Renal transplantation is considered to be the optimal replacement therapy for children with end stage renal disease. However, the number of pediatric renal transplants in Japan is much lower than in the USA and/or Europe. Since October 1997, pediatric (< 15 years) recipients are given priority over adult recipients for organ sharing, only if one or two HLA-DR antigen (s) are matched between the recipient and pediatric (< 15 years) donor. However, the number of pediatric transplants is not increasing. One hundred and twenty-four pediatric renal transplantations were performed in Tokyo Women's Medical University between 1983 and 1999, of which 18(14.5 %) were cadaveric transplants and the others (106, 85.5 %) were livingrelated transplants. We examined 18 pediatric cadaveric renal transplantations. Seven patients received their graft from pediatric donors less than 15 years of age and 11 from adult donors . The mean age at transplantation was 13.2 years (range 4.5-18.7 years) . Major etiologies of renal disease are hereditary renal disease (38.8 %), chronic glomerulonephritis (33 .3 %), and focal segmental glomerulosclerosis [FSGS] (16.7 %). Zero matches in HLA-DR locus were observed in 72.2 %. Patient survival rate was 100 %. Graft survival rates at 1 and 5 years after transplantation were 83 % and 64 % successively . There was no significant difference between the graft survival of cadaveric and livingrelated transplantation at 1 and 5 years. All 5 patients who received their graft between 1994 and 1998 have maintained normal graft function. Causes of their graft loss were chronic rejection in 3, recurrence of FSGS in 2, primary non function in 1, and graft thrombosis in 1. Donor age and HLA-DR mismatching did not affect the outcome. We propose that pediatric renal grafts should be provided to children with priority, regardless of their HLA-A, B and HLA-DR matching.

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Trandolapril is a newly developed angiotensin converting enzyme inhibitor (ACEI) whose characteristic is that it undergoes hepatic excretion. ACEI appears to have a specific reno-protective and antiproteinuric role in patients with chronic glomerulonephritis (CGN) . Although renally excreted ACEI tend to accumulate and cause side effects in patients with renal dysfunction, the pharmacokinetics of trandolapril were not affected by renal dysfunction. We compared the effect of other renally excreted ACEI with those of trandolapril on serum creatinine (s-Cr), creatinine clearance (Ccr), proteinuria and total protein (TP) in CGN patients who switched from another ACEI to trandolapril. Twelve hypertensive patients with chronic renal failure (nine males and three females, ranging from 30 to 72 years of age) who were treated by other renally excreted ACEIs for long periods (2 to 8 years) with some effects on proteinuria and renal function, were enrolled in the present study. After ACEI therapy, s-Cr had decreased (2.09 to 1.80 mg/dl, p<0.01) as well as proteinuria (1.65 to 0.71 g/day, p<0.01) . A single daily oral dose of lmg of trandolapril was administered to these patients regardless of their blood pressure status and renal functions. After change to trandolapril therapy, s-Cr (2.25 to 2.06 mg/dl, p<0.01) and urinary protein (1.82 to 1.34 g/day, p<0.05) significantly decreased. On the contrary, both Ccr and TP significantly increased at the level of 39.4 to 44.4 ml/min (p<0.05) and 6.80 to 7.02g/dl (p<0.01), respectively. No apparent side effects, such as hyperkalemia, hyponatremia, anemia or worsening of the existing renal dysfunction except for coughing, were observed in these patients. Furthermore, none of the 12 patients treated with trandolapril required discontinuation of the compound. In conclusion, it was shown from this study that trandolapril is effective for the treatment of hypertensive patients with renal insufficiency irrespective of the original diseases. Thus, it can be envisaged that trandolapril is one of the most appropriate agents compared to other renally excreted ACEI for these patients with renal insufficiency. We recommend the change from other ACEIs to trandolapril, when renal dysfunction might be due to ACEI accumulation.

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Effects of infusion of a non-ionic contrast medium (iopamidol, 370 mg I/ml) on renal function in a normovolemic state were examined in patients with normal and mildly affected renal function who underwent coronary angiography (CAG). The patients were divided into three groups : group I (n=69) with serum creatinine (S-Cr) level<1.0 mg/dl ; group II (n= 50) with S-Cr level of 1.0 to 1.3 mg/dl and group III (n=17) with S-Cr level of 1.3 to 2.0 mg/dl. Patients with S-Cr2.0 mg/dl were subjected to 3-h hemodialysis immediately after CAG (group HD, n=11) . Serum (S) and urine (U) values of Cr, Na, K, Cl, β²-microglobulin (β²MG), and U-N-acetyl-β-Dglucosaminidase (NAG) were measured before and 24 h after CAG. U-NAG and U-β^2MG were corrected for U-Cr, and fractional excretion of β²MG (FEβ^2MG) was determined. Basal U-NAG/Cr, U-β²MG/Cr and FEβ^2MG were increased in groups III and HD, suggesting the preexistence of tubular dysfunction. SCr was increased significantly only in group I, but there was no change in S-β²MG. U-NAG/Cr after CAG was elevated in all the groups, whereas U-β²MG/Cr (or FEβ^2MG) was increased only in group III. Greater than two-fold increases of U-NAG/Cr were noted equally in groups I through III. In contrast, the greater than two-fold increase of U-β²MG/Cr (or FEβ^2MG) occurred more frequently in group III as compared to the other groups. The incidences of such cases in group HD were similar to those of group III. The half life of serum iodide concentration was significantly shortened by 3-h HD (1.8±0.3 h vs. 15.9±3.8h without HD). In conclusion, patients presenting S-Cr≥ 1.3 mg/dl were at high risk of renal tubular dysfunction even when contrast media was administered in the absence of significant increase in S-Cr. Whether an increase in U-NAG/Cr indicates tubular damage or is merely the result of tubular reabsorption of the agent remains to be clarified. Post-CAG hemodialysis efficiently eliminates contrast medium from the circulation.

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Sclerosing encapsulating peritonitis (SEP) is a most serious complication of continuous ambulatory peritoneal dialysis (CAPD) . Although the criteria of diagnosis and guidelines for therapy of SEP have been proposed by the Japanese SEP Study Group already, SEP is refractory to treatment when the disease process is complete. It is important to detect the latent phase of SEP (pre-SEP state) in order to treat patients at an early stage. We evaluated the characteristics of ascites in four patients with massive ascites accumulation after discontinuation of CAPD. Age and the duration of CAPD of the subjects were 53.3±9.7 years and 126.5±6.8 months, respectively. However, the patients were withdrawn from CAPD because of peritonitis or ultrafiltration failure. We also followed cytokines and parameters of collagen metabolism of ascites in two patients during adrenocorticosteroid therapy and conducted a histopathological evaluation of the peritoneum of an autopsy case who had died of pneumonia. Ascites seems to be exudative because of the high concentration of protein, cytokines and parameters of collagen metabolism such as interleukin-1β, interleukin-6, transforming growth factor-β¹, procollagen 3 peptide, and type IV collagen 7S, the levels of which were 21.3±9.3 pg/ml, 8, 153±7, 327 pg/ml, 6.7±3.6 ng/ml, 89.3±67.8 U/ml, and 59.0±36.2 ng/ml, respectively. The histopathological findings of the peritoneum from the autopsy case showed dense fibrous tissue permeated with inflammatory infiltration and widespread infiltration of fibrin. These findings suggested that the peritoneum was inflamed when massive ascites accumulated. The amount of ascites and concentration of cytokines and parameters of collagen metabolism of ascites diminished during adrenocorticosteroid therapy. We concluded that massive and refractory accumulation of ascites appearing after the discontinuation of CAPD should be regarded as a sign of the pre-SEP state, and prophylactic treatment should be started at this stage of disease.

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We report a case of hepatitis C virus-associated glomerulonephropathy presenting with MPO-ANCA-positive, rapidly progressive glomerulonephritis (RPGN). A 60-year-old woman was admitted to our hospital for evaluation of RPGN. Laboratory evaluation revealed microhematuria, proteinuria (800 mg/day), anemia, renal failure (blood urea nitrogen 27 mg/dl, serum creatinine 2.2 mg/dl), cryoglobulinemia, hypocomplementemia, positive MPO-ANCA (232 EU), and hepatitis C virus infection (GOT 58 IU/l, GPT 38 IU/l, HCV-RNA (PCR)1, 200 kcopy/ml, serotype 1). After admission, the patient's renal function and anemia deteriorated rapidly, then prednisolone (30 mg/day) was started. After treatment her renal function gradually improved, then a renal and liver biopsy was performed. The renal biopsy revealed six sclerosing fibrous crescentic glomeruli in twelve glomeruli. Immunofluorescent examination revealed granular deposits of IgG, C₃, and fibrinogen along the glomerular basement membrane and mesangial matrix. The pathogenesis of RPGN in this case may relate to the deposition of immune complexes in the glomeruli because immunofluorescent examination was revealed to be the immune-complex type, but not pauci-immune type nephritis. Liver histology revealed chronic active hepatitis with mild piecemeal necrosis and did not reveal vasculitis. Although her renal function was improved after treatment with prednisolone, she suffered from pulmonary manifestations (dry cough etc.) on the 120th hospital day. Suddenly she died because of pulmonary hemorrhage on the 180th hospital day. These findings suggest that various HCV-induced immunological abnormalities, such as positive MPO-ANCA, cryoglobulinemia and hypocomplementemia, play an important role in the pathogenesis of this RPGN, although we could not demonstrate deposition within glomeruli of immune complexes containing HCV. The effect of interferon therapy on such immunological abnormalities remains to be documented. Since interferon is known to have immunomodulatory effects, we selected corticosteroid therapy. Future studies need to focus on the optimal treatment strategy for hepatitis C virus-associated glomerulonephritis.

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