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Volume 70, No. 6/2008(December)
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Review
Therapeutic and predictive targets of AKI
R. Yalavarthy and C.L. Edelstein
453
48$
Abstract
Acute kidney injury (AKI) is a very common condition encountered in a hospital setting. AKI is an independent risk factor for in-hospital mortality. In this review, we discuss in detail about the tubular, inflammatory and vascular molecular targets of AKI which may result in therapies to improve mortality and biomarkers for earlier diagnosis of AKI.Correspondence to:
C.L. Edelstein, MD, PhD; University of Colorado at Denver and Health Sciences Center, 12700 E. 9th Ave., Mail Box C281, Aurora, CO 80045, USA
Email: charles.edelstein@uchsc.edu
R. Yalavarthy and C.L. Edelstein
Departments of Kidney Diseases and Hypertension, University of Colorado at Denver and Health Sciences Center, Denver, CO, USA Acute kidney injury (AKI) is a very common condition encountered in a hospital setting. AKI is an independent risk factor for in-hospital mortality. In this review, we discuss in detail about the tubular, inflammatory and vascular molecular targets of AKI which may result in therapies to improve mortality and biomarkers for earlier diagnosis of AKI.Correspondence to:
C.L. Edelstein, MD, PhD; University of Colorado at Denver and Health Sciences Center, 12700 E. 9th Ave., Mail Box C281, Aurora, CO 80045, USA
Email: charles.edelstein@uchsc.edu
Original
Glomerular crescent formation in renal amyloidosis. A clinicopathological study and demonstration of upregulated cell-mediated immunity
K. Masutani, M. Nagata, H. Ikeda, K. Takeda, R. Katafuchi, H. Hirakata, K. Tsuruya, and M. Iida
464
48$
Abstract
Background: Several studies examined glomerular crescents associated with renal amyloidosis. However, the incidence of crescents, the association between the 2 lesions, treatment and outcome are still controversial. Patients and methods: We studied 107 consecutive biopsies of renal amyloidosis, and found cellular or fibrocellular crescents in 13 cases (12.1%). We investigated the clinical characteristics, pathological findings, treatment and outcome. We also performed immunohistochemical staining using T cell, macrophage and osteopontin (OPN) markers. Results: Amyloid was of the AA type in 12 cases, and all patients had rheumatoid arthritis. Six cases with AA amyloidosis had crescentic glomerulonephritis (CrGN), and 5 presented with rapidly progressive glomerulonephritis (RPGN). The percentage of crescents correlated negatively with serum albumin (r = –0.83, p < 0.001), and positively with serum creatinine (r = 0.72, p < 0.01) and urinary protein excretion (r = 0.85, p < 0.001). All RPGN patients developed end-stage renal disease, and 2 patients died shortly after treatment. Microscopic examination showed inflammatory cells within the glomeruli, and immunohistochemical study revealed abundant intrarenal T cells and macrophages in CrGN cases. Strong expression of OPN was observed in tubular epithelial cells and intraglomerular macrophages. Conclusion: Cellular immune responses play a crucial role in glomerular crescents in renal amyloidosis. Immunosuppressive treatment is often ineffective and raises the risk of complications in CrGN with abundant glomerular sclerosis and tubulointerstitial injury.Correspondence to:
K. Tsuruya, MD, PhD; Department of Integrated Therapy for Chronic Kidney Disease, Graduate School of Medical Sciences, Kyshu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, Japan
Email: tsuruya@intmed2.med.kyushu-u.ac.jp
K. Masutani1,2, M. Nagata1, H. Ikeda1, K. Takeda3, R. Katafuchi4, H. Hirakata2,5, K. Tsuruya1,6 and M. Iida1
1Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kiyushu University, 2Kidney Care Unit, Kyushu University Hospital Fukuoka, 3Division of Nephrology Aso Iizuka Hospital Iizuka, 4Department of Internal Medicine, National Fukuoka East Medical Center Koga, 5Kidney Unit, Fukuoka Red Cross Hospital Fukuoka, 6Department of Integrated Therapy for Chronic Kidney Disease, Graduate School of Medical Sciences, Kyushu University Fukuoka, Japan Background: Several studies examined glomerular crescents associated with renal amyloidosis. However, the incidence of crescents, the association between the 2 lesions, treatment and outcome are still controversial. Patients and methods: We studied 107 consecutive biopsies of renal amyloidosis, and found cellular or fibrocellular crescents in 13 cases (12.1%). We investigated the clinical characteristics, pathological findings, treatment and outcome. We also performed immunohistochemical staining using T cell, macrophage and osteopontin (OPN) markers. Results: Amyloid was of the AA type in 12 cases, and all patients had rheumatoid arthritis. Six cases with AA amyloidosis had crescentic glomerulonephritis (CrGN), and 5 presented with rapidly progressive glomerulonephritis (RPGN). The percentage of crescents correlated negatively with serum albumin (r = –0.83, p < 0.001), and positively with serum creatinine (r = 0.72, p < 0.01) and urinary protein excretion (r = 0.85, p < 0.001). All RPGN patients developed end-stage renal disease, and 2 patients died shortly after treatment. Microscopic examination showed inflammatory cells within the glomeruli, and immunohistochemical study revealed abundant intrarenal T cells and macrophages in CrGN cases. Strong expression of OPN was observed in tubular epithelial cells and intraglomerular macrophages. Conclusion: Cellular immune responses play a crucial role in glomerular crescents in renal amyloidosis. Immunosuppressive treatment is often ineffective and raises the risk of complications in CrGN with abundant glomerular sclerosis and tubulointerstitial injury.Correspondence to:
K. Tsuruya, MD, PhD; Department of Integrated Therapy for Chronic Kidney Disease, Graduate School of Medical Sciences, Kyshu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, Japan
Email: tsuruya@intmed2.med.kyushu-u.ac.jp
Original
Is treatment with N-acetylcysteine to prevent contrast-induced nephropathy when using bicarbonate hydration out of date?
A.E. Heng, E. Cellarier, B. Aublet-Cuvelier, V. Decalf, P. Motreff, X. Marcaggi, P. Deteix and B. Souweine
475
44$
Abstract
Aims: Chronic renal failure (CRF) is a major risk factor for contrast-induced nephropathy (CIN) and could be prevented by bicarbonate hydration. The effect of N-acetylcysteine (NAC) in preventing CIN in patients treated by bicarbonate hydration has never been investigated. Methods: Patients admitted for cardiac angiography from January 2002 to November 2004, with stable CRF (glomerular filtration rate (GFR) < 56 ml/min, Cockcroft-Gault formula) were included in a prospective, randomized, double-blind study comparing the efficacy of oral NAC + bicarbonate hydration vs oral placebo + bicarbonate hydration to prevent CIN. NAC 1,200 mg twice daily or placebo was given on Day –1 and Day 0 (Day 0 = cardiac angiography). A 1.4% bicarbonate solution (1 ml/ kg/h) was administered 12 hours before and after cardiac angiography. The overall CIN incidence on Day 2 was defined by one or more of the following criteria: increase in serum creatinine > 44.2 µmol/l, increase in serum creatinine > 25% or decrease in GFR > 5 ml/ min. Results: Between NAC group (n = 28) and placebo group (n = 32) there was no difference in baseline demographics (age, sex ratio, weight, arterial hypertension, diabetes), in Day 0 characteristics (serum creatinine, GFR, hematocrit, protidemia) and in Day 0 cardiac angiography procedure (diagnostic or interventional, number of stents, type and volume of contrast media infused). The overall incidence of CIN in the NAC and placebo groups was 7.1 vs 9.3% (p = 1), respectively, and the rates of the observed criteria a, b, and c were 0 vs 6.3% (p = 0.49), 3.5 vs 6.3% (p = 1), and 7.1 vs 9.3% (p = 1). Conclusion: In CRF patients undergoing cardiac angiography, the use of bicarbonate hydration is associated with a very low incidence of CIN. In these conditions, on the basis of our results, we cannot draw any meaningful conclusion on the effect of NAC on the prevention of CIN.Correspondence to:
A.E. Heng, MD; CHU Clermont-Ferrand, Service de Néphrologie Réanimation Médicale, Hôp G Montpied, 63003 Clermont-Ferrand, France
Email: aheng@chu-clermontferrand.fr
A.E. Heng1, E. Cellarier2, B. Aublet-Cuvelier2, V. Decalf3, P. Motreff3, X. Marcaggi4, P. Deteix5 and B. Souweine5
1,2,3Hôpital Gabriel Montpied, Service de Néphrologie Réanimation Médicale, CHU Clermont-Ferrand, 4CHR Vichy, service de cardiologie, Vichy, 5Univ. Clermont 1, UFR Médecine, Clermont-Ferrand, France Aims: Chronic renal failure (CRF) is a major risk factor for contrast-induced nephropathy (CIN) and could be prevented by bicarbonate hydration. The effect of N-acetylcysteine (NAC) in preventing CIN in patients treated by bicarbonate hydration has never been investigated. Methods: Patients admitted for cardiac angiography from January 2002 to November 2004, with stable CRF (glomerular filtration rate (GFR) < 56 ml/min, Cockcroft-Gault formula) were included in a prospective, randomized, double-blind study comparing the efficacy of oral NAC + bicarbonate hydration vs oral placebo + bicarbonate hydration to prevent CIN. NAC 1,200 mg twice daily or placebo was given on Day –1 and Day 0 (Day 0 = cardiac angiography). A 1.4% bicarbonate solution (1 ml/ kg/h) was administered 12 hours before and after cardiac angiography. The overall CIN incidence on Day 2 was defined by one or more of the following criteria: increase in serum creatinine > 44.2 µmol/l, increase in serum creatinine > 25% or decrease in GFR > 5 ml/ min. Results: Between NAC group (n = 28) and placebo group (n = 32) there was no difference in baseline demographics (age, sex ratio, weight, arterial hypertension, diabetes), in Day 0 characteristics (serum creatinine, GFR, hematocrit, protidemia) and in Day 0 cardiac angiography procedure (diagnostic or interventional, number of stents, type and volume of contrast media infused). The overall incidence of CIN in the NAC and placebo groups was 7.1 vs 9.3% (p = 1), respectively, and the rates of the observed criteria a, b, and c were 0 vs 6.3% (p = 0.49), 3.5 vs 6.3% (p = 1), and 7.1 vs 9.3% (p = 1). Conclusion: In CRF patients undergoing cardiac angiography, the use of bicarbonate hydration is associated with a very low incidence of CIN. In these conditions, on the basis of our results, we cannot draw any meaningful conclusion on the effect of NAC on the prevention of CIN.Correspondence to:
A.E. Heng, MD; CHU Clermont-Ferrand, Service de Néphrologie Réanimation Médicale, Hôp G Montpied, 63003 Clermont-Ferrand, France
Email: aheng@chu-clermontferrand.fr
Original
Outcome and risk factors for mortality in children with acute renal failure
J.-W. Chang, H.-L. Tsai, H.-H. Wang, and L.-Y. Yang,
485
24$
Abstract
Background: Acute renal failure (ARF) is an important cause of morbidity and mortality in children. Here, we investigate etiology, comorbidities, outcome and risk factors associated with mortality in these children with ARF. Methods: We retrospectively reviewed the characteristics of 58 children with ARF diagnosed between January 1997 and December 2006 at a single institute. Factors including age, sex, clinical features and laboratory parameters were compared between survivors and non-survivors. Results: ARF was secondary to extrarenal causes in 79.3% of cases. Sepsis (18.9%), hematooncologic disease (18.9%) and cardiovascular disease (18.9%), were the main causes of ARF. Primary renal disease due to acute glomerulonephrits, nephrotic syndrome, hemolytic uremic syndrome and obstructive uropathy accounted for 20.7% of the cases. The overall mortality rate was 51.7%. There were no significant differences between survivors and non-survivors in gender and changes in the peak levels of calcium, phosphorous and uric acid levels. The mortality rate was significantly higher when ARF occurred in younger children (p = 0.019), secondary to systemic disease (p = 0.038, odds ratio 4.3; 95% confidence interval (CI) 1.0, 17.9), sepsis (p < 0.001, odds ratio 19.7; 95% CI 5.1, 76.4), use of ventilator (p < 0.001, odds ratio 35; 95% CI 6.7, 182.7), multiple organ failure (p < 0.001) and non-use of renal replacement therapy (p = 0.018, odds ratio, 3.6; 95% CI interval 1.2, 10.6) on univariate analysis. Multiple logistic regression analysis revealed that sepsis (p = 0.011, odds ratio, 11.3; 95% CI 1.7, 73.0) and numbers of organ failures (p = 0.001, odds ratio 8.14; 95% CI 2.5, 26.7) were independently associated with mortality. Conclusion: This study found that sepsis and number of organ failures were independent predictors of mortality in children with ARF.Correspondence to:
L.-Y. Yang, MD, PhD; Department of Pediatrics, Veterans General Hospital, No. 201, Section 2, Taipei, 11217, Taiwan
Email: yangly@vghtpe.gov.tw
J.-W. Chang1,3, H.-L. Tsai2,3, H.-H. Wang1,3 and L.-Y. Yang1,3
1Department of Pediatrics, 2Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, 3Institute of Clinical Medicine, National Yang Ming University, School of Medicine, Taipei, Taiwan Background: Acute renal failure (ARF) is an important cause of morbidity and mortality in children. Here, we investigate etiology, comorbidities, outcome and risk factors associated with mortality in these children with ARF. Methods: We retrospectively reviewed the characteristics of 58 children with ARF diagnosed between January 1997 and December 2006 at a single institute. Factors including age, sex, clinical features and laboratory parameters were compared between survivors and non-survivors. Results: ARF was secondary to extrarenal causes in 79.3% of cases. Sepsis (18.9%), hematooncologic disease (18.9%) and cardiovascular disease (18.9%), were the main causes of ARF. Primary renal disease due to acute glomerulonephrits, nephrotic syndrome, hemolytic uremic syndrome and obstructive uropathy accounted for 20.7% of the cases. The overall mortality rate was 51.7%. There were no significant differences between survivors and non-survivors in gender and changes in the peak levels of calcium, phosphorous and uric acid levels. The mortality rate was significantly higher when ARF occurred in younger children (p = 0.019), secondary to systemic disease (p = 0.038, odds ratio 4.3; 95% confidence interval (CI) 1.0, 17.9), sepsis (p < 0.001, odds ratio 19.7; 95% CI 5.1, 76.4), use of ventilator (p < 0.001, odds ratio 35; 95% CI 6.7, 182.7), multiple organ failure (p < 0.001) and non-use of renal replacement therapy (p = 0.018, odds ratio, 3.6; 95% CI interval 1.2, 10.6) on univariate analysis. Multiple logistic regression analysis revealed that sepsis (p = 0.011, odds ratio, 11.3; 95% CI 1.7, 73.0) and numbers of organ failures (p = 0.001, odds ratio 8.14; 95% CI 2.5, 26.7) were independently associated with mortality. Conclusion: This study found that sepsis and number of organ failures were independent predictors of mortality in children with ARF.Correspondence to:
L.-Y. Yang, MD, PhD; Department of Pediatrics, Veterans General Hospital, No. 201, Section 2, Taipei, 11217, Taiwan
Email: yangly@vghtpe.gov.tw
Original
The utility of 6-month protocol renal biopsy under modern immunosuppression
A. Yango, R. Gohh, L.J. Wang, P. Morrissey, M. Shih, K. Lowery, K. Charpentier, A. Gautam, C. Mendonca, S. Kumar, L. Dworkin and A. Monaco
490
28$
Abstract
Background: Protocol biopsies after renal transplantation are useful in detecting subclinical rejection. In earlier studies, the incidence of subclinical rejection was high among renal transplant recipients on a cyclosporine-based immunosuppression. However, recent data show that subclinical rejection is low under tacrolimus-based immunosuppression. This study evaluates the utility of 6-month protocol biopsy in renal transplant recipients under induction with rabbit antithymocyte globulin and maintenance immunosuppression with tacrolimus, mycophenolate mofetil (MMF) and corticosteroids. Methods: 6-month protocol biopsies on 40 transplant recipients were analyzed for borderline and subclinical rejections. Allograft injury at biopsy was evaluated using the chronic allograft damage index score system (CADI) and was compared with initial scores obtained at implantation. Results: Borderline rejection was detected in 1 out of 40 patients. No case of subclinical rejection was detected at protocol biopsy. In 31 patients with corresponding implantation biopsies, mean CADI score increased from 1.1 ± 1.4 to 2.8 ± 2.1 at 6 months despite stable graft function. In the subgroup of patients with a 6-month CADI score of 2 or less (n = 11), graft function remained stable at 12 months post transplant (65.3 ± 16.9 ml/min/1.73 m2 at 6 months vs. 65.2 ± 16.7 ml/min/1.73 m2 at 12 months, p = 0.96). In contrast, allograft function declined significantly at 12 months in those with a 6-month CADI score of > 2 (n = 20) (64.3 ± 13.5 ml/min/1.73 m2 at 6 months vs. 51 ± 9.8 ml/min/1.73 m2 at 12 months, p = 0.0006). Conclusions: While the incidence of borderline and subclinical is low under antilymphocyte antibody induction and tacrolimus-based immunosuppression, chronic allograft damage is highly prevalent at 6 months post transplantation. Our findings suggest that protocol biopsies under current immunosuppression may be more useful in the early detection of chronic allograft nephropathy (CAN).Correspondence to:
A. Yango, MD; Rhode Island Hospital, Division of Hypertension and Renal Diseases, Brown University School of Medicine, 593 Eddy Street, APC 9th Floor, Providence, RI 02903, USA
Email: ayango@lifespan.org
A. Yango1, R. Gohh1, L.J. Wang2, P. Morrissey3, M. Shih1, K. Lowery1, K. Charpentier3, A. Gautam3, C. Mendonca1, S. Kumar4, L. Dworkin1 and A. Monaco3
1Division of Hypertension and Renal Diseases, 2Department of Pathology, 3Division of Organ Transplantation, Rhode Island Hospital, Brown University School of Medicine, 4Division of Hematology and Oncology, St. Elizabeth Medical Center, Tufts University School of Medicine, Providence, RI, USA Background: Protocol biopsies after renal transplantation are useful in detecting subclinical rejection. In earlier studies, the incidence of subclinical rejection was high among renal transplant recipients on a cyclosporine-based immunosuppression. However, recent data show that subclinical rejection is low under tacrolimus-based immunosuppression. This study evaluates the utility of 6-month protocol biopsy in renal transplant recipients under induction with rabbit antithymocyte globulin and maintenance immunosuppression with tacrolimus, mycophenolate mofetil (MMF) and corticosteroids. Methods: 6-month protocol biopsies on 40 transplant recipients were analyzed for borderline and subclinical rejections. Allograft injury at biopsy was evaluated using the chronic allograft damage index score system (CADI) and was compared with initial scores obtained at implantation. Results: Borderline rejection was detected in 1 out of 40 patients. No case of subclinical rejection was detected at protocol biopsy. In 31 patients with corresponding implantation biopsies, mean CADI score increased from 1.1 ± 1.4 to 2.8 ± 2.1 at 6 months despite stable graft function. In the subgroup of patients with a 6-month CADI score of 2 or less (n = 11), graft function remained stable at 12 months post transplant (65.3 ± 16.9 ml/min/1.73 m2 at 6 months vs. 65.2 ± 16.7 ml/min/1.73 m2 at 12 months, p = 0.96). In contrast, allograft function declined significantly at 12 months in those with a 6-month CADI score of > 2 (n = 20) (64.3 ± 13.5 ml/min/1.73 m2 at 6 months vs. 51 ± 9.8 ml/min/1.73 m2 at 12 months, p = 0.0006). Conclusions: While the incidence of borderline and subclinical is low under antilymphocyte antibody induction and tacrolimus-based immunosuppression, chronic allograft damage is highly prevalent at 6 months post transplantation. Our findings suggest that protocol biopsies under current immunosuppression may be more useful in the early detection of chronic allograft nephropathy (CAN).Correspondence to:
A. Yango, MD; Rhode Island Hospital, Division of Hypertension and Renal Diseases, Brown University School of Medicine, 593 Eddy Street, APC 9th Floor, Providence, RI 02903, USA
Email: ayango@lifespan.org
Original
Patients undergoing dialysis therapy for 30 years or more survive with serious osteoarticular disorders
S. Yamamoto, J.J. Kazama, H. Maruyama, S. Nishi, I. Narita and F. Gejyo
496
32$
Abstract
Aims: Increasing numbers of patients are undergoing long-term dialysis therapy. It is crucial for their quality of life to overcome dialysis-related complications, such as dialysis-related amyloidosis (DRA) and other osteoarticular disorder. The aim of the study was to investigate the characteristics, such as dialysis-related complications, in chronic kidney disease (CKD) Stage 5D patients undergoing dialysis therapy for more than 30 years or more. Methods: From 2003 to 2006, 359 CKD Stage 5D patients who were admitted to a single tertiary-care center. The age and the duration of dialysis therapy, the purpose for hospital admission, and history of osteoarticular disorder, such as carpal tunnel syndrome (CTS), destructive spondyloarthropathy (DSA) and joint arthropathy, were studied. Results: The proportions of the patients undergoing dialysis therapy for 20 – 24, 25 – 29 years and 30 years or more were 8.9, 5.6, and 4.5% of all admitted patients, respectively. DSA was a major cause of hospital admissions in long-term dialysis patients, especially in those treated for 30 years or more. The rate of surgery for osteoarticular disorder, such as CTS, DSA and joint arthropathy, which may show the presence of DRA, was 25.0, 66.0 and 77.8% in 20 – 24 years, 25 – 29 years and 30 years or more after the initiation of dialysis therapy, respectively. The frequency and severity of osteoarticular disorder accelerated with the duration of dialysis therapy, especially in those treated for 30 years or more. The rate of parathyroidectomy for secondary hyperparathyroidism was performed for 37.5% in 22.1 ± 2.1 years after the initiation of dialysis treatment in the patients treated for 30 years or more. Mean age at the initiation of dialysis therapy was 27.3 ± 8.0 years, and primary cause of CKD was mainly chronic glomerulonephritis in the patients undergoing dialysis therapy for 30 years or more. Conclusion: CKD stage 5D patients undergoing dialysis therapy for 30 years or more survive with characteristics of younger age at initiation of dialysis therapy, chronic glomerulonephritis as a primary cause of CKD, and serious complication of osteoarticular disorders.Correspondence to:
S. Yamamoto, MD; Division of Clinical Nephrology and Rheumatology, Niigata University, Graduate School of Medical and Dental Science, 1-757, Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan
Email: yamamots@med.niigata-u.ac.jp
S. Yamamoto1, J.J. Kazama1, H. Maruyama2, S. Nishi3, I. Narita1 and F. Gejyo1
1Division of Clinical Nephrology and Rheumatology, 2Department of Clinical Nephroscience, 3Department of Blood Purification Center, Niigata University Medical and Dental Hospital, Niigata, Japan Aims: Increasing numbers of patients are undergoing long-term dialysis therapy. It is crucial for their quality of life to overcome dialysis-related complications, such as dialysis-related amyloidosis (DRA) and other osteoarticular disorder. The aim of the study was to investigate the characteristics, such as dialysis-related complications, in chronic kidney disease (CKD) Stage 5D patients undergoing dialysis therapy for more than 30 years or more. Methods: From 2003 to 2006, 359 CKD Stage 5D patients who were admitted to a single tertiary-care center. The age and the duration of dialysis therapy, the purpose for hospital admission, and history of osteoarticular disorder, such as carpal tunnel syndrome (CTS), destructive spondyloarthropathy (DSA) and joint arthropathy, were studied. Results: The proportions of the patients undergoing dialysis therapy for 20 – 24, 25 – 29 years and 30 years or more were 8.9, 5.6, and 4.5% of all admitted patients, respectively. DSA was a major cause of hospital admissions in long-term dialysis patients, especially in those treated for 30 years or more. The rate of surgery for osteoarticular disorder, such as CTS, DSA and joint arthropathy, which may show the presence of DRA, was 25.0, 66.0 and 77.8% in 20 – 24 years, 25 – 29 years and 30 years or more after the initiation of dialysis therapy, respectively. The frequency and severity of osteoarticular disorder accelerated with the duration of dialysis therapy, especially in those treated for 30 years or more. The rate of parathyroidectomy for secondary hyperparathyroidism was performed for 37.5% in 22.1 ± 2.1 years after the initiation of dialysis treatment in the patients treated for 30 years or more. Mean age at the initiation of dialysis therapy was 27.3 ± 8.0 years, and primary cause of CKD was mainly chronic glomerulonephritis in the patients undergoing dialysis therapy for 30 years or more. Conclusion: CKD stage 5D patients undergoing dialysis therapy for 30 years or more survive with characteristics of younger age at initiation of dialysis therapy, chronic glomerulonephritis as a primary cause of CKD, and serious complication of osteoarticular disorders.Correspondence to:
S. Yamamoto, MD; Division of Clinical Nephrology and Rheumatology, Niigata University, Graduate School of Medical and Dental Science, 1-757, Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan
Email: yamamots@med.niigata-u.ac.jp
Original
CRP measurement: does the assay matter in hemodialysis patients?
N. Kanaan, E. Goffin, D. Maisin, J. Struyven and M. Jadoul
503
24$
Abstract
Background: The serum level of C-reactive protein, an acute-phase marker of systemic inflammation, has been shown to predict cardiovascular events in the general population and cardiovascular and total mortality in hemodialysis patients. High-sensitivity CRP assays (hs-CRP) have been used in numerous studies. We hypothesized that the level of CRP as measured by the conventional assay (c-CRP) would predict mortality in hemodialysis patients with an accuracy similar to that of high-sensitivity assays. Methods: In April 2001 CRP serum level was measured with both a conventional and a high-sensitivity assay in 102 prevalent hemodialysis patients. Mortality was prospectively monitored over 6 years. Results: 49 patients (48%) died during follow-up. With both assays, almost 2/3 of patients had high CRP levels (> 1 mg/dl). Survival at 6 years was significantly lower in patients with high CRP levels, no matter which assay was used (31.5% for patients with high hs-CRP and 27.3% for patients with high c-CRP vs 48.4% for patients with low hs-CRP and 47.1% for patients with low c-CRP). Cardiovascular mortality was also higher in patients with high CRP levels, whatever the type of assay (conventional or high sensitivity) used. The correlation between the two tests was excellent. Conclusion: CRP level, measured by a conventional inexpensive assay, is predictive of mortality in hemodialysis patients.Correspondence to:
Dr. N. Kanaan; Department of Nephrology, Cliniques Universitaires, St. Luc, Université Catholique de Louvain, 10, Av. Hippocrate, 1200 Brussels, Belgium
Email: nada.Kanaan@uclouvain.be
N. Kanaan1, E. Goffin1, D. Maisin2, J. Struyven1 and M. Jadoul1
1Department of Nephrology, 2Department of Clinical Biology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium Background: The serum level of C-reactive protein, an acute-phase marker of systemic inflammation, has been shown to predict cardiovascular events in the general population and cardiovascular and total mortality in hemodialysis patients. High-sensitivity CRP assays (hs-CRP) have been used in numerous studies. We hypothesized that the level of CRP as measured by the conventional assay (c-CRP) would predict mortality in hemodialysis patients with an accuracy similar to that of high-sensitivity assays. Methods: In April 2001 CRP serum level was measured with both a conventional and a high-sensitivity assay in 102 prevalent hemodialysis patients. Mortality was prospectively monitored over 6 years. Results: 49 patients (48%) died during follow-up. With both assays, almost 2/3 of patients had high CRP levels (> 1 mg/dl). Survival at 6 years was significantly lower in patients with high CRP levels, no matter which assay was used (31.5% for patients with high hs-CRP and 27.3% for patients with high c-CRP vs 48.4% for patients with low hs-CRP and 47.1% for patients with low c-CRP). Cardiovascular mortality was also higher in patients with high CRP levels, whatever the type of assay (conventional or high sensitivity) used. The correlation between the two tests was excellent. Conclusion: CRP level, measured by a conventional inexpensive assay, is predictive of mortality in hemodialysis patients.Correspondence to:
Dr. N. Kanaan; Department of Nephrology, Cliniques Universitaires, St. Luc, Université Catholique de Louvain, 10, Av. Hippocrate, 1200 Brussels, Belgium
Email: nada.Kanaan@uclouvain.be
Original
Brain natriuretic peptide variations are linked to volume status in hemodialysis patients
S. Roueff, E. Martin, M.-L. Chauffert, I. Poli, K. Kihal, F. Yazbeck, A. Abbassi and M. Saint-Georges
508
28$
Abstract
Aims: To evaluate the usefulness of monthly brain natriuretic peptide (BNP) dosage in assessing dry weight in hemodialysis patients. Patients and methods: Over a 2-year period, we performed in 46 hemodialysis patients monthly BNP level measurements, and adapted dry weight following the determination of variations in BNP concentrations for each month during the study period. Then we tested our approach by looking for a statistical relation between monthly alterations in BNP levels and monthly variations in the patients’ weight, blood pressure, hemoglobinemia and albuminemia which are in themselves related to fluid status variations. Results: Monthly BNP level variations were found to be positively correlated with monthly end-dialysis weight alterations (r = +0.24, p < 0.001), with monthly systolic and diastolic blood pressure variations before dialysis (r = +0.09, p < 0.001; r = +0.24, p < 0.001), and with systolic and diastolic blood pressure changes after dialysis (r = +0.09, p = 0.001; r = +0.25, p < 0.001). Moreover, monthly BNP level variations were negatively correlated with monthly hemoglobinemia changes (r = –0.17, p = 0.004) and with monthly albuminemia alterations (r = –0.14, p = 0.001). Conclusion: In a non-selected population of hemodialysis patients it was found that monthly BNP level variations were positively correlated with monthly volume status alterations as evaluated by clinical and biological criteria. BNP appears to be a useful tool for dry weight assessment despite the absence of a standardized cut-off point for BNP levels in hemodialysis patients.Correspondence to:
S. Roueff; Centre de Traitement de l’Insuffisance Rénale Chronique, Hôpital National de Saint Maurice, 14 rue du Val d'Osne, 94415 Saint Maurice, France
Email: s.roueff@hopital-saint-maurice.fr
S. Roueff1, E. Martin2, M.-L. Chauffert3, I. Poli1, K. Kihal1, F. Yazbeck1, A. Abbassi1 and M. Saint-Georges1
1Centre de Traitement de l’Insuffisance Rénale Chronique, Hôpital National de Saint Maurice, 2Unité de Recherche Clinique. Hôpital Henri Mondor AP-HP, Créteil, 3Laboratoire de Biologie, Hôpital National de Saint Maurice, St. Maurice, France Aims: To evaluate the usefulness of monthly brain natriuretic peptide (BNP) dosage in assessing dry weight in hemodialysis patients. Patients and methods: Over a 2-year period, we performed in 46 hemodialysis patients monthly BNP level measurements, and adapted dry weight following the determination of variations in BNP concentrations for each month during the study period. Then we tested our approach by looking for a statistical relation between monthly alterations in BNP levels and monthly variations in the patients’ weight, blood pressure, hemoglobinemia and albuminemia which are in themselves related to fluid status variations. Results: Monthly BNP level variations were found to be positively correlated with monthly end-dialysis weight alterations (r = +0.24, p < 0.001), with monthly systolic and diastolic blood pressure variations before dialysis (r = +0.09, p < 0.001; r = +0.24, p < 0.001), and with systolic and diastolic blood pressure changes after dialysis (r = +0.09, p = 0.001; r = +0.25, p < 0.001). Moreover, monthly BNP level variations were negatively correlated with monthly hemoglobinemia changes (r = –0.17, p = 0.004) and with monthly albuminemia alterations (r = –0.14, p = 0.001). Conclusion: In a non-selected population of hemodialysis patients it was found that monthly BNP level variations were positively correlated with monthly volume status alterations as evaluated by clinical and biological criteria. BNP appears to be a useful tool for dry weight assessment despite the absence of a standardized cut-off point for BNP levels in hemodialysis patients.Correspondence to:
S. Roueff; Centre de Traitement de l’Insuffisance Rénale Chronique, Hôpital National de Saint Maurice, 14 rue du Val d'Osne, 94415 Saint Maurice, France
Email: s.roueff@hopital-saint-maurice.fr
Case Report
Nephrogenic systemic fibrosis: the first Italian gadolinium-proven case
S. Bainotti, E. Rota, M. Bertrero, O. Tamburrini, A. Balducci and M. Formica,
514
20$
Abstract
Nephrogenic systemic fibrosis (NSF) is a systemic disease, recently described in patients with advanced chronic kidney disease (CKD), characterized by progressive scleromyxedema-like fibrotic involvement mainly of the skin. We describe the case of a 66-year-old woman on chronic hemodialysis for end-stage renal failure, also affected by hypothyroidism, secondary hyperparathyroidism and occluding arteriopathy, for which she underwent a contrast-enhanced magnetic resonance angiography of the lower limbs in February 2007. One month later, she began complaining of progressive, painful distal lower limb stiffness, which subsequently spread to all four limbs and to the whole trunk. A deep-skin biopsy, taken from an affected area, showed gadolinium deposits. The case reported is, to best of our knowledge, the first Italian case of NSF. This diagnosis should be considered with care in CKD patients with a recent exposure to a gadolinium-based contrast agent, complaining of limb stiffness, especially in the presence of risk factors.Correspondence to:
Dr. M. Formica; S.C. Nefrologia e Dialisi, Via S. Bernardino 4, 12076 Ceva (CN), Italy
Email: mformica@asl16.sanitacn.it
S. Bainotti1, E. Rota2, M. Bertrero3, O. Tamburrini4, A. Balducci5 and M. Formica1,6
1Nephrology Department, Ceva Hospital, Ceva, 2Neurology Department, S. Croce Hospital, Mondovì, 3Dermatology Department, S. Croce e Carle Hospital, Cuneo, 4Radiology Department, University “Magna Grecia”, Catanzaro, 5Nephrology Department, S. Giovanni-Addolorata Hospital, Roma, 6Nephrology Department, S. Croce e Carle Hospital, Cuneo, Italy Nephrogenic systemic fibrosis (NSF) is a systemic disease, recently described in patients with advanced chronic kidney disease (CKD), characterized by progressive scleromyxedema-like fibrotic involvement mainly of the skin. We describe the case of a 66-year-old woman on chronic hemodialysis for end-stage renal failure, also affected by hypothyroidism, secondary hyperparathyroidism and occluding arteriopathy, for which she underwent a contrast-enhanced magnetic resonance angiography of the lower limbs in February 2007. One month later, she began complaining of progressive, painful distal lower limb stiffness, which subsequently spread to all four limbs and to the whole trunk. A deep-skin biopsy, taken from an affected area, showed gadolinium deposits. The case reported is, to best of our knowledge, the first Italian case of NSF. This diagnosis should be considered with care in CKD patients with a recent exposure to a gadolinium-based contrast agent, complaining of limb stiffness, especially in the presence of risk factors.Correspondence to:
Dr. M. Formica; S.C. Nefrologia e Dialisi, Via S. Bernardino 4, 12076 Ceva (CN), Italy
Email: mformica@asl16.sanitacn.it
Case Report
Gadolinium nephrotoxicity: case report of a rare entity and review of the literature
O.J. Badero, L. Schlanger and D. Rizk
518
24$
Abstract
Radiocontrast exposure has now become an important cause of iatrogenic acute kidney injury (AKI) in hospitalized patients due to an increase in the number of diagnostic and interventional procedures done. Gadolinium, a well-known paramagnetic contrast agent used primarily for magnetic resonance imaging (MRI), has attracted a lot of attention for its safety in patients at risk for AKI, namely those with chronic kidney disease (CKD) and diabetes. Since its widespread use, a few cases of gadolinium nephrotoxicity have been reported in the literature. However, this remains a largely unrecognized complication in the field of nephrology. Here we describe such a case of AKI due to gadolinium toxicity in a 65-year-old African-American man with a history of hypertension, diabetes and chronic kidney disease, who was admitted for a toe infection and consequently developed AKI from multiple imaging studies involving the use of gadolinium.Correspondence to:
O.J. Badero, MD; SUNY Downstate Medical Center, 450 Clarkson Ave Box 50, Brooklyn, NY 11203, USA
Email: timibade@yahoo.com
O.J. Badero, L. Schlanger and D. Rizk
Division of Nephrology, Emory University School of Medicine, Atlanta, GA, USA Radiocontrast exposure has now become an important cause of iatrogenic acute kidney injury (AKI) in hospitalized patients due to an increase in the number of diagnostic and interventional procedures done. Gadolinium, a well-known paramagnetic contrast agent used primarily for magnetic resonance imaging (MRI), has attracted a lot of attention for its safety in patients at risk for AKI, namely those with chronic kidney disease (CKD) and diabetes. Since its widespread use, a few cases of gadolinium nephrotoxicity have been reported in the literature. However, this remains a largely unrecognized complication in the field of nephrology. Here we describe such a case of AKI due to gadolinium toxicity in a 65-year-old African-American man with a history of hypertension, diabetes and chronic kidney disease, who was admitted for a toe infection and consequently developed AKI from multiple imaging studies involving the use of gadolinium.Correspondence to:
O.J. Badero, MD; SUNY Downstate Medical Center, 450 Clarkson Ave Box 50, Brooklyn, NY 11203, USA
Email: timibade@yahoo.com
Case Report
Acute renal and hepatic failure associated with allopurinol treatment
R.M. Fagugli, G. Gentile, G. Ferrara and R. Brugnano
523
20$
Abstract
Hyperuricemia is present in about 5% of the population, and allopurinol is frequently used to treat it. The use of this drug can be associated with a number of side effects, indicating allergic reactions, such as skin rash, reversible after its withdrawal. In some cases more severe hypersensitivity reactions may be seen, such as erythema multiforme exudativum, or Steven-Johnson Syndrome (SJS). Reversible clinical hepatotoxicity, as well as acute renal failure, may also develop after allopurinol therapy. We describe here the case of a 74-year-old woman with chronic renal failure who was admitted to hospital after 1week of sore throat and fever, presenting mucous membrane lesions, widespread blistering of the skin, evolving to flaccid vesicles and bullae, and extensive epidermal detachment associated with acute renal failure and cholestatic jaundice. A diagnosis of allopurinol-induced toxic epidermal necrolysis (TEN) was established. Allopurinol was discontinued, and intensive care management was required: the patient was successfully treated by using intravenous immunoglobulin (IVIg), standard hemodialysis, and albumin dialysis (Molecular Adsorbents Recirculating System – MARS, Teraklin AG, Rostock, Germany). Allopurinol-induced TEN is extremely rare, however, the survival rate is extremely low. Clinicians should be aware of this potentially severe adverse effect. This report emphasizes the importance of an aggressive pharmacological and dialysis treatment in the case of TEN.Correspondence to:
Dr. R.M. Fagugli; S.C. Nefrologia e Dialisi, Ospedale Silvestrini, Azienda Ospedaliera di Perugia, 06100 Perugia, Italy
Email: rmfag@fastwebnet.it
R.M. Fagugli, G. Gentile, G. Ferrara and R. Brugnano
S.C. Nefrologia e Dialisi, Azienda Ospedaliera di Perugia, Italy Hyperuricemia is present in about 5% of the population, and allopurinol is frequently used to treat it. The use of this drug can be associated with a number of side effects, indicating allergic reactions, such as skin rash, reversible after its withdrawal. In some cases more severe hypersensitivity reactions may be seen, such as erythema multiforme exudativum, or Steven-Johnson Syndrome (SJS). Reversible clinical hepatotoxicity, as well as acute renal failure, may also develop after allopurinol therapy. We describe here the case of a 74-year-old woman with chronic renal failure who was admitted to hospital after 1week of sore throat and fever, presenting mucous membrane lesions, widespread blistering of the skin, evolving to flaccid vesicles and bullae, and extensive epidermal detachment associated with acute renal failure and cholestatic jaundice. A diagnosis of allopurinol-induced toxic epidermal necrolysis (TEN) was established. Allopurinol was discontinued, and intensive care management was required: the patient was successfully treated by using intravenous immunoglobulin (IVIg), standard hemodialysis, and albumin dialysis (Molecular Adsorbents Recirculating System – MARS, Teraklin AG, Rostock, Germany). Allopurinol-induced TEN is extremely rare, however, the survival rate is extremely low. Clinicians should be aware of this potentially severe adverse effect. This report emphasizes the importance of an aggressive pharmacological and dialysis treatment in the case of TEN.Correspondence to:
Dr. R.M. Fagugli; S.C. Nefrologia e Dialisi, Ospedale Silvestrini, Azienda Ospedaliera di Perugia, 06100 Perugia, Italy
Email: rmfag@fastwebnet.it
Case Report
Membranoproliferative glomerulonephritis and light-chain nephropathy in association with chronic lymphocytic leukemia
R. Mutluay, S. Zeynep Aki, Y. Erten, C. Konca, M. Yagci, G. Barit and S. Sindel
527
24$
Abstract
The incidence of nephrotic syndrome co-existing with chronic lymphocytic leukemia (CLL) is a rare condition. Almost any glomerular pathology may accompany CLL. The most frequent of all is membranoproliferative glomerulonephritis (MPGN). Moreover, in 5 – 10% of patients with CLL, monoclonal gammopathy may be detected in serum and/or urine samples. There are no well-established treatment protocols for those CLL patients with accompanying nephrotic syndrome. In this case report, we present a 55-year-old female patient diagnosed with CLL, developing nephrotic syndrome, renal dysfunction and IgG k-type monoclonal gammopathy in the follow-up. The renal biopsy revealed glomerular and tubular deposits of k-chain and histopathology of membranoproliferative glomerulonephritis. Rituximab along with CVP (cyclophosphamide – vincristine – prednisolone) chemotherapy regimen was initiated. At the end of 6 courses of treatment, the patient was on “nephrologic” partial remission as the serum creatinine and albumin levels had returned to normal and proteinuria decreased by more than 50%. The patient was also in partial remission for CLL. In conclusion, in patients with CLL and nephrotic syndrome, presence of MPGN along with light-chain nephropathy is rarely reported. Several different treatment protocols are discussed for these patients. Among these regimes, R-CVP is an acceptable alternative for CLL patients with MPGN.Correspondence to:
Dr. C. Konca; Gazi University Faculty of Medicine, Department of Internal Medicine, Gazi Üniversitesi Hastanesi Ic Hastaliklari ABD, 06500 Besevler Ankara, Turkey
Email: ceylakonca@hotmail.com
R. Mutluay1, S. Zeynep Aki2, Y. Erten1, C. Konca3, M. Yagci2, G. Barit4 and S. Sindel1
1Department of Nephrology, 2Department of Hematology, 3Department of Internal Medicine, and 4Department of Pathology, Faculty of Medicine, Gazi University, Besevler Ankara, Turkey The incidence of nephrotic syndrome co-existing with chronic lymphocytic leukemia (CLL) is a rare condition. Almost any glomerular pathology may accompany CLL. The most frequent of all is membranoproliferative glomerulonephritis (MPGN). Moreover, in 5 – 10% of patients with CLL, monoclonal gammopathy may be detected in serum and/or urine samples. There are no well-established treatment protocols for those CLL patients with accompanying nephrotic syndrome. In this case report, we present a 55-year-old female patient diagnosed with CLL, developing nephrotic syndrome, renal dysfunction and IgG k-type monoclonal gammopathy in the follow-up. The renal biopsy revealed glomerular and tubular deposits of k-chain and histopathology of membranoproliferative glomerulonephritis. Rituximab along with CVP (cyclophosphamide – vincristine – prednisolone) chemotherapy regimen was initiated. At the end of 6 courses of treatment, the patient was on “nephrologic” partial remission as the serum creatinine and albumin levels had returned to normal and proteinuria decreased by more than 50%. The patient was also in partial remission for CLL. In conclusion, in patients with CLL and nephrotic syndrome, presence of MPGN along with light-chain nephropathy is rarely reported. Several different treatment protocols are discussed for these patients. Among these regimes, R-CVP is an acceptable alternative for CLL patients with MPGN.Correspondence to:
Dr. C. Konca; Gazi University Faculty of Medicine, Department of Internal Medicine, Gazi Üniversitesi Hastanesi Ic Hastaliklari ABD, 06500 Besevler Ankara, Turkey
Email: ceylakonca@hotmail.com
Case Report
Simultaneous acute nephrosis and hepatitis in secondary syphilis
Y.-C. Tsai, L.-I. Chen and H.-C. Chen,
532
24$
Abstract
Simultaneous occurrence of acute nephrosis and hepatitis in secondary syphilis is rare. We report a 24-year-old man who presented with sudden onset of nephrotic syndrome, acute hepatitis, and skin lesions associated with secondary syphilis. A renal biopsy demonstrated electron-dense deposits located in the subepithelial, mesangial and intramembranous areas under electron microscopy. Light microscopy revealed a mild increase in mesangial matrix with normal glomerular cellularity. Immunofluorescent examination showed granular deposition of IgG and IgA along the glomerular capillary basement membrane without deposits of complements. These morphological changes differed from those reported previously. All, the heavy proteinuria, disturbances of liver function, and skin lesions resolved after 4-week treatment.Correspondence to:
H.-C. Chen, MD; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University, Hospital, 100 Tzyou First Road, Kaohsiung, Taiwan
Email: chenhc@kmu.edu.tw
Y.-C. Tsai1, L.-I. Chen1 and H.-C. Chen1,2
1Department of Internal Medicine, Division of Nephrology and 2Faculty of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan Simultaneous occurrence of acute nephrosis and hepatitis in secondary syphilis is rare. We report a 24-year-old man who presented with sudden onset of nephrotic syndrome, acute hepatitis, and skin lesions associated with secondary syphilis. A renal biopsy demonstrated electron-dense deposits located in the subepithelial, mesangial and intramembranous areas under electron microscopy. Light microscopy revealed a mild increase in mesangial matrix with normal glomerular cellularity. Immunofluorescent examination showed granular deposition of IgG and IgA along the glomerular capillary basement membrane without deposits of complements. These morphological changes differed from those reported previously. All, the heavy proteinuria, disturbances of liver function, and skin lesions resolved after 4-week treatment.Correspondence to:
H.-C. Chen, MD; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University, Hospital, 100 Tzyou First Road, Kaohsiung, Taiwan
Email: chenhc@kmu.edu.tw
Case Report
Aristolochic acid nephropathy due to herbal drug intake manifested differently as Fanconi’s syndrome and end-stage renal failure – a 7-year follow-up
P.-I. Kong, Y.-W. Chiu, M.-C. Kuo, S.-C. Chen, J.-M. Chang, J.-C. Tsai, S.-J. Hwang, and H.-C. Chen,
537
24$
Abstract
Aristolochic acid (AA) may reduce glomerular or proximal tubular function, or both. We report a married couple taking AA-containing herbal drugs. The man developed Fanconi’s syndrome (FS) whereas his wife reached end-stage renal failure (ESRF). He was a 36-year-old alcoholic cirrhotic patient who had taken the Chinese herbal drugs for 6 years, presenting with muscle weakness and laboratory findings of FS; the renal pathological findings were compatible with the diagnosis of aristolochic acid nephropathy (AAN). His 38-year-old wife, who took a lower cumulative amount of the same herbal drug for a shorter duration, developed advanced renal failure and severe anemia with pathological findings of extensive tubular atrophy, interstitial fibrosis but spared glomeruli. AA-I was detected in one of the herbal drugs. The wife has been on hemodialysis for 7 years, but the husband is still at the stage of slowly progressive chronic renal failure and persistent FS. None of their 5 children ever took the herbal drug, and none had renal problems during follow-up. It is important to trace the history of herbal drug intake in all the family members because of the possibility of sharing of drugs within a family. In addition to the effect of cumulative doses of AAs and the potentially higher susceptibility of females to AAN, the roles of liver cirrhosis and related vasodilators in the protection of the renal interstitium from fibrosis are questions that warrant further study.Correspondence to:
S.-J. Hwang, MD; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
Email: sjhwang@kmu.edu.tw
P.-I. Kong1, Y.-W. Chiu1, M.-C. Kuo1,3, S.-C. Chen2, J.-M. Chang2,3, J.-C. Tsai1,3, S.-J. Hwang1,3 and H.-C. Chen1,3
1Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, 2Department of Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, and 3Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan Aristolochic acid (AA) may reduce glomerular or proximal tubular function, or both. We report a married couple taking AA-containing herbal drugs. The man developed Fanconi’s syndrome (FS) whereas his wife reached end-stage renal failure (ESRF). He was a 36-year-old alcoholic cirrhotic patient who had taken the Chinese herbal drugs for 6 years, presenting with muscle weakness and laboratory findings of FS; the renal pathological findings were compatible with the diagnosis of aristolochic acid nephropathy (AAN). His 38-year-old wife, who took a lower cumulative amount of the same herbal drug for a shorter duration, developed advanced renal failure and severe anemia with pathological findings of extensive tubular atrophy, interstitial fibrosis but spared glomeruli. AA-I was detected in one of the herbal drugs. The wife has been on hemodialysis for 7 years, but the husband is still at the stage of slowly progressive chronic renal failure and persistent FS. None of their 5 children ever took the herbal drug, and none had renal problems during follow-up. It is important to trace the history of herbal drug intake in all the family members because of the possibility of sharing of drugs within a family. In addition to the effect of cumulative doses of AAs and the potentially higher susceptibility of females to AAN, the roles of liver cirrhosis and related vasodilators in the protection of the renal interstitium from fibrosis are questions that warrant further study.Correspondence to:
S.-J. Hwang, MD; Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, 100 Tzyou 1st Road, Kaohsiung 807, Taiwan
Email: sjhwang@kmu.edu.tw
Case Report
A case of disseminated Nocardia farcinica diagnosed through DNA sequencing in a kidney transplantation patient
B.S. Park, Y.J. Park, Y.J. Kim, S.W. Kang, Y.H. Kim, J.H. Shin, Y.C. Yoon and Y.W. Kim
542
20$
Abstract
Nocardia is a rare gram-positive bacteria causing opportunistic infection, and belongs to the aerobic Actinomycetes group. As the mortality in the immunocompromised patients with nocardiosis is high, early diagnosis and treatment is very important. However, clinical manifestations of infection caused by Nocardia are very variable and early diagnosis is limited by the difficulty in obtaining specimens and its isolation. Rapid diagnosis of Nocardia infection may allow for earlier effective therapy, thus improving patient outcome. We report a case of Nocardia farcinica diagnosed by DNA sequencing through blood culture in a renal transplant recipient with severe pneumonia and multiple brain abscesses.Correspondence to:
Y.W. Kim, MD, PhD; Deparment of Medicine, Busan Paik Hospital, School of Medicine, Inje University, Inje University School of Medicine, Gaegeum 2-dong, Busanjin-gu, Busan, 614-735, Korea
Email: Kyw8625@chol.com
B.S. Park1, Y.J. Park1, Y.J. Kim1, S.W. Kang1, Y.H. Kim1, J.H. Shin2, Y.C. Yoon3 and Y.W. Kim1
Department of 1Internal Medicine, 2Laboratory Medicine and 3Chest Surgery, School of Medicine, Inje University, Busan, South Korea Nocardia is a rare gram-positive bacteria causing opportunistic infection, and belongs to the aerobic Actinomycetes group. As the mortality in the immunocompromised patients with nocardiosis is high, early diagnosis and treatment is very important. However, clinical manifestations of infection caused by Nocardia are very variable and early diagnosis is limited by the difficulty in obtaining specimens and its isolation. Rapid diagnosis of Nocardia infection may allow for earlier effective therapy, thus improving patient outcome. We report a case of Nocardia farcinica diagnosed by DNA sequencing through blood culture in a renal transplant recipient with severe pneumonia and multiple brain abscesses.Correspondence to:
Y.W. Kim, MD, PhD; Deparment of Medicine, Busan Paik Hospital, School of Medicine, Inje University, Inje University School of Medicine, Gaegeum 2-dong, Busanjin-gu, Busan, 614-735, Korea
Email: Kyw8625@chol.com
Case Report
Mycobacterium fortuitum infection in continuous ambulatory peritoneal dialysis
T. Hod, R. Kushnir, Y. Paitan and Z. Korzets
546
36$
Abstract
Mycobacterium fortuitum group species is an atypical rapidly growing nontuberculous mycobacterium. It has been increasingly recognized as a potential pathogen mostly encountered in skin and soft tissue infections. Rarely, however, it has been associated with catheter-related infections, either central venous lines or peritoneal dialysis catheters. In this report we describe 2 patients maintained on continuous ambulatory peritoneal dialysis who developed Mycobacterium fortuitum peritonitis and a catheter tunnel abscess, respectively. Molecular biology identification of the isolates was performed in both cases. The literature is reviewed regarding all similar cases.Correspondence to:
Dr. Y. Paitan; Clinical Microbiology Laboratory
Meir Medical Center, 59 Tshernichovski, Kfar Saba, Israel 44281
Email: yossi.paitan@clalit.org.il
T. Hod2, R. Kushnir1, Y. Paitan1 and Z. Korzets2
1Clinical Microbiology Laboratory, 2Department of Nephrology and Hypertension, Meir Medical Center, Kfar-Saba, Israel Mycobacterium fortuitum group species is an atypical rapidly growing nontuberculous mycobacterium. It has been increasingly recognized as a potential pathogen mostly encountered in skin and soft tissue infections. Rarely, however, it has been associated with catheter-related infections, either central venous lines or peritoneal dialysis catheters. In this report we describe 2 patients maintained on continuous ambulatory peritoneal dialysis who developed Mycobacterium fortuitum peritonitis and a catheter tunnel abscess, respectively. Molecular biology identification of the isolates was performed in both cases. The literature is reviewed regarding all similar cases.Correspondence to:
Dr. Y. Paitan; Clinical Microbiology Laboratory
Meir Medical Center, 59 Tshernichovski, Kfar Saba, Israel 44281
Email: yossi.paitan@clalit.org.il
Case Report
The position of the peritoneal dialysis catheter is not essential for a correct performance
R. Palomar, P. Morales, A. Domínguez-Diez, L. Martín, A.L. Martín de Francisco and M. Arias
554
20$
Abstract
The success of chronic peritoneal dialysis (PD) is a well-functioning catheter. It is recommended to place the tip of PD access in the intraabdominal deep pelvic area. The authors’ objectives were to prove if the PD device should be necessarily located in the pelvic area to function properly, and if the X-ray exploration should be compulsory when blinded implantation technique is used. 42 stable patients on PD were included in the study, infusion and drainage times were recorded and an abdominal X-ray was performed at the same time. Catheter was correctly located in 25 (59.5%) cases and in 17 (40.5%) it was malpositioned. We observed that there were no differences in infusion times, but in the first group drainage was faster than in the second although not significant: infusion 10.5 vs. 10.6 minutes and drainage 14.7 vs. 15.8 minutes. These clinical observations support the fact that catheters’ function would not necessarily depend on its intraabdominal position and that a radiological exploration should not be mandatory.Correspondence to:
R. Palomar, MD; Nephrology Department, Valdecilla University Hospital, Avenida Marques de Valdecilla s/n. 39008 Santander, Spain
Email: nefpfm@humv.es
R. Palomar1, P. Morales1, A. Domínguez-Diez2, L. Martín1, A.L. Martín de Francisco1 and M. Arias1
1Nephrology and General 2Surgery Departments, Valdecilla Universitary Hospital, Santander, Spain The success of chronic peritoneal dialysis (PD) is a well-functioning catheter. It is recommended to place the tip of PD access in the intraabdominal deep pelvic area. The authors’ objectives were to prove if the PD device should be necessarily located in the pelvic area to function properly, and if the X-ray exploration should be compulsory when blinded implantation technique is used. 42 stable patients on PD were included in the study, infusion and drainage times were recorded and an abdominal X-ray was performed at the same time. Catheter was correctly located in 25 (59.5%) cases and in 17 (40.5%) it was malpositioned. We observed that there were no differences in infusion times, but in the first group drainage was faster than in the second although not significant: infusion 10.5 vs. 10.6 minutes and drainage 14.7 vs. 15.8 minutes. These clinical observations support the fact that catheters’ function would not necessarily depend on its intraabdominal position and that a radiological exploration should not be mandatory.Correspondence to:
R. Palomar, MD; Nephrology Department, Valdecilla University Hospital, Avenida Marques de Valdecilla s/n. 39008 Santander, Spain
Email: nefpfm@humv.es
Case Report
Induction of continuous ambulatory peritoneal dialysis after retroperitoneoscopic nephrectomy
A. Mima, A. Kanematsu, T. Matsubara, N. Iehara, T. Kita and A. Fukatsu
558
16$
Abstract
Induction of continuous ambulatory peritoneal dialysis (CAPD) as treatment of end-stage renal disease is difficult for patients requiring nephrectomy with traditional surgery, and usually hemodialysis is selected for these patients. In a 61-year-old woman with end-stage renal failure a left renal tumor was diagnosed by abdominal ultrasonography, enhanced computed tomography and magnetic resonance imaging. Following an urology consultation, we decided to perform left kidney nephrectomy. We estimated that she had to undergo dialysis permanently after nephrectomy. She desired to be treated by CAPD, however, we decided after allowing for a postoperative period for complete healing of the peritoneum to avoid complications. This is why during the interim period between surgery and induction of CAPD she underwent hemodialysis (HD) in a local outpatient HD center and in our hospital. We selected a retroperitoneoscopic approach for nephrectomy. Pathology evaluation revealed a renal cell carcinoma. 4 months after nephrectomy, CAPD catheter implantation was performed by using laparoscopy and CAPD was started. At the present time, the patient is doing well on CAPD. To our knowledge, there are no clear indications regarding initiation of peritoneal dialysis after nephrectomy. The retroperitoneoscopic approach for nephrectomy allows for initiation of peritoneal dialysis after nephrectomy within a relative short postoperative period.Correspondence to:
A. Mima, MD, PhD; Department of Nephrology, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
Email: amima@kuhp.kyoto-u.ac.jp
A. Mima1, A. Kanematsu2, T. Matsubara1, N. Iehara1, T. Kita3 and A. Fukatsu1
1Departments of Nephrology, 2Urology and 3Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan Induction of continuous ambulatory peritoneal dialysis (CAPD) as treatment of end-stage renal disease is difficult for patients requiring nephrectomy with traditional surgery, and usually hemodialysis is selected for these patients. In a 61-year-old woman with end-stage renal failure a left renal tumor was diagnosed by abdominal ultrasonography, enhanced computed tomography and magnetic resonance imaging. Following an urology consultation, we decided to perform left kidney nephrectomy. We estimated that she had to undergo dialysis permanently after nephrectomy. She desired to be treated by CAPD, however, we decided after allowing for a postoperative period for complete healing of the peritoneum to avoid complications. This is why during the interim period between surgery and induction of CAPD she underwent hemodialysis (HD) in a local outpatient HD center and in our hospital. We selected a retroperitoneoscopic approach for nephrectomy. Pathology evaluation revealed a renal cell carcinoma. 4 months after nephrectomy, CAPD catheter implantation was performed by using laparoscopy and CAPD was started. At the present time, the patient is doing well on CAPD. To our knowledge, there are no clear indications regarding initiation of peritoneal dialysis after nephrectomy. The retroperitoneoscopic approach for nephrectomy allows for initiation of peritoneal dialysis after nephrectomy within a relative short postoperative period.Correspondence to:
A. Mima, MD, PhD; Department of Nephrology, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
Email: amima@kuhp.kyoto-u.ac.jp
Letter to the Editor
Quality of life and tryptophan levels in chronic renal failure patients on hemodialysis
M. Viljoen, P. Bipath, C. Govender and C.D. Potgieter
561
12$
Abstract
M. Viljoen, P. Bipath, C. Govender and C.D. Potgieter
Letter to the Editor
Amiodarone-tacrolimus interaction in kidney transplantation
K. Kisters, M. Cziborra, C. Funke, S. Brylak and M. Hausberg
563
8$
Abstract
K. Kisters, M. Cziborra, C. Funke, S. Brylak and M. Hausberg
Erratum
564
8$
Abstract
