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Abstract

T. Nakamura, T. Sugaya, Y. Kawagoe, Y. Ueda, S. Osada and H. Koide

¹Department of Medicine, Shinmatsudo Central General Hospital, Chiba, ²Research Unit for Organ Regeneration, Riken Kobe Institute, Hyogo, ³Department of Pathology, Koshigaya Hospital, Dokkyo University School of Medicine, Saitama, and ⁴Department of Medicine, Koto Hospital, Tokyo, Japan
Aims: Focal glomerulosclerosis (FGS) and minor glomerular abnormalities are kidney diseases characterized by massive proteinuria. Urinary liver-type fatty acid-binding protein (L-FABP), an intracellular carrier protein of free fatty acids, is expressed in proximal tubules of the human kidney. Patients with FGS show significant improvement with low-density lipoprotein (LDL) apheresis. The aim of the present study was to determine whether urinary L-FABP levels differ between patients with FGS and those with minor glomerular abnormalities and whether levels are altered by LDL apheresis. Patients and methods: There were 24 patients with minor glomerular abnormalities (nephrotic stage, n = 14, remission stage, n = 10), 17 patients with FGS, and 20 healthy age-matched subjects were included in the present study. Urinary L-FABP levels were measured by enzyme-linked immunosorbent assay and compared. All patients with minor glomerular abnormalities at the nephrotic stage received prednisolone for 6 months, and all FGS patients received some form of immunosuppression therapy with prednisolone, cyclophosphamide or mizoribine for 12 months. LDL apheresis was performed in eight FGS patients with drug-resistant nephrotic syndrome. Results: Urinary L-FABP levels were significantly higher in the 17 FGS patients (82.0 ± 44.4 mg/g.Cr) than in the 24 patients with minor glomerular abnormalities (10.2 ± 8.4 mg/g.Cr) (p < 0.01) and in the 20 healthy subjects (7.4 ± 4.2 mg/g.Cr) (p < 0.01). Urinary L-FABP levels differed little between nephrotic stage and remission stage in patients with minor glomerular abnormalities. Urinary L-FABP levels were significantly higher in the eight drug-resistant FGS patients (122.6 ± 78.4 mg/g.Cr) than in the nine drug-sensitive FGS patients (45.9 ± 32.0 mg/g.Cr). Urinary L-FABP levels did not correlate with levels of other clinical markers including serum creatinine, urinary protein, and urinary N-acetyl-b-D- glucosaminidase. In the eight drug-resistant FGS patients, LDL-apheresis significantly reduced urinary protein excretion (p < 0.01) and urinary L-FABP levels (p < 0.01). Conclusions: Urinary L-FABP may be a useful diagnostic indicator for differentiation between FGS and minor glomerular abnormalities. LDL apheresis may be effective in ameliorating tubulointerstitial lesions associated with FGS.Correspondence to:
Dr. H. Koide
Department of Medicine
Koto Hospital
6-8-5 Ojima, Koto-ku
Tokyo 136-0072, Japan
Email: hkoide@koto-hospital.or.jp

Abstract

M. Buyukcelik, N. Cengiz, H. Dursun, M. Soran, A.K. Bayazit, A. Noyan and A. Anarat

¹Department of Pediatric Nephrology, Cukurova University, School of Medicine Adana, and ²Department of Pediatric Nephrology, Baskent University, Medical Faculty, Adana Research and Medical Training Hospital Center, Adana, Turkey
Aims: We herein report the results of intravenous pulse cyclophosphamide (IVCP) therapy of 5 patients with steroid-resistant focal segmental glomerulosclerosis (FSGS). All patients had been treated with oral and intravenous pulse methylprednisolone and failed to respond to steroids from onset and were considered as primary steroid-resistant. Before starting IVCP, all patients were also treated with other immunosuppressive drugs with or without steroids, but none of them responded to such therapies and no patient had any NPSH2 gene mutations. Methods: IVCP was given monthly at a dose of 500 mg/m2 for 6 months. At the end of 6 months, IVCP was discontinued in case there was no response. Otherwise, IVCP was continued for every 2 months. Oral prednisone was given concurrently at 60 mg/m2 daily for 6 weeks and then 40 mg/m2 on alternate days for 4 weeks. Prednisone was then tapered to 10 mg/m2 alternate days and continued during the therapy period. Results: Only 1 of these patients achieved remission after IVCP while 4 patients showed no response to IVCP. 2 patients who did not achieve remission progressed to end-stage renal disease (ESRD) and 2 others who had not been treated with cyclosporine before underwent cyclosporine therapy. None of our patients has suffered from adverse effects of IVCP. Conclusion: We found that IVCP had a limited beneficial effect in treatment of steroid-resistant FSGS and it may be suggested that IVCP can be tried to treat steroid-resistant patients, also for patients with primary steroid resistance and those who do not respond to other immunosuppressive therapies.Correspondence to:
M. Buyukcelik, MD Department of Pediatric Nephrology Cukurova University School of Medicine Balcali, Adana 01330, Turkey
Email: buyukcelikm66@yahoo.com

Abstract

R.F. Gagnon, A.I. Alli, M.D. Edwardes, A.K. Watters and C.M. Tsoukas

Departments of ¹Medicine and ²Pathology, McGill University Medical Center, Montreal, QC, Canada
Indinavir is a potent HIV-1 protease inhibitor included in current antiretroviral therapeutic regimens. It is associated with renal and urological complications ascribed to indinavir crystalluria. We have previously reported that indinavir crystalluria is frequently observed soon after initiation of therapy. In a cohort of 54 asymptomatic indinavir-naïve HIV-1-infected individuals during their first year of treatment with indinavir, approximately 25% of urinalyses (U/A) contained indinavir crystals. Because the determinants of the crystalluria are unknown, we examined the relationship between urine specific gravity (SG) and pH, singly and in combination, and indinavir crystalluria in these subjects. A total of 579 U/A were obtained from the study subjects at their scheduled monthly outpatient medical assessments. The frequency of indinavir crystalluria was lower in U/A with lower pH, irrespective of the SG. Conversely, U/A with high pH (³ 6.0) had a higher frequency of indinavir crystalluria, which was further influenced by the urine SG. As a result, nearly half of the U/A (46.7%) with high pH (³ 6.0) and intermediate-high SG (³ 1.015) contained indinavir crystals. In conclusion, the frequency of indinavir crystalluria in asymptomatic HIV-1 infected individuals during their first year of treatment with indinavir was markedly influenced by the urine pH and SG. Our findings suggest that low urine pH may have a protective effect against indinavir crystalluria across the entire range of urine SG.Correspondence to:
Dr. R.F. Gagnon
Division of Nephrology
Room L4-516, Montreal General Hospital
1650 Cedar Avenue
Montreal, Quebec, H3G 1A4, Canada
Email: raymonde.gagnon@muhc.mcgill.ca

Abstract

D.A. Hadley, L.J. Bryant and H.C. Ruckle

Division of Urology, Loma Linda University Medical Center, Loma Linda, CA, USA
Aims: Renal angiomyolipoma (AML) associated with tuberous sclerosis (TS) presents a treatment dilemma due to multifocal tumors with a potential for significant growth and subsequent hemorrhage. We reviewed the literature and our experience with AML and TS patients to determine the long-term behavior of these lesions. Materials and methods: We reviewed 8 patients (16 renal units) with bilateral renal AMLs and comorbid TS. We evaluated their renal function, renal imaging, and clinical course. Patients were followed for a mean of 11.5 years (range 3.5 – 21 years). Results: The records of 8 patients (7 females, 1 male) with a mean age of 33.1 years (range 21 – 54) were evaluated. The mean serum creatinine of these patients at the time of diagnosis was 0.75 mg/dl (range 0.4 – 1.1). Mean serum creatinine at last follow-up was 0.83 mg/dl (range 0.6 – 1.3). The average size of the largest lesion was 13.9 cm (range: 0.5 – 28). Of the 8 patients, 6 received treatment during the course of their disease, including arterial embolization of 7 renal units in 5 symptomatic patients (2 patients needed 2 embolizations). Partial nephrectomy was performed on 2 renal units in 2 patients, and a total nephrectomy was performed in 1971 on another patient. Currently, all 8 patients have stable renal function; 4 patients are asymptomatic with regards to their lesions, while the other 4 patients report transient flank pain adequately controlled with oral analgesics (2 patients with propoxyphene plus acetaminophen 100/650 mg PO t.i.d. p.r.n., the other 2 patients with ibuprofen 600 mg PO p.r.n.). None of the patients experienced life-threatening hemorrhage or required dialysis. Conclusions: Our study and a review of the literature have not revealed an obvious or quantitative risk of morbidity or mortality from renal hemorrhage directly related to AMLs of any specific size in TS patients. Due to multiple lesions and distortion of anatomy it can be difficult to distinguish individual lesions for preemptive treatment in asymptomatic patients. If size criteria alone are used, multiple treatments will be required over the course of the patient’s life. Also, preemptive treatment exposes patients to iatrogenic morbidity. Consideration should be given to medical management of AMLs in TS patients with asymptomatic, slowly enlarging tumors that maintain features of an AML. Embolization, partial nephrectomy, or other ablative treatments (i.e. cryotherapy and RFA) can be reserved for symptomatic patients.Correspondence to:
H.C. Ruckle, MD
Division of Urology
Loma Linda University Medical Center
11234 Anderson Street, Room A560
Loma Linda, CA 92354, USA
Email: bstrong@ahs.llumc.edu

Abstract

C.-C. Wu, L.-K. Yeung, W.-S. Tsai, C.-F. Tseng, P. Chu, T.-Y. Huang, Y.-F. Lin and K.-C. Lu

¹Division of Nephrology, ³Division of Gastroenterology and Hepatology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, and ²Division of Nephrology, Department of Medicine, Cardinal Tien Hospital, Fu-Jen Catholic University, School of Medicine, Taipei, Taiwan
Background: Acute renal failure (ARF) is a life-threatening entity that frequently complicates advanced liver disease. This study documents a number of factors that may predispose to or precipitate ARF and influence outcomes in patients with advanced liver disease. Comparisons are also made between subgroups of patients with viral and alcohol-induced liver cirrhosis in those with ARF. Patients and methods: We conducted a retrospective chart review over one year of 127 consecutive hospital admissions in 82 patients who were diagnosed with advanced liver cirrhosis (Child-Pugh Class C) in a tertiary care center. A diagnosis of ARF was made in 29 admissions and another 98 admissions not complicated by ARF served as controls. This study evaluated different etiologies of ARF and developed a database which included clinical features, biochemical parameters, the etiology of cirrhosis, possible predisposing factors, and precipitating events. Version II of the Acute Physiology and Chronic Health Physiology Scoring system (APACHE II) was applied to predict short-term hospital mortality rates. Results: ARF occurred in 29 admissions over the one-year study period (23%). The mean age of these patients was 56.8 ± 12.0 years, and 73% were men. The patients with ARF had significant hyponatremia and higher levels of serum bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and white cell counts on admission than the controls. Patients who developed ARF were more likely to have had infection, especially septicemia, and gastrointestinal (GI) bleeding. Mortality rate in the patients with ARF was much higher than in those patients without ARF (72% vs. 13%, p < 0.001). The patients with viral cirrhosis and ARF were found to have higher leukocyte counts, serum bilirubin levels, and more frequent incidence of infection, septicemia and GI bleeding compared to the patients with alcoholic liver cirrhosis and ARF. Those with viral hepatitis were also significantly older and had more frequent incidence of ascites, but had lower levels of g-glutamyl transpeptidase and less frequent incidence of encephalopathy. Conclusions: The risk of ARF is significantly increased in patients with advanced liver cirrhosis presenting with marked hyperbilirubinemia, hyponatremia, elevated liver enzymes, infection, and GI bleeding. The presence of ARF leads to higher mortality rates in both viral and alcohol-induced liver cirrhosis.Correspondence to:
K.-C. Lu, MD
23rd F, No 65, Min-Chiuan Rd
Hsin-Tien City, Taipei, Taiwan
Email: syjan@ms14.hinet.net

Abstract

R. Palsson, K.A. Laliberte and J.L. Niles

¹Division of Nephrology and Department of Medicine, Landspitali University Hospital, Reykjavik, Iceland, ²Medical Intensive Care Unit, and ³Renal Unit and Department of Medicine, and Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
Background: Several types of replacement fluid and methods of anticoagulation have been employed for continuous renal replacement therapy, but there is no consensus on a preferred approach. We evaluated the indications for the selection of replacement fluid and anticoagulant among critically ill patients receiving continuous venovenous hemofiltration (CVVH) and assessed the effect of the selection on the efficacy of anticoagulation and complications. Methods: We retrospectively studied 29 consecutive patients who received CVVH in the Medical Intensive Care Unit at Massachusetts General Hospital. There were 3 types of replacement solution available, an isotonic citrate solution which was also used for regional anticoagulation of the extracorporeal circuit, and bicarbonate and lactate solutions which were used with low-dose heparin or no anticoagulant. Blood flow rate was set at 120 ml/min when citrate replacement fluid was used and at 200 ml/min with bicarbonate or lactate. The replacement fluid was administered proximal to the hemofilter at a constant rate of 1,600 ml/h. Results: There were 22 patients who received citrate replacement fluid which was mainly chosen for the purpose of anticoagulation in the setting of contraindications to heparin. 12 patients received bicarbonate, predominantly when citrate was considered contraindicated due to liver failure or high-anion gap metabolic acidosis, and 2 received lactate; 8 of these 14 patients were anticoagulated with heparin and 6 were managed without anticoagulation. There were 44 filters used in the patients receiving citrate with a median filter life of 42.0 (interquartile range 22.2 – 70.7) hours. Only 8 of the 44 filters were lost due to clotting. Heparin was used for anticoagulation of 17 filters and no anticoagulation was used in the case of 15 filters, resulting in a median filter life of 43.0 (13.5 – 75.0) and 12.0 (4.0 – 33.0) hours, respectively. Clinically significant bleeding occurred in 2 patients, 1 receiving citrate and another receiving heparin. No patient had evidence for citrate toxicity, metabolic alkalosis or hypernatremia. 14 (48.3%) patients survived. Conclusions: The use of regional citrate anticoagulation of the CVVH circuit appears advantageous in patients with increased risk of bleeding and bicarbonate-based replacement fluid seems desirable in patients with lactic acidosis due to shock and/or severe liver failure. Tailoring the type of replacement fluid and method of anticoagulation to the individual patient leads to long filter lives, excellent metabolic control and minimal complications.Correspondence to:
J.L. Niles, MD
Renal Unit, Bartlett 901
Massachusetts General Hospital
55 Fruit Street
Boston, MA 02114, USA
Email: JLNiles@Partners.org

Abstract

S. Panagoutsos, K. Kantartzi, P. Passadakis, E. Yannatos, E. Mourvati, M. Theodoridis, P. Kriki, E. Thodis and V. Vargemezis

Division of Nephrology, Democritus University of Thrace, Alexandroupolis, Greece
Aims: The two main renal replacement therapies (RRT) – hemodialysis (HD) and peritoneal dialysis (PD) – have been considered to be antagonistic in most published studies on the clinical outcomes of dialysis patients. Recently, it has been suggested that the complementary use of both modalities as an integrated care (IC) strategy might improve the survival rate of end-stage renal disease patients. The aim of this study was to estimate the final clinical outcome of PD patients when they transfer to HD because of complications related to PD. Materials and methods: We retrospectively analyzed data from the following patients that started RRT during the last 10 years: 33 PD patients (IC group; age 55 ± 15 years, mean ± SD) who transferred to HD, 134 PD patients (PD group, age 64 ± 11 years) who remained in PD, and 132 HD patients (HD group, age 48 ± 16 years) who started and continued in HD. The main reasons for the transfer to HD were relapsed peritonitis and loss of ultrafiltration, while various comorbid risk factors were adjusted by Cox hazards regression model (age, presence of diabetes or/and cardiovascular disease, serum hemoglobin and albumin levels, as well as the modality per se). Results: 3- and 5-year survival rates for the IC, PD and HD groups were 97% and 81%, 54% and 28%, and 92% and 83%, respectively. The 5-year survival rate was significantly higher in IC patients than in PD patients (p < 0.00001) but, was not different from that in HD patients. Conclusions: Our results show that the IC of dialysis patients undergoing RRT improves the survival of patients on PD if they are transferred to HD upon the appearance of PD related complications.Correspondence to:
Dr. K. Kantartzi
15 Kolokotroni Str
Alexandroupolis 68100, Greece
Email: Polych@med.duth.gr

Abstract

M. Iyoda, T. Hato, K. Matsumoto, J. Ito, Y. Ajiro, A. Kuroki, T. Shibata, K. Kitazawa and T. Sugisaki

Department of Nephrology, Showa University School of Medicine, Tokyo, Japan
Herein we describe a case of a patient with rapidly progressive glomerulonephritis after Chlamydia pneumoniae infection. An 88-year-old woman who had had C. pneumoniae infection two months previously was admitted to our hospital with complaints of dyspnea and generalized edema. Laboratory tests revealed acute renal failure, polyclonal hypergammaglobulinemia, highly increased level of C-reactive protein, and hematoproteinuria. A renal biopsy revealed mesangial and endocapillary proliferative glomerulonephritis with crescents. She responded to high-dose steroids, cyclophosphamide, minocycline, and plasma exchange treatment with the remission of oliguric renal failure. The percentage of the subset of CD3+ TCR+ Vb11+ cells markedly increased to 9.6% (normal range: < 1.04%) at the onset of the disease and decreased to 0.1% after the treatment. These clinicopathological features were similar to those of superantigen-associated glomerulonephritis after methicillin-resistant Staphylococcus aureus infection. We suggest that the superantigenic mechanism is one of the possible pathomechanisms of this glomerulonephritis.Correspondence to:
M. Iyoda, MD 3801 NE 77th, St # 303 Seattle, WA 98115, USA
Email: iyoda@med.showa-u.ac.jp

Abstract

C. Okuse, H. Yotsuyanagi, N. Yamada, H. Ikeda, H. Takahashi, M. Suzuki, S. Kondo, K. Kimura, J. Koike and F. Itoh

¹Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kwasaki, ²Division of Infectious Diseases, Department of Internal Medicine, University of Tokyo, ³Division of Nephrology and Hypertension, Department of Internal Medicine, ⁴Department of Diagnostic Pathology, St. Marianna University School of Medicine, Kawasaki, Japan
We present a case of chronic hepatitis B with membranous nephropathy, that was improved by lamivudine treatment. A 37-year-old man was admitted to our hospital for the evaluation of proteinuria. He was diagnosed as having chronic glomerulonephritis associated with chronic hepatitis B. Histopathological findings of the renal biopsy specimen indicated membranous nephropathy. He suffered from nephrotic syndrome associated with leg edema, which was parallel to the exacerbation of hepatitis. Lamivudine was started for the treatment of hepatitis, which caused the disappearance of serum hepatitis B virus DNA and the normalization of ALT level in 4 weeks. Additionally, proteinuria disappeared 120 weeks after the treatment was started. Lamivudine treatment may remit HBV-associated nephropathy. Correspondence to:
C. Okuse, MD
Department of Internal Medicine
Division of Gastroenterology and Hepatology
St. Marianna University School of Medicine
2-16-1 Sugao, Miyamae-ku
Kawasaki 216-8511, Japan
Email: C2okuse@marianna-u.ac.jp

Abstract

K. Terui, M. Shoji, J. Yamashiki, Y. Hirai, A. Ishiguro, S. Tsutaya, K. Kageyama, M. Yasujima and T. Suda

¹Department of Endocrinology, Aomori Prefectural Central Hospital, ²The Third Department of Internal Medicine, ³Department of Laboratory Medicine, ⁴The First Department of Internal Medicine, Hirosaki University School of Medicine, and ⁵Department of Clinical Laboratory, Hirosaki University Hospital, Aomori, Japan
Gitelman syndrome is an inherited renal disorder characterized by impaired NaCl reabsorption in the distal convoluted tubule leading to hypokalemia, hypomagnesemia and normocalcemic hypocalciuria. It has been shown that this syndrome results from mutations in the gene encoding the thiazide-sensitive sodium chloride cotransporter (TSC). We performed the mutational analysis in the TSC gene of a 30-year-old Japanese woman with Gitelman syndrome and found two mutations at adjacent spots in both alleles. One was a frame shift mutation which generated stop codon at position 671, the other was a single nucleotide mutation, which resulted in an aminoacid substitution at position 672, Met to Ile. Her 52-year-old mother and two daughters had neither hypokalemia nor hypomagnesemia. However, her mother and her 8-year-old daughter had the Met672Ile mutation as heterozygotes. Her 4-year-old daughter had the same frame shift mutation as her mother, a heterozygotic mutation. These results suggest that Gitelman syndrome requires 2 compound heterozygotic mutations and the coexistence of the large deletion in the C-terminal domain with Met672Ile substitution of the TSC could impair the transporter activity underling the hypokalemia and hypomagnesemia in this patient.Correspondence to:
K. Terui, MD
The Third Department of Internal Medicine
Hirosaki University School of Medicine
5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
Email: terui@cc.hirosaki-u.ac.jp

Abstract

H. Nishi, A. Abe, A. Kita, T. Toki, N. Noda, D. Tsuchihashi, T. Abe, M. Umezu, H. Yokozaki and M. Fukagawa

¹Division of Nephrology and Dialysis Center, Kobe University School of Medicine, and ²Division of Surgical Pathology, Department of Biomedical Informatics, Kobe University Graduate School of Medicine, Kobe, Japan
Although venous thrombosis is one of the common complications in nephrotic patients, cerebral venous thrombosis (CVT) is rarely reported. CVT is so difficult to be detected by conventional diagnostic methods that it is sometimes overlooked despite its potential severity. We report a 79-year-old female with nephrotic syndrome due to systemic amyloidosis who suddenly altered mental status during her hospitalization. The underlying etiology had been not identified by physical examinations, various laboratory data, and repeated computed tomography, and finally she died. The post-mortem examination showed a massive thrombus impacted in intracranial left-sided transverse and sigmoid sinus. This case suggests that CVT can occur in a nephrotic patient who presents unexplained neurological signs and symptoms, which might not be detected only through conventional diagnostic tests.Correspondence to:
M. Fukagawa, MD, PhD, FJSIM, FASN Associate Professor and Director Division of Nephrology and Dialysis Center Kobe University School of Medicine 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan

Abstract

Y. Iwazu, S. Muto, S. Ikeuchi, S. Yanagiba, Y. Miyata, Y. Asano and E. Kusano

Department of Nephrology, Jichi Medical School, Minamikawachi, Kawachi, Tochigi, Japan
Despite the crucial role of calcium in myocardial contractility, hypocalcemia has very rarely been reported as a reversible cause of heart failure. In this article, we describe a case of a 51-year-old woman with advanced stages of chronic renal failure after parathyroidectomy who exhibited congestive heart failure, severe hypocalcemia, hypomagnesemia and hypokalemia. Severe hypocalcemia resulted from discontinuation of taking calcium supplements after parathyroidectomy and from reduced 1.25(OH)2D3 synthesis by damaged kidneys. The patient presented with reduced left ventricular ejection fraction (EF) and ECG abnormalities (T wave alternans and increased QTc dispersion), both of which improved after correction of serum calcium levels. Her serum levels of total calcium corrected for serum albumin, but not serum levels of magnesium or potassium, positively and negatively correlated with EF and QTc dispersion, respectively. In the present case, both heart failure and the ECG abnormalities are directly associated with hypocalcemia.Correspondence to:
S. Muto, MD, PhD Department of Nephrology Jichi Medical School Minamikawachi Tochigi 329-0498 Japan
Email: smuto@jichi.ac.jp

Abstract

S. Unver, E.M. Atasoyu, T.R. Evrenkaya, N. Ozmen, Y. Arslan and B. Karaman

¹Department of Nephrology, ²Department of Cardiology, ³Department of Cardio-Vascular Surgery, and ⁴Department of Radiology, GATA Haydarpasa Training Hospital, Istanbul, Turkey
Despite being widely reported in patients with neoplasms, vena cava superior (VCS) syndrome linked to thrombosis is a major catheter complication that can be encountered during the use of the hemodialysis catheter. Antithrombin III (AT-III), responsible for a large part of thrombin inactivation capacity in plasma, is the most powerful inhibitor of the thrombosis process. This report describes a case of VCS syndrome developing two weeks following the extraction of a right-sided subclavian catheter in a patient transferred from peritoneal dialysis to hemodialysis for one week due to leakage. The patient presented complaining of swelling and pain in the right arm. At Doppler examination, total thrombosis was observed in the subclavian and internal jugular vein. At advanced examinations due to lack of response to heparin and clinical worsening, VCS and AT-III deficiency were determined. Following thrombolytic therapy with streptokinase, AT-III levels were raised by the administration of plasma, and clinical and radiological stabilization was established by continuing heparin and continuous oral anticoagulant therapy.Correspondence to:
S. Unver, MD GATA Haydarpasa Training Hospital Department of Nephrology 81327 Kadikoy, Istanbul, Turkey
Email: suatunver@yahoo.com

Abstract

Y. Kitoh, S. Tsuruoka, M. Ohmori, K. Sugimoto, T. Saitoh and A. Fujimura

Abstract

K. Kisters, B. Gremmler, J. Kozianka and M. Hausberg

Abstract

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Volume 65, No. 1/2006(January)