease. Heroin nephropathy has all but disappeared and has been replaced by HIV nephropathy. The prognosis of HIV infected patients maintained by dialysis has greatly improved. Sickle glomerulopathy (kidney disease associated with sickle cell anemia) may cause the nephrotic syndrome in 4 percent of patients with severe sickle cell anemia, heralding death within 2 years in one half of patients and ESRD in two thirds; survival has not improved with dialysis. Diabetes is now the most common cause of ESRD. 92 references.

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Efficacy of Mycophenolate Mofetil in Patients with Diffuse Proliferative Lupus Nephritis. New England Journal of Medicine. 343(16): 1156-1162. October 19, 2000.

The combination of cyclophosphamide and prednisolone is effective for the treatment of severe lupus nephritis (kidney inflammation associated with systemic lupus erythematosus or SLE) but has serious adverse effects. This article reports on a study that investigated the efficacy of mycophenolate mofetil in patients (n = 42) with proliferative lupus nephritis. The authors compared the efficacy and side effects of a regimen of prednisolone and mycophenolate mofetil given for 12 months (group 1) with those of a regimen of prednisolone and cyclophosphamide given for 6 months, followed by prednisolone and azathioprine for 6 months (group 2). Of the patients in Group 1 (n = 21), 81 percent had a complete remission, and 14 percent had a partial remission, as compared with 76 percent and 14 percent, respectively, of the 21 patients in Group 2. The improvements in the degree of proteinuria (protein in the urine) and the serum albumin (protein levels in the blood) and creatinine concentrations were similar in the two groups. One patient in each group discontinued treatment because of side effects. Infections were noted in 19 percent of the patients in Group 1 and in 33 percent of those in Group 2. Other adverse effects occurred only in group 2; they included amenorrhea (23 percent), hair loss (19 percent), leukopenia (10 percent), and death (10 percent). The rates of relapse were 15 percent in Group 1, and 11 percent in Group 2. The authors conclude that for the treatment of diffuse proliferative lupus nephritis, the combination of mycophenolate mofetil and prednisolone is as effective as a regimen of cyclophosphamide and prednisolone followed by azathioprine and prednisolone, with similar levels of toxicity. 2 figures. 4 tables. 15 references.

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Evaluation of the Transplant Recipient. In: Danovitch, G.M., ed. Handbook of Kidney Transplantation. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins. 2000. p. 130-145.

This chapter on evaluation of the transplant recipient is from a handbook of kidney transplantation that provides practical information on therapy, patient monitoring, and patient care management. In this chapter, the authors stress that the potential kidney transplant recipient must be evaluated by the transplantation team to determine whether he or she is a suitable candidate. The patient must also make a personal evaluation of the transplantation option, and the transplant team must see to it that the patient's evaluation is an educated one. The excellent statistics achieved by most transplantation centers for graft survival and morbidity have changed the attitude of both physicians and patients regarding the appropriateness of transplantation. Now, nearly all patients with end stage renal disease (ESRD) can be regarded as potentially acceptable candidates for transplantation. Instead of denying the option to broad groups of patients, such as the elderly or those with diabetes mellitus and coronary artery disease, each person's candidacy should be evaluated individually. The author of this article outlines and briefly explains contraindications to kidney transplantation, including malignancy, chronic infection, severe extrarenal disease, noncompliance, and psychiatric illness. Other topics include the general medical evaluation of the recipient, urologic evaluation, patient education concerns, special features related to the primary kidney disease (including diabetes mellitus, systemic lupus erythematosus, focal glomerulosclerosis, Goodpasture's syndrome, Alport's syndrome, amyloidosis, paraproteinemia, polycystic kidney disease, Fabry's disease, scleroderma, hyperoxaluria, thrombotic thrombocytopenic purpura, systemic vasculitis and Wegener's granulomatosis, and sickle cell disease), risk factors related to organ system diseases, and risk factors related to individual patient characteristics (age, obesity, malnutrition, peritoneal dialysis, previous transplantations, double organ candidates). 4 tables. 17 references.

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Lower Urinary Tract Symptoms in Patients with Sjogren's Syndrome and Systemic Lupus Erythematosus. International Urogynecology Journal. 11(2): 84-86. 2000.

Sjogren's syndrome (SS) and systemic lupus erythematosus (SLE) are autoimmune diseases which have many similarities with interstitial cystitis (IC), a urinary bladder disease with unknown etiology. This article reports on a survey studying the occurrence, severity, and nature of lower urinary tract symptoms among patients with SS or SLE. The results showed that these patients have significantly more urinary complaints, especially irritative bladder symptoms, than age and sex matched controls. The authors studied 36 patients with SS, 85 patients with SLE, and 121 controls. In these groups, 25 percent, 29 percent, and 66 percent, respectively, were free of urinary symptoms. The prevalences of mild symptoms were 61 percent (SS), 62 percent (SLE), and 27 percent (control group); and severe symptoms 14 percent (SS), 9 percent (SLE), and 7 percent (control group). SS and SLE patients with urinary complaints reported mostly urinary frequency (27 percent of SS and 62 percent of SLE patients) and suprapubic pain (36 percent of SS and 34 percent of SLE patients). The most common symptom in the control group was stress urinary incontinence. The frequency of lower urinary tract problems in patients with SS and SLE supports the concept that autoimmune disorders also have bladder manifestations. 2 tables. 21 references.

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Progress in the Treatment of Proliferative Lupus Nephritis. Current Opinion in Nephrology and Hypertension. 9(2): 107-115. 2000.

Lupus nephritis (kidney inflammation associated with systemic lupus erythematosus, or SLE) is often well developed at the time of diagnosis. This article reviews progress in the treatment of proliferative lupus nephritis. High dose corticosteroids are universally accepted as the initial approach to the control of severe inflammation in the kidney. Long term disease control and the minimization of iatrogenic (physician caused) risk usually require adjunctive therapies that target the more fundamental immunoregulatory disturbances of lymphoid cells. Of the available cytotoxic drugs, cyclophosphamide is currently among the most effective, although it cannot be considered ideal in terms of efficacy or toxicity. New prospects for the treatment of proliferative lupus nephritis include novel immunosuppressive agents (e.g., mycophenolate, cyclosporine, fludarabine), combination chemotherapy (e.g., cyclophosphamide plus fludarabine), and sequential chemotherapy (e.g., cyclophosphamide followed by azathioprine), immunological reconstitution using intensive cytoreductive chemotherapy (with or without stem cell rescue), and co stimulatory molecule inhibition. Gene therapy remains an attractive prospect, but its feasibility clearly depends on the further definition of lupus promoting genes and the availability of methods to establish stable expression of disease corrective genes in the appropriate lymphoid cells. 3 figures. 83 references.

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Seeing the Forest Through the Trees: For Many Patients IC Is Not Just a Bladder Disease. ICA Update. 15(1): 4-6. 2000.

This article, from a newsletter from the Interstitial Cystitis Association (ICA), reminds readers of the variations in interstitial cystitis (IC) that may occur. IC patients, when comparing their symptoms with other IC patients, may have found that not all experience the same urinary and pelvic symptoms (urinary frequency, urgency, and pain). And while some IC patients' symptoms are limited to the pelvic region or urinary tract, others have found that they experience symptoms beyond the bladder as well. The author reassures readers that if they notice that there seems to be more going on with their IC than just a bladder disease, they may be accurately perceiving certain related disorders that may be occurring. The author then outlines the top three related disorders: allergies, irritable bowel syndrome (IBS), and sensitive skin. Other conditions that are often related to IC are also discussed: vulvodynia, fibromyalgia, migraine, endometriosis, urge incontinence, asthma, inflammatory bowel disease (Crohn's disease and ulcerative colitis), and lupus erythematosis. The author notes that it may be that several different contributing factors or processes are occurring simultaneously in some IC patients. Research continues to study the involvement of neural, immune, and endocrine systems. For some patients, just knowing that these associated disorders and their connection to IC are being studied is a source of validation for the myriad of symptoms experienced beyond the bladder. The author encourages readers to seek out urologists who are developing multimodal approaches to treating IC and other related diseases. 1 figure. 14 references.

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