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Volume 71, No. 5/2009(May)
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Review
The evaluation of a successful home hemodialysis program: establishing a prospective framework for quality
P. Komenda, C. Chan, R.P. Pauly, A. Levin, M. Copland, A. Pierratos and M.M. Sood; The CAN-SLEEP investigators: CANadian Slow Long nightly ExtEnded dialysis Programs
467
36$
Abstract
A mounting body of clinical data and purported quality of life benefits has been primarily responsible for a renewed interest in programs providing longer more frequent home hemodialysis. As novel forms of home hemodialysis (HHD) like nocturnal (nightly) home hemodialysis (NHD) move from strictly the academic “experimental” arenas to potentially the preferred renal replacement modality for patients, it will be necessary for programs to plan and evaluate standardized metrics for program quality. This will be essential for smaller, less experienced centers to gauge their outcomes against larger, more established programs. Driven by market forces primarily in the United States, conventional hemodialysis programs have begun to explore optimal strategies for reporting quality of care in their respective dialysis centers. Extrapolating this to home hemodialysis modalities the question remains which criteria do we use as measures of quality? The evidence is limited to small, observational studies and one small randomized controlled trial. Extrapolating existing quality indices from conventional hemodialysis seems reasonable however may miss many of the true clinically significant advantages of HHD as a modality. Although definitive evidence does not yet exist for intensive home hemodialysis strategies, clearly clinicians, payers and patients are convinced enough of this approach for programs to justify the expansion of these modalities. We have laid the groundwork for the CANadian Slow Long nightly ExtEnded dialysis Programs (CAN-SLEEP), a multicenter cohort aimed to investigate the clinical and programmatic outcomes of NHD. This will allow for the assessment of numerous outcomes on a global scale for this state-of-the art dialysis modality in the form of a multidimensional programmatic evaluation.Correspondence to:
P. Komenda MD, FRCPC, MHA, CHE; St. Boniface General Hospital, 409 Tache Ave, BG007, Winnipeg, MB, R2H 3A6, Canada
Email: paulkomenda@yahoo.com
P. Komenda1, C. Chan2, R.P. Pauly3, A. Levin4, M. Copland4, A. Pierratos5 and M.M. Sood1; The CAN-SLEEP investigators: CANadian Slow Long nightly ExtEnded dialysis Programs
1Department of Medicine, Section of Nephrology, St. Boniface General Hospital, University of Manitoba, Manitoba Renal Program, Winnipeg, 2Department of Medicine, Section of Nephrology, Toronto General Hospital, University of Toronto, Toronto, 3Department of Medicine, Section of Nephrology, University of Alberta, Edmonton, 4Department of Medicine, Division of Nephrology, University of British Columbia, British Columbia Renal Agency, Vancouver, and 5Department of Nephrology, Humber River Regional Hospital, University of Toronto, Toronto, Canada A mounting body of clinical data and purported quality of life benefits has been primarily responsible for a renewed interest in programs providing longer more frequent home hemodialysis. As novel forms of home hemodialysis (HHD) like nocturnal (nightly) home hemodialysis (NHD) move from strictly the academic “experimental” arenas to potentially the preferred renal replacement modality for patients, it will be necessary for programs to plan and evaluate standardized metrics for program quality. This will be essential for smaller, less experienced centers to gauge their outcomes against larger, more established programs. Driven by market forces primarily in the United States, conventional hemodialysis programs have begun to explore optimal strategies for reporting quality of care in their respective dialysis centers. Extrapolating this to home hemodialysis modalities the question remains which criteria do we use as measures of quality? The evidence is limited to small, observational studies and one small randomized controlled trial. Extrapolating existing quality indices from conventional hemodialysis seems reasonable however may miss many of the true clinically significant advantages of HHD as a modality. Although definitive evidence does not yet exist for intensive home hemodialysis strategies, clearly clinicians, payers and patients are convinced enough of this approach for programs to justify the expansion of these modalities. We have laid the groundwork for the CANadian Slow Long nightly ExtEnded dialysis Programs (CAN-SLEEP), a multicenter cohort aimed to investigate the clinical and programmatic outcomes of NHD. This will allow for the assessment of numerous outcomes on a global scale for this state-of-the art dialysis modality in the form of a multidimensional programmatic evaluation.Correspondence to:
P. Komenda MD, FRCPC, MHA, CHE; St. Boniface General Hospital, 409 Tache Ave, BG007, Winnipeg, MB, R2H 3A6, Canada
Email: paulkomenda@yahoo.com
Original
Occult chronic kidney disease: discordance among different methods used to estimate glomerular filtration rate in a healthy population
M.P. Marco, S. Muray, J.M. Valdivielso and E. Fernández
475
32$
Abstract
Background: Chronic kidney disease is a widely recognized cardiovascular risk factor. Its detection within large populations depends upon the method used to estimate glomerular filtration. The Cockcroft and MDRD equations are widely used, although their accuracy is limited in certain cases. Methods: The present study analyzes glomerular filtration values in 674 young, healthy subjects using five methods: Cockcroft, Cockcroft corrected for body surface, MDRD-4 Lund-Malmö and Sawyer formulas. Glomerular filtration values obtained with the first three methods were compared using ANOVA. The Spearman coefficient was calculated to estimate the correlation between MDRD-4 and Cockcroft values, and between Cockcroft values and body mass index. Results: There was a slight glomerular filtration rate decrease (< 90 ml/min) seen in 394 subjects using the Cockcroft equation, and in 344 subjects using the MDRD-4 formula. The prevalence of chronic kidney disease (glomerular filtration < 60 ml/min) was seen in 3 subjects using the MDRD-4 equation and 161 subjects using the Cockcroft formula. There was significant discordance, by method, between values obtained, with 40% of the population being classified into different stages (> 90 or < 90 ml/min) depending on the formula used. In 8% of the population there was even greater discordance, because they had strictly normal renal function according to MDRD-4 (> 90 ml/min) but fell into chronic kidney disease Stage 3 (< 60 ml/min) according to the Cockcroft formula. There was poor correlation between glomerular filtration rates obtained using the Cockcroft and MDRD-4 equations, suggesting that the subjects with a glomerular filtration rate decrease detected by the two methods were not the same ones. There was correlation between body mass index and glomerular filtration rates obtained with Cockcroft, Cockcroft corrected for body surface and Sawyer formulas and not with MDRD and Lund-Malmö equations. Conclusions: There are important discrepancies between the methods used to assess renal function in healthy populations. These limitations must be taken into account when deciding on strategies for diagnosis and control of occult chronic kidney disease in the general population.Correspondence to:
Dr. M. P. Marco Mayayo; Servicio de Nefrologia, Hospital Universitari Arnau de Vilanova, Rovira Roure 80, 25198 Lleida, Spain
Email: mmarco@arnau.scs.es
M.P. Marco1, S. Muray1, J.M. Valdivielso2 and E. Fernández1,2
1Nephrology Service, Hospital Universitari Arnau de Vilanova, and 2Universitat de Lleida, Lleida, Spain Background: Chronic kidney disease is a widely recognized cardiovascular risk factor. Its detection within large populations depends upon the method used to estimate glomerular filtration. The Cockcroft and MDRD equations are widely used, although their accuracy is limited in certain cases. Methods: The present study analyzes glomerular filtration values in 674 young, healthy subjects using five methods: Cockcroft, Cockcroft corrected for body surface, MDRD-4 Lund-Malmö and Sawyer formulas. Glomerular filtration values obtained with the first three methods were compared using ANOVA. The Spearman coefficient was calculated to estimate the correlation between MDRD-4 and Cockcroft values, and between Cockcroft values and body mass index. Results: There was a slight glomerular filtration rate decrease (< 90 ml/min) seen in 394 subjects using the Cockcroft equation, and in 344 subjects using the MDRD-4 formula. The prevalence of chronic kidney disease (glomerular filtration < 60 ml/min) was seen in 3 subjects using the MDRD-4 equation and 161 subjects using the Cockcroft formula. There was significant discordance, by method, between values obtained, with 40% of the population being classified into different stages (> 90 or < 90 ml/min) depending on the formula used. In 8% of the population there was even greater discordance, because they had strictly normal renal function according to MDRD-4 (> 90 ml/min) but fell into chronic kidney disease Stage 3 (< 60 ml/min) according to the Cockcroft formula. There was poor correlation between glomerular filtration rates obtained using the Cockcroft and MDRD-4 equations, suggesting that the subjects with a glomerular filtration rate decrease detected by the two methods were not the same ones. There was correlation between body mass index and glomerular filtration rates obtained with Cockcroft, Cockcroft corrected for body surface and Sawyer formulas and not with MDRD and Lund-Malmö equations. Conclusions: There are important discrepancies between the methods used to assess renal function in healthy populations. These limitations must be taken into account when deciding on strategies for diagnosis and control of occult chronic kidney disease in the general population.Correspondence to:
Dr. M. P. Marco Mayayo; Servicio de Nefrologia, Hospital Universitari Arnau de Vilanova, Rovira Roure 80, 25198 Lleida, Spain
Email: mmarco@arnau.scs.es
Original
Estimation of GFR by different creatinine- and cystatin-C-based equations in anorexia nervosa
P. Delanaye, E. Cavalier, R.P. Radermecker, N. Paquot, G. Depas, J.-P. Chapelle, A.J. Scheen and J.-M. Krzesinski
482
44$
Abstract
Background: Patients with anorexia nervosa (AN) are at high risk of renal failure. Glomerular filtration rate (GFR) is overestimated when estimated by the creatinine-based equations. We have studied the accuracy and precision of cystatin C-based equations. Method: 27 AN patients were included. GFR was measured with the chromium-51-ethylenediaminetetraacetate (51Cr-EDTA) method. We have compared the accuracy and precision of creatinine-based equations (MDRD and Cockcroft) with those of different new cystatin C-based equations. Results: The creatinine-based equations overestimate measured GFR, especially the MDRD study equation. All the cystatin C-based equations also overestimate measured GFR. The Cockcroft and Gault formula and the cystatin C-based equation published by Rule have the best accuracy and precision, but these last performances remain unsatisfactory. Conclusion: Both creatinine and cystatin C-based equations strongly overestimate measured in patients with AN.Correspondence to:
Pierre Delanaye, MD; Service de Dialyse, CHU Sart Tilman, 4000 Liège, Belgium
Email: pierre_delanaye@yahoo.fr
P. Delanaye1, E. Cavalier2, R.P. Radermecker3, N. Paquot3, G. Depas4, J.-P. Chapelle2, A.J. Scheen3 and J.-M. Krzesinski1
1Department of Nephrology-Dialysis, 2Department of Clinical Chemistry, 3Department of Diabetes, Nutrition and Metabolic Disorders, and 4Department of Nuclear Medicine, University of Liège, CHU Sart Tilman, Liège, Belgium Background: Patients with anorexia nervosa (AN) are at high risk of renal failure. Glomerular filtration rate (GFR) is overestimated when estimated by the creatinine-based equations. We have studied the accuracy and precision of cystatin C-based equations. Method: 27 AN patients were included. GFR was measured with the chromium-51-ethylenediaminetetraacetate (51Cr-EDTA) method. We have compared the accuracy and precision of creatinine-based equations (MDRD and Cockcroft) with those of different new cystatin C-based equations. Results: The creatinine-based equations overestimate measured GFR, especially the MDRD study equation. All the cystatin C-based equations also overestimate measured GFR. The Cockcroft and Gault formula and the cystatin C-based equation published by Rule have the best accuracy and precision, but these last performances remain unsatisfactory. Conclusion: Both creatinine and cystatin C-based equations strongly overestimate measured in patients with AN.Correspondence to:
Pierre Delanaye, MD; Service de Dialyse, CHU Sart Tilman, 4000 Liège, Belgium
Email: pierre_delanaye@yahoo.fr
Original
Renal tubular dysfunction in human visceral leishmaniasis (Kala-azar)
F. Agenor Araújo Lima Verde, F. Araújo Lima Verde, E. De Francesco Daher, G. Martins dos Santos, A. Saboia Neto, and E. Mendoça Lima Verde
492
40$
Abstract
Background: There are few studies about the functional tubular disturbances in human Kala-azar. The aim of this study was to investigate alterations in tubular reabsorption of urinary proteins, sodium, potassium, chloride, glucose, uric acid, inorganic phosphate and amino acids in patients with the chronic form of kala-azar. Patients and methods: This is a cross-sectional study of 55 patients with visceral leishmaniasis (Kala-azar). The laboratorial investigation was: creatinine clearance and daily urinary excretion of total proteins, albumin, IgG, beta2-microglobulin, sodium, potassium, chloride, calcium, inorganic phosphate, uric acid and glucose. Plasma and urinary protein electrophoresis were performed in agarose gel. Urinary light chains were determined by the nephelometric method and amino acids by chromatography. All data were compared to those of a control group. Results: Hypoalbuminemia, hypergammaglobulinemia as well as increased plasma levels of both IgG and beta2-microglobulins were found in all patients with Kala-azar. The mean urinary protein excretion was 277 ± 66 mg/day. Increased albumin excretion was observed in 44% of patients accounting for 17% of the total urinary protein excretion. Proteinuria consisted predominantly of low molecular weight protein fractions that migrated with alpha1, alpha2, beta and especially gamma globulins. Urinary beta2-microglobulin excretion was elevated in all patients. Immune electrophoresis showed increased urinary excretion rates of kappa (27%) and lampda (42%) light chains. The Bence-Jones test was positive in 20% of patients. Immunofixation was negative for monoclonal peak. The principal alterations were hyponatremia 94.6%, hypokalemia 26%, hypochloremia 27.2%, hypocalcemia 32%, hypomagnesemia 41.8%, hypouricemia 14.3%, Increased urinary excretion fraction were: sodium 15%, potassium 26%, chloride 33.3%, calcium 32%, inorganic phosphate 27.2%, magnesium 100% with hypermagnesiuria, uric acid 44%. Glucosuria was found in one third of patients. Conclusion: There was evidence of renal proximal tubular damage with alterations in the reabsorption of proteins and light chains with characteristics of a tubular proteinuria, Disturbances of tubular reabsorption of uric acid, calcium, phosphate, glucose and magnesium were also observed.Correspondence to:
Dr. E. Mendonça Lima Verde; Av. Rui Barbosa, 3131Joaquim Távora, 60115-222 Fortaleza, Ceará, Brazil
Email: elimaverde@hotmail.com
F. Agenor Araújo Lima Verde1, F. Araújo Lima Verde1,2, E. De Francesco Daher2,3, G. Martins dos Santos4, A. Saboia Neto1,5 and E. Mendoça Lima Verde1,3
1Nephrology Institute of Ceará (INECE), 2Resident of Nephrology, Federal University of Rio Grande do Sul, Brazil, 3Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, 4Resident of Nephrology, Department of Internal Medicine, School of Medicine, Federal University of Ceará, Fortaleza, Ceará, Brazil, and 5Medical Student at Christus University, Fortaleza, Brazil Background: There are few studies about the functional tubular disturbances in human Kala-azar. The aim of this study was to investigate alterations in tubular reabsorption of urinary proteins, sodium, potassium, chloride, glucose, uric acid, inorganic phosphate and amino acids in patients with the chronic form of kala-azar. Patients and methods: This is a cross-sectional study of 55 patients with visceral leishmaniasis (Kala-azar). The laboratorial investigation was: creatinine clearance and daily urinary excretion of total proteins, albumin, IgG, beta2-microglobulin, sodium, potassium, chloride, calcium, inorganic phosphate, uric acid and glucose. Plasma and urinary protein electrophoresis were performed in agarose gel. Urinary light chains were determined by the nephelometric method and amino acids by chromatography. All data were compared to those of a control group. Results: Hypoalbuminemia, hypergammaglobulinemia as well as increased plasma levels of both IgG and beta2-microglobulins were found in all patients with Kala-azar. The mean urinary protein excretion was 277 ± 66 mg/day. Increased albumin excretion was observed in 44% of patients accounting for 17% of the total urinary protein excretion. Proteinuria consisted predominantly of low molecular weight protein fractions that migrated with alpha1, alpha2, beta and especially gamma globulins. Urinary beta2-microglobulin excretion was elevated in all patients. Immune electrophoresis showed increased urinary excretion rates of kappa (27%) and lampda (42%) light chains. The Bence-Jones test was positive in 20% of patients. Immunofixation was negative for monoclonal peak. The principal alterations were hyponatremia 94.6%, hypokalemia 26%, hypochloremia 27.2%, hypocalcemia 32%, hypomagnesemia 41.8%, hypouricemia 14.3%, Increased urinary excretion fraction were: sodium 15%, potassium 26%, chloride 33.3%, calcium 32%, inorganic phosphate 27.2%, magnesium 100% with hypermagnesiuria, uric acid 44%. Glucosuria was found in one third of patients. Conclusion: There was evidence of renal proximal tubular damage with alterations in the reabsorption of proteins and light chains with characteristics of a tubular proteinuria, Disturbances of tubular reabsorption of uric acid, calcium, phosphate, glucose and magnesium were also observed.Correspondence to:
Dr. E. Mendonça Lima Verde; Av. Rui Barbosa, 3131Joaquim Távora, 60115-222 Fortaleza, Ceará, Brazil
Email: elimaverde@hotmail.com
Original
Biofilm formation by Escherichia coli isolated from patients with urinary tract infections
J. Salo, J.-J. Sevander, T. Tapiainen, I. Ikäheimo, T. Pokka, M. Koskela and M. Uhari
501
32$
Abstract
Aims: The significance of biofilm formation for the clinical picture of urinary tract infections (UTI) is largely unknown. We wanted to find out whether Escherichia coli (E. coli) strains isolated from UTI patients differ in their ability to form biofilms and whether this ability is associated with the clinical presentation of UTI. Material and methods: 70 E. coli strains were isolated from patients with cystitis (43 strains), pyelonephritis (11 strains) and urosepsis (16 strains) and biofilm formation was assessed on polystyrene microtiter plates by measuring the optical density (OD) of the attached material after 72 h of incubation and crystal violet staining of the bacteria. The formation of organized biofilm structures and the viability of the attached bacteria were verified by scanning electron microscopy and confocal scanning laser microscopy in a subsample of 22 strains. Results: 31% of the E. coli strains formed a biofilm. The strains isolated from patients with pyelonephritis had higher ODs than those from patients with cystitis (difference of the means 0.19, 95% confidence limits (CL) 0.06 – 0.32, p = 0.02). The E. coli strains susceptible to antibiotics had higher ODs than the resistant strains (difference of the means 0.21, 95% CL 0.03 – 0.27, p = 0.016). Conclusions: The ability of bacteria to persist and grow in a biofilm seems to be one of the important factors in both the resistance to antibiotics and the severity of urinary tract inflammation.Correspondence to:
J. Salo, MD; Department of Pediatrics, University of Oulu, PO-Box 5000, 90014 University of Oulu, Finland
Email: jarmo.salo@oulu.fi
J. Salo1, J.-J. Sevander2, T. Tapiainen1, I. Ikäheimo2, T. Pokka1, M. Koskela2 and M. Uhari1
1Department of Pediatrics and 2Laboratory of Clinical Microbiology, Oulu University Hospital, Finland Aims: The significance of biofilm formation for the clinical picture of urinary tract infections (UTI) is largely unknown. We wanted to find out whether Escherichia coli (E. coli) strains isolated from UTI patients differ in their ability to form biofilms and whether this ability is associated with the clinical presentation of UTI. Material and methods: 70 E. coli strains were isolated from patients with cystitis (43 strains), pyelonephritis (11 strains) and urosepsis (16 strains) and biofilm formation was assessed on polystyrene microtiter plates by measuring the optical density (OD) of the attached material after 72 h of incubation and crystal violet staining of the bacteria. The formation of organized biofilm structures and the viability of the attached bacteria were verified by scanning electron microscopy and confocal scanning laser microscopy in a subsample of 22 strains. Results: 31% of the E. coli strains formed a biofilm. The strains isolated from patients with pyelonephritis had higher ODs than those from patients with cystitis (difference of the means 0.19, 95% confidence limits (CL) 0.06 – 0.32, p = 0.02). The E. coli strains susceptible to antibiotics had higher ODs than the resistant strains (difference of the means 0.21, 95% CL 0.03 – 0.27, p = 0.016). Conclusions: The ability of bacteria to persist and grow in a biofilm seems to be one of the important factors in both the resistance to antibiotics and the severity of urinary tract inflammation.Correspondence to:
J. Salo, MD; Department of Pediatrics, University of Oulu, PO-Box 5000, 90014 University of Oulu, Finland
Email: jarmo.salo@oulu.fi
Original
The relationship between n-3 long-chain polyunsaturated fatty acids and pulse wave velocity in diabetic and non-diabetic patients under long-term hemodialysis. A horizontal study
K. Hamazaki*, Y. Terashima, M. Itomura, S. Sawazaki, H. Inagaki, M. Kuroda, S. Tomita, H. Hirata and T. Hamazaki
508
28$
Abstract
Background: Diabetes mellitus (DM) and deficiency in n-3 long-chain polyunsaturated fatty acids (n-3 LCPUFAs) are known to increase the incidence of cardiovascular disease (CVD). However, it has not yet been reported whether n-3 LCPUFAs are related to arteriosclerosis in patients under long-term hemodialysis (HD). Methods: Pulse wave velocity from the brachium to the ankle (baPWV) was measured as a marker of arteriosclerosis with a volume-plethysmographic apparatus in 147 long-term HD patients (non-diabetic (non-DM): 51 males/42 females, 62 ± 14 y; and DM: 33 males/21 females, 67 ± 9 y). The fatty acid composition of the total phospholipid fraction from washed RBCs was analyzed by gas chromatography. Analyses were adjusted for age, sex, diastolic blood pressure, pulse, body mass index, duration of HD treatment, smoking status, LDL/HDL-cholesterol ratios and diabetes mellitus (DM). Results: The mean baPWV was 18.9 ± 5.2 and 23.7 ± 6.3 m/s in non-DM and DM patients, respectively. The mean baPWV in DM patients was significantly higher than that of non-DM patients after adjustment (p = 0.0002). Multiple regression analysis showed that there was a significant inverse association between baPWV and docosahexaenoic acid (DHA) levels (p = 0.017) and DHA/arachidonic acid (AA) ratios (p = 0.012) in RBC in non-DM patients after adjustment but not in DM patients. Conclusions: We suggest that n-3 LCPUFAs may be a negative risk factor of CVD also in non-DM HD patients. In DM patients the effects of n-3 PUFAs on the vascular system became undetectable probably because DM overwhelmingly affected PWV. Further studies in a prospective manner are necessary.Correspondence to:
K. Hamazaki, MD, PhD; Department of Public Health, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
Email: keihama@med.u-toyama.ac.jp
K. Hamazaki1*, Y. Terashima1, M. Itomura1, S. Sawazaki2, H. Inagaki3, M. Kuroda3, S. Tomita4, H. Hirata4 and T. Hamazaki1
1Section of Clinical Application, Department of Clinical Sciences, Institute of Natural Medicine, 2First Department of Internal Medicine, Faculty of Medicine, University of Toyama, 3Asanagi Hospital, Takaoka, and 4Jounan Clinic, Toyama, Japan Background: Diabetes mellitus (DM) and deficiency in n-3 long-chain polyunsaturated fatty acids (n-3 LCPUFAs) are known to increase the incidence of cardiovascular disease (CVD). However, it has not yet been reported whether n-3 LCPUFAs are related to arteriosclerosis in patients under long-term hemodialysis (HD). Methods: Pulse wave velocity from the brachium to the ankle (baPWV) was measured as a marker of arteriosclerosis with a volume-plethysmographic apparatus in 147 long-term HD patients (non-diabetic (non-DM): 51 males/42 females, 62 ± 14 y; and DM: 33 males/21 females, 67 ± 9 y). The fatty acid composition of the total phospholipid fraction from washed RBCs was analyzed by gas chromatography. Analyses were adjusted for age, sex, diastolic blood pressure, pulse, body mass index, duration of HD treatment, smoking status, LDL/HDL-cholesterol ratios and diabetes mellitus (DM). Results: The mean baPWV was 18.9 ± 5.2 and 23.7 ± 6.3 m/s in non-DM and DM patients, respectively. The mean baPWV in DM patients was significantly higher than that of non-DM patients after adjustment (p = 0.0002). Multiple regression analysis showed that there was a significant inverse association between baPWV and docosahexaenoic acid (DHA) levels (p = 0.017) and DHA/arachidonic acid (AA) ratios (p = 0.012) in RBC in non-DM patients after adjustment but not in DM patients. Conclusions: We suggest that n-3 LCPUFAs may be a negative risk factor of CVD also in non-DM HD patients. In DM patients the effects of n-3 PUFAs on the vascular system became undetectable probably because DM overwhelmingly affected PWV. Further studies in a prospective manner are necessary.Correspondence to:
K. Hamazaki, MD, PhD; Department of Public Health, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
Email: keihama@med.u-toyama.ac.jp
Original
Comparison of the effects of polysulfone and polyester-polymer alloy dialyzers on glycemic control in diabetic patients undergoing hemodialysis
M. Abe, K. Okada, T. Maruyama, K. Ikeda, F. Kikuchi, K. Kaizu and K. Matsumoto
514
32$
Abstract
Blood Purification, Social Insurance Yokohama Central Hospital, Yokohama, Japan
Background: Though different high-flux dialyzers are available, there are no comparative studies on their glycemic control effects on diabetic hemodialysis (HD) patients. In this crossover study, we compared the effects of polysulfone (PS) and polyester-polymer alloy (PEPA) dialyzers. Methods: We recruited 47 diabetic HD patients. The conventional dialyzers were replaced with PS or PEPA dialyzers and the patients were treated for 16 weeks. Subsequently, after interchanging the PS and PEPA dialyzers, the treatment continued for another 16 weeks. For each dialyzer, we analyzed the glycemic control effect and measured their clearance and reduction rates of insulin. Results: The PEPA dialyzer lowered the glycated albumin (GA) levels more significantly than the PS dialyzer. While the groups exhibited no differences in metabolic parameters, the clearance and reduction rates of insulin were more significant in the PS. A significant decrease was observed in the levels of GA, fasting plasma glucose, and glycated hemoglobin in patients with lower fasting C-peptide levels (< 6.0 ng/ml). Conclusion: Glycemic control in diabetic HD patients is affected by the type of dialyzer used. Our results indicate that the PEPA dialyzer is more potent in controlling glycemia than the PS dialyzer in diabetic HD patients.Correspondence to:
M. Abe, MD; Division of Nephrology, Hypertension and Endocrinology, Department of Medicine, Nihon University School of Medicine 30-1, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
Email: mabe@med.nihon-u.ac.jp
M. Abe1, K. Okada1, T. Maruyama1, K. Ikeda1, F. Kikuchi2, K. Kaizu3 and K. Matsumoto1
1Division of Nephrology, Hypertension and Endocrinology, Department of Medicine, Nihon University School of Medicine, 2Department of Nephrology and Blood Purification, Yamato Hospital, Tokyo and 3Department of Nephrology and Blood Purification, Social Insurance Yokohama Central Hospital, Yokohama, Japan
Background: Though different high-flux dialyzers are available, there are no comparative studies on their glycemic control effects on diabetic hemodialysis (HD) patients. In this crossover study, we compared the effects of polysulfone (PS) and polyester-polymer alloy (PEPA) dialyzers. Methods: We recruited 47 diabetic HD patients. The conventional dialyzers were replaced with PS or PEPA dialyzers and the patients were treated for 16 weeks. Subsequently, after interchanging the PS and PEPA dialyzers, the treatment continued for another 16 weeks. For each dialyzer, we analyzed the glycemic control effect and measured their clearance and reduction rates of insulin. Results: The PEPA dialyzer lowered the glycated albumin (GA) levels more significantly than the PS dialyzer. While the groups exhibited no differences in metabolic parameters, the clearance and reduction rates of insulin were more significant in the PS. A significant decrease was observed in the levels of GA, fasting plasma glucose, and glycated hemoglobin in patients with lower fasting C-peptide levels (< 6.0 ng/ml). Conclusion: Glycemic control in diabetic HD patients is affected by the type of dialyzer used. Our results indicate that the PEPA dialyzer is more potent in controlling glycemia than the PS dialyzer in diabetic HD patients.Correspondence to:
M. Abe, MD; Division of Nephrology, Hypertension and Endocrinology, Department of Medicine, Nihon University School of Medicine 30-1, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
Email: mabe@med.nihon-u.ac.jp
Original
Erythropoiesis-stimulating agent withdrawal and oxidative stress in hemodialysis
P. Monostori, Z. Hracskó, E. Karg, I.S. Varga, Z. Kiss, T. Boros, É. Kiss, I. Haszon, F. Papp, V. Sümegi, C. Bereczki and S. Túri
521
28$
Abstract
Aims: Variation of the action of erythropoiesis-stimulating agent (ESA) may modify oxidative stress in hemodialyzed (HD) patients. Our aim was to follow changes of oxidative stress during withdrawal and subsequent resumption of ESA therapy. Patients and methods: After a 14-day suspension of epoietin-beta treatment, 11 HD patients received epoietin-beta and 10 patients darbepoietin-alpha. The whole blood oxidized and reduced glutathione (GSSG, GSH) and erythrocyte malondialdehyde (E-MDA) concentrations and the erythrocyte superoxide dismutase (E-SOD) and catalase (E-CAT) activities were determined before the ESA-free interval (baseline) and at Weeks 2, 6, 10 and 14. Results: In both groups, the ratios GSSG/ GSH were increased at Weeks 2 and 6 (p < 0.001). The E-MDA levels were elevated (p < 0.01) and the E-SOD activities were decreased (p < 0.001) at Week 6. By Week 14, these markers had returned to the baseline, whereas the GSH (p < 0.001) and E-CAT activity levels (p < 0.001) had increased. Conclusions: An increase in oxidative stress was revealed by the ratio GSSG/GSH directly after the short-term withdrawal of epoietin-b therapy in HD. This new finding may have implications in conditions involving transiently depressed ESA action. For both ESAs, the early phase of readministration was associated with similarly increased oxidative stress, with a subsequent return to the baseline level.Correspondence to:
P. Monostori, BPh; Department of Pediatrics, University of Szeged, Szeged, Korányi fasor 14-15, 6720, Hungary
Email: monostoripeter@gmail.com
P. Monostori1, Z. Hracskó2, E. Karg1, I.S. Varga2, Z. Kiss3, T. Boros1, É. Kiss1, I. Haszon1, F. Papp1, V. Sümegi1, C. Bereczki1 and S. Túri1
1Department of Pediatrics, 2Department of Biochemistry and Molecular Biology, University of Szeged, and 3Department of Medical Affairs, Amgen Ltd., Budapest, Hungary Aims: Variation of the action of erythropoiesis-stimulating agent (ESA) may modify oxidative stress in hemodialyzed (HD) patients. Our aim was to follow changes of oxidative stress during withdrawal and subsequent resumption of ESA therapy. Patients and methods: After a 14-day suspension of epoietin-beta treatment, 11 HD patients received epoietin-beta and 10 patients darbepoietin-alpha. The whole blood oxidized and reduced glutathione (GSSG, GSH) and erythrocyte malondialdehyde (E-MDA) concentrations and the erythrocyte superoxide dismutase (E-SOD) and catalase (E-CAT) activities were determined before the ESA-free interval (baseline) and at Weeks 2, 6, 10 and 14. Results: In both groups, the ratios GSSG/ GSH were increased at Weeks 2 and 6 (p < 0.001). The E-MDA levels were elevated (p < 0.01) and the E-SOD activities were decreased (p < 0.001) at Week 6. By Week 14, these markers had returned to the baseline, whereas the GSH (p < 0.001) and E-CAT activity levels (p < 0.001) had increased. Conclusions: An increase in oxidative stress was revealed by the ratio GSSG/GSH directly after the short-term withdrawal of epoietin-b therapy in HD. This new finding may have implications in conditions involving transiently depressed ESA action. For both ESAs, the early phase of readministration was associated with similarly increased oxidative stress, with a subsequent return to the baseline level.Correspondence to:
P. Monostori, BPh; Department of Pediatrics, University of Szeged, Szeged, Korányi fasor 14-15, 6720, Hungary
Email: monostoripeter@gmail.com
Original
Effect of resistance exercise during hemodialysis on physical function and quality of life: randomized controlled trial
E. Segura-Ortí, E. Kouidi and J.F. Lisón
527
48$
Abstract
Aims: The objective of this study was to determine whether 24 weeks resistance training during hemodialysis could improve exercise capacity, muscle strength, physical functioning and health-related quality of life compared to a low intensity aerobic program. Material and methods: 27 patients (55.6 ± 17.6 years) were recruited from two hemodialysis clinics in Valencia (Spain). Patients were randomized to resistance training (n = 19) or low-intensity aerobic training (n = 8). Resistance training consisted of three sets of 4 exercises at an intensity of 12 – 15 out of 20 at the rate of perceived exertion scale (Borg scale measuring self-rated exercise intensity) using weights and elastic bands on every session during 24 weeks. Primary outcomes included physical performance tests, evaluated by the “sit-to-stand-to-sit tests” and the 6 minutes walking test, and knee extensor muscles strength, evaluated by isometric dynamometry. Secondary outcomes included cardiorespiratory fitness, measured by time and METs (measure of energy expenditure as ml of oxygen per kg of weight and per minute; 1 MET is equal to 3.5 ml O2/kg/min) achieved on a graded exercise test, and quality of life, measured by the SF-36 questionnaire. Results: No differences were noted in change-over-time between the two groups in any of the physical performance tests. However, a significant change was found in change-over-time in right knee extensor muscles dynamometry, and intragroup analysis showed a significant improvement in resistance training groups in the physical performance tests and METs. Conclusions: These findings suggest that resistance training during hemodialysis improves patient’s physical functioning.Correspondence to:
E. Segura-Ortí; Universidad CEU Cardenal Herrera, Avda. Seminario s/n, 46113 Moncada (Valencia), Spain
Email: esegura@uch.ceu.es
E. Segura-Ortí1, E. Kouidi2 and J.F. Lisón1
1Department of Physiotherapy, Universidad CEU Cardenal Herrera, Valencia, Spain, and 2Sports Medicine Laboratory, Aristotle University Thessaloniki, Greece Aims: The objective of this study was to determine whether 24 weeks resistance training during hemodialysis could improve exercise capacity, muscle strength, physical functioning and health-related quality of life compared to a low intensity aerobic program. Material and methods: 27 patients (55.6 ± 17.6 years) were recruited from two hemodialysis clinics in Valencia (Spain). Patients were randomized to resistance training (n = 19) or low-intensity aerobic training (n = 8). Resistance training consisted of three sets of 4 exercises at an intensity of 12 – 15 out of 20 at the rate of perceived exertion scale (Borg scale measuring self-rated exercise intensity) using weights and elastic bands on every session during 24 weeks. Primary outcomes included physical performance tests, evaluated by the “sit-to-stand-to-sit tests” and the 6 minutes walking test, and knee extensor muscles strength, evaluated by isometric dynamometry. Secondary outcomes included cardiorespiratory fitness, measured by time and METs (measure of energy expenditure as ml of oxygen per kg of weight and per minute; 1 MET is equal to 3.5 ml O2/kg/min) achieved on a graded exercise test, and quality of life, measured by the SF-36 questionnaire. Results: No differences were noted in change-over-time between the two groups in any of the physical performance tests. However, a significant change was found in change-over-time in right knee extensor muscles dynamometry, and intragroup analysis showed a significant improvement in resistance training groups in the physical performance tests and METs. Conclusions: These findings suggest that resistance training during hemodialysis improves patient’s physical functioning.Correspondence to:
E. Segura-Ortí; Universidad CEU Cardenal Herrera, Avda. Seminario s/n, 46113 Moncada (Valencia), Spain
Email: esegura@uch.ceu.es
Original
Prevalence of hypercalcitoninemia in patients on maintenance dialysis referred to kidney transplantation
B. Akan, G. Böhmig, G. Sunder-Plassmann and K.A. Borchhardt
538
24$
Abstract
Aims: Elevated calcitonin concentrations in dialysis patients had led to thyroidectomy for a benign C-cell hyperplasia in dozens of patients in the past decade. The prevalence of hypercalcitoninemia, however, has not been examined in a large cohort of dialysis patients. Methods: We, therefore, measured calcitonin concentrations in 283 dialysis patients. We used different reference intervals: according to the threshold to perform further stimulation tests (i.e. > 10 pg/ml) and new reference intervals for the currently used assay (i.e. serum calcitonin concentration < 11.5 pg/ml in men and < 4.6 pg/ml in women). Results: Median calcitonin concentrations of men and women were 12 (1; 290) pg/ml vs 2 pg/ml (1; 45), respectively, (p < 0.0001). The prevalence of hypercalcitoninemia was 10% in women and 58% in men using a cut-off of 10 pg/ml. Applying the new reference intervals 31% of women and 54% of men presented with hypercalcitoninemia. All patients with basal calcitonin concentrations above 50 pg/ml were men (highest calcitonin concentration was 290 pg/ml). Two of them underwent thyroidectomy and had C-cell hyperplasia. Conclusion: The prevalence of hypercalcitoninemia in dialysis patients amounts to 46%. It is more common in male than in female dialysis patients.Correspondence to:
Dr. K. Borchhardt; Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, 1090 Wien, Austria
Email: kyra.borchhardt@meduniwien.ac.at
B. Akan, G. Böhmig, G. Sunder-Plassmann and K.A. Borchhardt
Department of Medicine III, Division of Nephrology and Dialysis, Medical University Vienna, Austria Aims: Elevated calcitonin concentrations in dialysis patients had led to thyroidectomy for a benign C-cell hyperplasia in dozens of patients in the past decade. The prevalence of hypercalcitoninemia, however, has not been examined in a large cohort of dialysis patients. Methods: We, therefore, measured calcitonin concentrations in 283 dialysis patients. We used different reference intervals: according to the threshold to perform further stimulation tests (i.e. > 10 pg/ml) and new reference intervals for the currently used assay (i.e. serum calcitonin concentration < 11.5 pg/ml in men and < 4.6 pg/ml in women). Results: Median calcitonin concentrations of men and women were 12 (1; 290) pg/ml vs 2 pg/ml (1; 45), respectively, (p < 0.0001). The prevalence of hypercalcitoninemia was 10% in women and 58% in men using a cut-off of 10 pg/ml. Applying the new reference intervals 31% of women and 54% of men presented with hypercalcitoninemia. All patients with basal calcitonin concentrations above 50 pg/ml were men (highest calcitonin concentration was 290 pg/ml). Two of them underwent thyroidectomy and had C-cell hyperplasia. Conclusion: The prevalence of hypercalcitoninemia in dialysis patients amounts to 46%. It is more common in male than in female dialysis patients.Correspondence to:
Dr. K. Borchhardt; Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, 1090 Wien, Austria
Email: kyra.borchhardt@meduniwien.ac.at
Original
Percutaneous transluminal angioplasty as first-line treatment of transplant renal artery stenosis
B.F. Henning, S. Kuchlbauer, C.A. Böger, A. Obed, S. Farkas, C. Zülke, M. Scherer, A. Walberer, M. Banas, B. Krüger, H.J. Schlitt, B. Banas and B.K. Krämer
543
32$
Abstract
Background: Transplant renal artery stenosis (TRAS) is a frequent complication after renal transplantation, however long-term follow-up data after interventional treatment are rare. Patients: In our transplant center 11 of 264 consecutive renal transplant recipients (4.17%) were diagnosed with TRAS. In addition, TRAS occurred in 2 renal transplant recipients that had been transplanted at other centers but who had their follow-up examinations in our center. Either a rise of the serum creatinine level and/or worsened systemic hypertension or routine examination with color Doppler sonography were indications for further diagnostic workup. Methods: Direct angiography of the transplant renal artery was performed followed by percutaneous transluminal angioplasty (PTA) after the diagnosis of TRAS was confirmed in all of these patients. Results: The immediate success rate for PTA was 92.3% (12/13). Only 1 patient with a severe kinking of the transplant renal artery had to undergo surgery to restore renal function. No complications occurred after the interventions. Thereafter the patients were monitored for a mean observation period of 33.15 months. Serum creatinine levels were significantly lower after the intervention, and estimated glomerular filtration rate (eGFR) increased accordingly. With regard to blood pressure there was only a trend for lower blood pressure levels and less antihypertensive use, whereas the dose of the prescribed drugs decreased significantly with time after interventional treatment of TRAS. In addition, a long-lasting rise of the hemoglobin levels could also be demonstrated. Conclusion: In summary, the beneficial effect of PTA of TRAS on renal function is long-lasting. Therefore, PTA, usually combined with stent placement, should be first-line treatment in TRAS in all patients. Surgical revascularization is only warranted, if PTA fails.Correspondence to:
Dr. B. Henning; Department of Medicine I, Marienhospital Herne, Ruhr-University Bochum, Germany
Email: Bernhard.henning@ruhr-universität.bochum.de
B.F. Henning1, S. Kuchlbauer2, C.A. Böger2, A. Obed3, S. Farkas3, C. Zülke3, M. Scherer3, A. Walberer1,2, M. Banas2, B. Krüger1,2, H.J. Schlitt3, B. Banas2 and B.K. Krämer1,2
1Department of Medicine I, Marienhospital Herne, Ruhr University Bochum, 2Department of Nephrology, and 3Department of Surgery, University of Regensburg, Germany Background: Transplant renal artery stenosis (TRAS) is a frequent complication after renal transplantation, however long-term follow-up data after interventional treatment are rare. Patients: In our transplant center 11 of 264 consecutive renal transplant recipients (4.17%) were diagnosed with TRAS. In addition, TRAS occurred in 2 renal transplant recipients that had been transplanted at other centers but who had their follow-up examinations in our center. Either a rise of the serum creatinine level and/or worsened systemic hypertension or routine examination with color Doppler sonography were indications for further diagnostic workup. Methods: Direct angiography of the transplant renal artery was performed followed by percutaneous transluminal angioplasty (PTA) after the diagnosis of TRAS was confirmed in all of these patients. Results: The immediate success rate for PTA was 92.3% (12/13). Only 1 patient with a severe kinking of the transplant renal artery had to undergo surgery to restore renal function. No complications occurred after the interventions. Thereafter the patients were monitored for a mean observation period of 33.15 months. Serum creatinine levels were significantly lower after the intervention, and estimated glomerular filtration rate (eGFR) increased accordingly. With regard to blood pressure there was only a trend for lower blood pressure levels and less antihypertensive use, whereas the dose of the prescribed drugs decreased significantly with time after interventional treatment of TRAS. In addition, a long-lasting rise of the hemoglobin levels could also be demonstrated. Conclusion: In summary, the beneficial effect of PTA of TRAS on renal function is long-lasting. Therefore, PTA, usually combined with stent placement, should be first-line treatment in TRAS in all patients. Surgical revascularization is only warranted, if PTA fails.Correspondence to:
Dr. B. Henning; Department of Medicine I, Marienhospital Herne, Ruhr-University Bochum, Germany
Email: Bernhard.henning@ruhr-universität.bochum.de
Case Report
Renal histology before and after effective enzyme replacement therapy in a patient with classical Fabry’s disease
S. Hirashio, T. Taguchi, T. Naito, K. Maki, S. Ogata, K. Taniyama, Y. Taniguchi and N. Yorioka
550
32$
Abstract
A 38-year-old man underwent renal biopsy because of proteinuria. It revealed swelling and vacuolation of glomerular epithelial cells, as well as myelin-like structures characteristic of Fabry’s disease. Detection of decreased plasma activity of alpha-galactosidase A confirmed the diagnosis. Enzyme replacement therapy was provided with recombinant agalsidase-beta, resulting in improvement of his symptoms. When renal biopsy was repeated, specific staining for globotriaosylceramide showed that renal deposits were decreased by enzyme therapy.Correspondence to:
Noriaki Yorioka MD, PhD; 1-2-3 Kasumi, Minami-ku Hiroshima, 734-8551Japan
Email: nyorioka@hiroshima-u.ac.jp
S. Hirashio1,2, T. Taguchi3, T. Naito1, K. Maki1, S. Ogata4, K. Taniyama5, Y. Taniguchi6 and N. Yorioka7
1Department of Nephrology, Hiroshima University Hospital, 2Department of Nephrology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, 3Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, 4Department of Internal Medicine, Sanyo Hospital, 5Institute for Clinical Research, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, 6Division of Clinical Pharmacotherapeutics, Department of Pharmaceutical Science, Hiroshima International University, 7Department of Advanced Nephrology, and Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan A 38-year-old man underwent renal biopsy because of proteinuria. It revealed swelling and vacuolation of glomerular epithelial cells, as well as myelin-like structures characteristic of Fabry’s disease. Detection of decreased plasma activity of alpha-galactosidase A confirmed the diagnosis. Enzyme replacement therapy was provided with recombinant agalsidase-beta, resulting in improvement of his symptoms. When renal biopsy was repeated, specific staining for globotriaosylceramide showed that renal deposits were decreased by enzyme therapy.Correspondence to:
Noriaki Yorioka MD, PhD; 1-2-3 Kasumi, Minami-ku Hiroshima, 734-8551Japan
Email: nyorioka@hiroshima-u.ac.jp
Case Report
Acute renal failure by ingestion of Cortinarius species confounded with psychoactive mushrooms – a case series and literature survey
H. Frank, T. Zilker, M. Kirchmair, F. Eyer, B. Haberl, G. Tuerkoglu-Raach, M. Wessely, H.-J. Gröne and U. Heemann
557
28$
Abstract
Mushrooms of the Cortinarius species are nephrotoxic and can cause severe acute renal failure. The toxic effect is due to orellanine. It is suspected that the cytotoxic damage is caused by the production of oxygen-free radicals. Renal pathology shows tubular necrosis with interstitial nephritis. In addition to accidental intoxications as a consequence of mushroom meals, recent cases are often due to voluntary abuse of natural drugs like magic mushrooms. We report 4 current cases of acute renal failure from intoxication by Cortinarius species by confusing it with psychoactive fungi. Typical for the Cortinarius poisoning is the long latency period from ingestion until the onset of clinical symptoms (3 – 20 days). Diagnosis is based on microscopical identification of the mushroom spores, and detection of the orellanine toxin in leftover mushrooms. In renal biopsy tissue, orellanine is detectable by thin-layer chromaography technique up to 6 months after poisoning. There is no causative therapy, and treatment is symptomatic with adequate hemodialysis. In cases of otherwise unexplained acute renal failure, intoxication with nephrotoxic mushrooms should be considered.Correspondence to:
PD Dr. med. H. Frank; Department of Nephrology,
II. Medizinische Klinik und Poliklinik, Ismaninger Strasse 22, 81675 München, Germany
Email: Helga.Frank@Irz.tu-muenchen.de
H. Frank1, T. Zilker2, M. Kirchmair3, F. Eyer2, B. Haberl2, G. Tuerkoglu-Raach4, M. Wessely5, H.-J. Gröne6 and U. Heemann1
1Department of Nephrology, Klinikum rechts der Isar, Technische Universität München, 2Department of Toxikology, Klinikum rechts der Isar, Technische Universität München, 3Institut für Mikrobiologie, Leopold-Franzens-Universität Innsbruck, Austria, 4Nephrology, Campus Innenstadt, Universität München, 5Nephrology, Campus Großhadern, Universität München, and 6Department of Cellular and Molecular Pathology, Deutsches Krebsforschungszentrum Heidelberg, Germany Mushrooms of the Cortinarius species are nephrotoxic and can cause severe acute renal failure. The toxic effect is due to orellanine. It is suspected that the cytotoxic damage is caused by the production of oxygen-free radicals. Renal pathology shows tubular necrosis with interstitial nephritis. In addition to accidental intoxications as a consequence of mushroom meals, recent cases are often due to voluntary abuse of natural drugs like magic mushrooms. We report 4 current cases of acute renal failure from intoxication by Cortinarius species by confusing it with psychoactive fungi. Typical for the Cortinarius poisoning is the long latency period from ingestion until the onset of clinical symptoms (3 – 20 days). Diagnosis is based on microscopical identification of the mushroom spores, and detection of the orellanine toxin in leftover mushrooms. In renal biopsy tissue, orellanine is detectable by thin-layer chromaography technique up to 6 months after poisoning. There is no causative therapy, and treatment is symptomatic with adequate hemodialysis. In cases of otherwise unexplained acute renal failure, intoxication with nephrotoxic mushrooms should be considered.Correspondence to:
PD Dr. med. H. Frank; Department of Nephrology,
II. Medizinische Klinik und Poliklinik, Ismaninger Strasse 22, 81675 München, Germany
Email: Helga.Frank@Irz.tu-muenchen.de
Case Report
Hemolytic uremic syndrome as a primary manifestation of acute human immunodeficiency virus infection
A.M. Gomes, A. Ventura, C. Almeida, M. Correia, V. Tavares, M. Mota and J. Seabra
563
20$
Abstract
Hemolytic uremic syndrome may be associated with human immunodeficiency virus infection but it occurs in advanced stages of human immunodeficiency virus disease. As in other forms of hemolytic uremic syndrome plasmapheresis seems to be the treatment of choice. The authors present an unusual case of hemolytic uremic syndrome associated with acute human immunodeficiency virus infection in a 38 year-old black male. The patient was admitted with fever, asthenia, nausea, diarrhea, and reduced urinary output. He was found to have anemia, thrombocytopenia and severe renal failure. Hemolytic uremic syndrome was diagnosed and he was started on plasmapheresis and hemodialysis. Serological tests were consistent with acute human immunodeficiency virus infection: the enzyme linked immunosorbent assay for human immunodeficiency virus was weakly positive, Western Blot test was negative and human immunodeficiency virus RNA quantification was positive, with > 1,000,000 copies/µl. After 4 daily treatment sessions, patient’s clinical condition improved and hemoglobin, platelets, lactic dehydrogenase and renal function normalized.Correspondence to:
Dr. A.M. Gomes; Nephrology Department, Centro Hospitalar Vila Nova Gaia/Espinho, Rua Conceição Fernandes, 3343-502 Vila Nova de Gaia, Portugal
Email: ampgomes@gmail.com
A.M. Gomes1, A. Ventura1, C. Almeida1, M. Correia2, V. Tavares2, M. Mota2 and J. Seabra1
1Nephrology Department and 2Infectious Disease Unit, Centro Hospitalar Vila Nova Gaia/Espinho, Gaia, Portugal Hemolytic uremic syndrome may be associated with human immunodeficiency virus infection but it occurs in advanced stages of human immunodeficiency virus disease. As in other forms of hemolytic uremic syndrome plasmapheresis seems to be the treatment of choice. The authors present an unusual case of hemolytic uremic syndrome associated with acute human immunodeficiency virus infection in a 38 year-old black male. The patient was admitted with fever, asthenia, nausea, diarrhea, and reduced urinary output. He was found to have anemia, thrombocytopenia and severe renal failure. Hemolytic uremic syndrome was diagnosed and he was started on plasmapheresis and hemodialysis. Serological tests were consistent with acute human immunodeficiency virus infection: the enzyme linked immunosorbent assay for human immunodeficiency virus was weakly positive, Western Blot test was negative and human immunodeficiency virus RNA quantification was positive, with > 1,000,000 copies/µl. After 4 daily treatment sessions, patient’s clinical condition improved and hemoglobin, platelets, lactic dehydrogenase and renal function normalized.Correspondence to:
Dr. A.M. Gomes; Nephrology Department, Centro Hospitalar Vila Nova Gaia/Espinho, Rua Conceição Fernandes, 3343-502 Vila Nova de Gaia, Portugal
Email: ampgomes@gmail.com
Case Report
Tenofovir-related acute kidney injury and proximal tubule dysfunction precipitated by diclofenac: a case of drug-drug interaction
J. Morelle, L. Labriola, M. Lambert, J.-P. Cosyns, F. Jouret and M. Jadoul
567
20$
Abstract
We describe an HIV1-positive patient under long-term tenofovir treatment who developed a severe, biopsy-proven, acute tubular necrosis with proximal tubule (PT) dysfunction, precipitated by the very recent start of diclofenac, a nonsteroidal antiinflammatory drug (NSAID). Recent studies show that NSAIDs not only alter glomerular filtration but also multidrug resistance protein (MRP) 4-mediated PT secretion of several substrates. Since the patient tolerated tenofovir well for several years prior to diclofenac use, our observation suggests that diclofenac interfered with tenofovir clearance, thereby favoring its nephrotoxicity. NSAIDs should be avoided in patients under tenofovir.Correspondence to:
Prof. M. Jadoul; Department of Nephrology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Bruxelles, Belgium
Email: Michel.Jadoul@uclouvain.be
J. Morelle1, L. Labriola1, M. Lambert2, J.-P. Cosyns3, F. Jouret1 and M. Jadoul1
Departments of 1Nephrology, 2General Internal Medicine, and 3Pathology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium We describe an HIV1-positive patient under long-term tenofovir treatment who developed a severe, biopsy-proven, acute tubular necrosis with proximal tubule (PT) dysfunction, precipitated by the very recent start of diclofenac, a nonsteroidal antiinflammatory drug (NSAID). Recent studies show that NSAIDs not only alter glomerular filtration but also multidrug resistance protein (MRP) 4-mediated PT secretion of several substrates. Since the patient tolerated tenofovir well for several years prior to diclofenac use, our observation suggests that diclofenac interfered with tenofovir clearance, thereby favoring its nephrotoxicity. NSAIDs should be avoided in patients under tenofovir.Correspondence to:
Prof. M. Jadoul; Department of Nephrology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Bruxelles, Belgium
Email: Michel.Jadoul@uclouvain.be
Case Report
Amanita phalloides poisoning-induced end-stage renal failure
C. Garrouste, M. Hémery, A.M. Boudat and N. Kamar
571
20$
Abstract
Fungi poisoning is quite frequent: in particular, Amanita phalloides has life-threatening toxicity. It is responsible for fulminant hepatitis, and also has renal toxicity. Herein, we report on a patient who developed acute renal failure after ingesting A. phalloides, which required definitive renal replacement therapy, despite rapid liver injury recovery. A kidney biopsy showed massive acute tubular necrosis, mainly in the proximal convoluted tubule, and mild interstitial infiltration by mononuclear cells.Correspondence to:
N. Kamar MD, PhD; CHU Rangueil, Service de Néphrologie, Transplantation d’Organes, Hémodialyse, 1 av. Jean Poulhès, TSA 50032, 31059 Toulouse Cedex 9, France
Email: kamar.n@chu-toulouse.fr
C. Garrouste1,2, M. Hémery1, A.M. Boudat3 and N. Kamar2,4
1Department of Nephrology, Tarbes, 2Department of Nephrology, Dialysis and Multiorgan Transplantation, University Hospital, CHU Rangueil, Toulouse, 3Department of Pathology, Department of Nephrology, Tarbes, and 4INSERM U858, IFR 31, Toulouse, France Fungi poisoning is quite frequent: in particular, Amanita phalloides has life-threatening toxicity. It is responsible for fulminant hepatitis, and also has renal toxicity. Herein, we report on a patient who developed acute renal failure after ingesting A. phalloides, which required definitive renal replacement therapy, despite rapid liver injury recovery. A kidney biopsy showed massive acute tubular necrosis, mainly in the proximal convoluted tubule, and mild interstitial infiltration by mononuclear cells.Correspondence to:
N. Kamar MD, PhD; CHU Rangueil, Service de Néphrologie, Transplantation d’Organes, Hémodialyse, 1 av. Jean Poulhès, TSA 50032, 31059 Toulouse Cedex 9, France
Email: kamar.n@chu-toulouse.fr
Case Report
Transitory lupus anticoagulant antibodies leading to a quickly resolvable left ventricular thrombus in a young female patient on peritoneal dialysis
M. Koch and R. Beckmann
575
20$
Abstract
We present a 38-year-old female patient on peritoneal dialysis for 3 years due to mesangioproliferative glomerulonephritis since early adolescence and chronic failure of the right kidney transplants. In early 2006 she was treated with high-dose cortisone due to cryptogenic, organized pneumonia. During a routine echocardiographic examination performed because of occurrence of cerebral symptoms such as diminished visual and auditory acuity in the patient, we detected a mobile, left ventricular thrombus of unusual large size, along with serologically measured Lupus anticoagulant antibodies (LA). The thrombus could be completely lyzed within only 12 hours by urokinese and antithrombotic danaparoid sodium therapy without surgical intervention. Successful treatment was proven by negative LA antibody activity as well as by echocardiography. The general clinical health was greatly improved after rehabilitation 2 months after lysis. We assume that the patient may have had infection- or cortisone-triggered transitory LA antibodies causing the serious heart thrombus with hypokinesia in the apex cordis.Correspondence to:
M. Koch, MD; Gartenstraße 8, 40822 Mettmann, Germany
Email: Koch@dialyse-mettmann.de
M. Koch1 and R. Beckmann2
1Center of Nephrology Mettmann and 2Clinic of Cardiology Velbert, Germany We present a 38-year-old female patient on peritoneal dialysis for 3 years due to mesangioproliferative glomerulonephritis since early adolescence and chronic failure of the right kidney transplants. In early 2006 she was treated with high-dose cortisone due to cryptogenic, organized pneumonia. During a routine echocardiographic examination performed because of occurrence of cerebral symptoms such as diminished visual and auditory acuity in the patient, we detected a mobile, left ventricular thrombus of unusual large size, along with serologically measured Lupus anticoagulant antibodies (LA). The thrombus could be completely lyzed within only 12 hours by urokinese and antithrombotic danaparoid sodium therapy without surgical intervention. Successful treatment was proven by negative LA antibody activity as well as by echocardiography. The general clinical health was greatly improved after rehabilitation 2 months after lysis. We assume that the patient may have had infection- or cortisone-triggered transitory LA antibodies causing the serious heart thrombus with hypokinesia in the apex cordis.Correspondence to:
M. Koch, MD; Gartenstraße 8, 40822 Mettmann, Germany
Email: Koch@dialyse-mettmann.de
Case Report
Multiple hepatic nodules in a renal transplant recipient
K.-H. Shu, and J.-W. Chai
579
24$
Abstract
A 55-year-old female received a cadaveric renal transplant in 2003. Sixteen months later, multiple liver nodules were found in a routine abdominal sonogram follow-up. Serial studies were all negative for malignancy. She was placed on a quadruple immunosuppressive regimen, including prednisolone, cyclosporine, mycophenolate mofetil and sirolimus. Her graft function was stable with serum creatinine of 1.0 mg/dl and there had been no rejection since transplantation. Liver function and lipid profile were within normal limits. Serum ferritin level was 1,466 ng/ml. Two liver biopsies, 4 months apart, showed fatty metamorphosis of the liver and no tumor. She was closely watched and no malignancy was found in the subsequent 3 years. Cyclosporine and sirolimus were tapered and corticosteroid withdrawn gradually. Serum ferritin level gradually declined to 600 – 800 ng/ml in subsequent years. Interestingly, the liver nodules gradually disappeared and there were only a few left on the last follow-up in April, 2008.Correspondence to:
K.-H. Shu, MD; Division of Nephrology, Department of Medicine, Taichung Veterans,
General Hospital, Taichung, Taiwan
Email: khshu@vghtc.gov.tw
K.-H. Shu1,3 and J.-W. Chai2,4
1Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, 2Department of Radiology, Taichung Veterans General, 3School of Medicine, Chung-Shan Medical University, and 4College of Medicine, China Medical University, Taichung, Taiwan A 55-year-old female received a cadaveric renal transplant in 2003. Sixteen months later, multiple liver nodules were found in a routine abdominal sonogram follow-up. Serial studies were all negative for malignancy. She was placed on a quadruple immunosuppressive regimen, including prednisolone, cyclosporine, mycophenolate mofetil and sirolimus. Her graft function was stable with serum creatinine of 1.0 mg/dl and there had been no rejection since transplantation. Liver function and lipid profile were within normal limits. Serum ferritin level was 1,466 ng/ml. Two liver biopsies, 4 months apart, showed fatty metamorphosis of the liver and no tumor. She was closely watched and no malignancy was found in the subsequent 3 years. Cyclosporine and sirolimus were tapered and corticosteroid withdrawn gradually. Serum ferritin level gradually declined to 600 – 800 ng/ml in subsequent years. Interestingly, the liver nodules gradually disappeared and there were only a few left on the last follow-up in April, 2008.Correspondence to:
K.-H. Shu, MD; Division of Nephrology, Department of Medicine, Taichung Veterans,
General Hospital, Taichung, Taiwan
Email: khshu@vghtc.gov.tw
Case Report
The abnormal superficial radial artery does not restrict the successful creation of hemodialysis forearm arteriovenous fistula
W. Weyde, M. Krajewska, S.C. Zmonarski, W. Letachowicz, J. Penar, E. Watorek, T. Golebiowski, M. Kusztal, B. Dubinski, R. Badowski, J. Garcarek, K. Madziarska, R. Klak and M. Klinger
584
20$
Abstract
Anatomical variations of the radial artery are of clinical importance in end-stage renal disease patients awaiting creation of native arteriovenous fistula for hemodialysis. As radial-cephalic direct wrist fistula is a vascular access of choice, atypical localization of the distal part of the radial artery may lead to the false assumption of severe atherosclerotic lesions and prevent creation of such an access, despite good vessel conditions and convenient surgical approach. We present 7 patients with radial artery variations. In 5 patients with superficial radial artery, radial-cephalic direct wrist access was created. One patient, due to an anomaly misdiagnosis, had radial-cephalic fistula created on the contra lateral wrist. In the patient with hypoplastic radial artery brachial-basilic upper arm transposition was created.Correspondence to:
W. Weyde, MD, PhD; Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, ul. Traugutta 57/59, 50-417 Wroclaw, Poland
Email: ewatorek@wp.pl
W. Weyde1, M. Krajewska1, S.C. Zmonarski1, W. Letachowicz1, J. Penar1, E. Watorek1, T. Golebiowski1, M. Kusztal1, B. Dubinski1, R. Badowski2, J. Garcarek2, K. Madziarska1, R. Klak1 and M. Klinger1
1Department of Nephrology and Transplantation Medicine, and 2Department of Radiology, Wroclaw Medical University, Wroclaw, Poland Anatomical variations of the radial artery are of clinical importance in end-stage renal disease patients awaiting creation of native arteriovenous fistula for hemodialysis. As radial-cephalic direct wrist fistula is a vascular access of choice, atypical localization of the distal part of the radial artery may lead to the false assumption of severe atherosclerotic lesions and prevent creation of such an access, despite good vessel conditions and convenient surgical approach. We present 7 patients with radial artery variations. In 5 patients with superficial radial artery, radial-cephalic direct wrist access was created. One patient, due to an anomaly misdiagnosis, had radial-cephalic fistula created on the contra lateral wrist. In the patient with hypoplastic radial artery brachial-basilic upper arm transposition was created.Correspondence to:
W. Weyde, MD, PhD; Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, ul. Traugutta 57/59, 50-417 Wroclaw, Poland
Email: ewatorek@wp.pl
Letter to the Editor
Acute IgA nephropathy following high-voltage electrical burn injury
Y. Wang, H.-T. Tang, Z.-F. Xia and G.-Y. Wang
588
12$
Abstract
Y. Wang, H.-T. Tang, Z.-F. Xia and G.-Y. Wang
Letter to the Editor
Hepatic angiosarcoma – a rare liver tumor in a hemodialysis patient
M. Matsumoto, M. Tamura, T. Komiya, G. Aridome, R. Narita, M. Hisaoka, M. Ohtsuki and Y. Otsuji
590
16$
Abstract
M. Matsumoto, M. Tamura, T. Komiya, G. Aridome, R. Narita, M. Hisaoka, M. Ohtsuki and Y. Otsuji
