Volume 70, No. 1/2008(July)
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 Clinical Nephrology
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Review
Pathogenesis of diabetic macro- and microangiopathy
V. Gärtner and T.K. Eigentler
Abstract
V. Gärtner1 and T.K. Eigentler2
1Department of Pathology and 2Department of Dermatology, Eberhard Karls University Tübingen, Germany
Epidemiological investigations reveal that we must expect a rapid increase in cases of diabetes mellitus in the next few years. As a result, vascular complications in the form of macro- and microangiopathy are also expected to arise more frequently. A classical example of macroangiopathy is coronary arteriosclerosis, microangiopathy is exemplified by diabetic nephropathy. In patients suffering from diabetes, macroangiopathy manifests as atherosclerosis like in nondiabetic patients, characterized by formation of plaques that follows in stages but with an accelerated course due to the different risk factors, especially hyper- and dyslipidemia, with cumulative effects. Thus, atherosclerosis in diabetes begins earlier, is more markedly pronounced and progresses more rapidly. The pathogenetic concept is based on an endothelial lesion that occurs as a result of a diabetes-specific, endothelium-damaging parameters. In case of diabetic microangiopathy � histologically characterized by a progressive glomerulosclerosis, arteriolosclerosis and interstitial fibrosis � hyperglycemia, along with its consecutive and complex processes that induce matrix increase, is considered to be the primary pathogenetically relevant factor involved. Insulin resistance seems to be the major common denominator at the center of both diabetic macroangiopathy and microangiopathy.Correspondence to:
Prof. Dr. med. V. Gärtner
Department of Pathology
Eberhard Karls University
Liebermeisterstraße 8
72076 Tübingen, Germany
Email: hvgaertn@med.uni-tuebingen.de
Original
Serum cystatin C-based equation compared to serum creatinine-based equations for estimation of glomerular filtration rate in patients with chronic kidney disease
R. Hojs, S. Bevc, R. Ekart, M. Gorenjak and L. Puklavec
Abstract
R. Hojs1, S. Bevc1, R. Ekart1, M. Gorenjak2 and L. Puklavec3
1Department of Nephrology, Clinic of Internal Medicine, 2Department of Clinical Chemistry, 3Department of Nuclear Medicine, Clinical Internal Medicine, University Medical Center Maribor, Slovenia
Estimation of the glomerular filtration rate (GFR) is essential for the evaluation of patients with chronic kidney disease (CKD). The Cockcroft-Gault (CG) and modification of diet in renal disease (MDRD) formulas are serum creatinine-based equations, and the most widely used tests for renal function. Recently, serum cystatin C-based equations were proposed as markers for estimation of GFR. The present study compares our serum cystatin C-based equation (cystatin C formula) and serum creatinine-based equations for a large group of patients with CKD. In this study, 592 adult patients with CKD were enrolled. In each patient, serum creatinine was determined and creatinine clearance was calculated using the CG and MDRD formulas. The serum cystatin C was determined by an immunonephelometric method and our own cystatin C formula (GFR = 90.63 × cystatin C–1.192) for estimation of GFR was developed. GFR was measured using 51CrEDTA clearance, and the correlation, accuracy, bias and precision were determined. Ability to correctly estimate the patient’s GFR with different equations compared to gold standard below and above 60 ml/min/1.73 m2 was analyzed. The mean 51CrEDTA clearance was 47 ml/min/1.73 m2, the mean serum creatinine was 269 mmol/l and the mean serum cystatin C was 2.68 mg/l. Statistically significant correlation between 51CrEDTA clearance with the CG (r = 0.861) and MDRD (r = 0.909) formulas and the cystatin C formula (r = 0.899) was found. The receiver operating characteristic (ROC) curve analysis (cut-off for GFR 60 ml/min/1.73 m2) showed that the cystatin C formula had a significantly higher diagnostic accuracy than the CG formula (p<0.003). All equations underestimated the measured GFR and lacked precision. Analysis of ability to correctly predict the patient’s GFR below or above 60/ml/min/1.73 m2 showed a higher prediction for the cystatin C formula than the MDRD formula (91.6 versus 84.1%, p < 0.0005) and a higher prediction trend than the CG formula (91.6 versus 88.3%, p = 0.078). Our results indicate that serum cystatin C-based equation is a reliable marker of GFR with a very high diagnostic accuracy and ability to predict patients with CKD and GFR under 60/ml/min/1.73 m2.Correspondence to:
S. Bevc, MD, MSc
Univerzitetni klinicni center Maribor,
Klinika za interno medicino
Oddelek za nefrologijo,
Ljubljanska 5, 2000 Maribor, Slovenia
Email: sebastjanb@yahoo.com
Original
Is Cystatin C more sensitive than creatinine in detecting early chronic allograft nephropathy?
F. Ortiz, A. Harmoinen, T. Paavonen, P. Koskinen, C. Grönhagen-Riska and E. Honkanen
Abstract
F. Ortiz1, A. Harmoinen2, T. Paavonen3, P. Koskinen1, C. Grönhagen-Riska1 and E. Honkanen1
1Division of Nephrology, Department on Medicine, Helsinki University Central Hospital, Helsinki, 2Department on Chemistry, Savonlinna Central Hospital, Savonlinna, and 3Department of Pathology, Tampere University Central Hospital, Tampere, Finland
Background: Cystatin C (CyC) has been suggested as a more accurate indicator of renal function than creatinine (Crea). CyC performance against graft histopathology has not been investigated. Aim: To compare CyC and Crea-based methods as predictors of chronic allograft damage index (CADI). Material and methods: 105 protocol biopsies obtained at 6 months post-transplantation were classified with Banff´97 and CADI. CyC and Crea were measured concomitantly. Histology was correlated to CyC, Crea, their reciprocals, CyC-estimated GFR (Larsson), Cockroft and Gault (C&G) and abbreviated MDRD using Kendall’s t. The area under ROC curve (ROC-auc),sensitivity/specificity, positive and negative predictive values were calculated at CADI cut-off of 2. Results: Mild histological changes were best revealed by Crea, although with modest sensitivity/ specificity. A Crea threshold of 111 µmol/l distinguished 74% of the patients with CADI > 2 and excluded this condition in 66%. For Crea, ROC-auc was 0.72 (p<0.001). Crea and 1/Crea correlated best to CADI, chronic allograft nephropathy, chronic inflammation, tubular atrophy, vascular changes and glomerulopathy. Neither C&G nor MDRD improved Crea performance alone. CyC and Larsson formula performed the same (ROC-auc 0.67). A CyC threshold of 1.12 mg/l distinguished 69% of the patients with CADI > 2 and excluded it in 60%. Significant t correlation was found between CyC, 1/CyC and Larsson with CADI, chronic inflammation, tubular atrophy and chronic vascular changes. Conclusions: CyC, 1/CyC and Larsson-estimated GFR did not offer significant advantages over Crea in predicting mild histological allograft changes. Protocol biopsy provides information that cannot be sensitively predicted by biochemical measurements used in clinical practice.Correspondence to:
E. Honkanen, MD, PhD
Chief Physician of the Department of Medicine, Division of Nephrology, Helsinki University Central Hospital, Kasarmikatu 11-13, 00130 Helsinki, Finland
Email: eero.honkanen@hus.fi
Original
Gliquidone therapy of new-onset diabetes mellitus after kidney transplantation
T.R. Türk, S. Bandur, J. Nürnberger, A. Kribben, K. Mann, T. Philipp, U. Heemann, O. Viklicky and O. Witzke
Abstract
T.R. Türk1, S. Bandur2, J. Nürnberger1, A. Kribben1, K. Mann3, T. Philipp1, U. Heemann4, O. Viklicky2 and O. Witzke1
1Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Germany, 2Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic, 3Department of Endocrinology, University Hospital Essen, University of Duisburg-Essen and 4Department of Nephrology, Klinikum rechts der Isar der Technischen Universität München, Germany
Background: New-onset diabetes mellitus (NODM) in renal transplant recipients is a complication associated with an increased long-term morbidity and mortality. However, classic sulphonylureas have not been studied in transplanted patients to date. The purpose of this study was to investigate the use of gliquidone in NODM after renal transplantation. Methods: 47 Caucasian patients with NODM received gliquidone therapy (dose range 15 – 105 mg/d) and were followed for at least 6 months. Controls receiving rosiglitazone (n = 28) were chosen for comparison. Successful treatment was defined as a significant improvement of fasting blood glucose (FBG) concentrations, and HbA1c < 7% in the absence of glucosuria, and without the need for further antidiabetic agents. Results: 29 of the 47 patients were successfully treated with gliquidone. Mean FBG improved from 154 ± 62 mg/dl to 120 ± 30 mg/dl (p = 0.002). The success rate was similar in both groups (62 vs. 71%, p = 0.39). In 4 patients the initial daily dose of gliquidone had to be decreased due to symptoms of hypoglycemia. Pretreatment with other oral antidiabetics could be identified as a negative prognostic factor. Conclusions: The data of our retrospective database study suggest that gliquidone is a safe and effective treatment option for NODM. In comparison to rosiglitazone, gliquidone has shown similar efficacy.Correspondence to:
PD Dr. med. O. Witzke; Department of Nephrology, School of Medicine, University of Duisburg-Essen, Hufelandstraße 55, 45122 Essen, Germany
Email: oliver.witzke@uk-essen.de
Original
A trial comparing local pain after subcutaneous injection of epoetin-b versus darbepoetin-a in healthy volunteers
F. Berthoux, J.-P. Ryckelynck, S. Rouanet, S. Gelu-Mantoulet, F. Montestruc, P. Mouchel and G. Choukroun on behalf of the PAINLESS investigators and coordinators
Abstract
F. Berthoux1, J.-P. Ryckelynck2, S. Rouanet3, S. Gelu-Mantoulet3, F. Montestruc4, P. Mouchel4 and G. Choukroun5 on behalf of the PAINLESS investigators and coordinators
1Department of Nephrology, Dialysis and Renal Transplantation, North University Hospital Saint-Etienne, 2Department of Nephrology, Dialysis and Transplantation CHU de Caen, 3Therapharm Research Caen, 4F. Hoffmann-La Roche Ltd., Neuilly-sur-Seine, 5Department of Internal Medicine, Nephrology, Dialysis and Transplantation, CHU Amiens and Jules Verne University, Amiens, France
Background: The aim of this study was to compare local pain experienced with subcutaneous (s.c.) injection of epoetin-b vs. darbepoetin-a. Methods: 40 healthy volunteers were enrolled into this single-blind, crossover study. After receiving an injection of placebo, individuals were randomized to receive s.c. injections of epoetin-b 6,000 IU (0.3 ml) or darbepoetin-a 30 mg (0.3 ml), with a 1-week washout period between injections. Local pain was evaluated using a Visual Analog Scale (VAS) and a 6-item Verbal Rating Scale (VRS) immediately after (T0) and 1 h after injection (T1). Results: The respective mean (standard deviation) and median (range) VAS values at T0 were 1.2 (1.7) and 0.5 (0.0 – 6.9) for epoetin-b vs. 2.8 (2.4) and 1.9 (0.0 – 9.0) for darbepoetin-a (p<0.0001). At T0, VRS scores demonstrated that 51% of individuals experienced no pain after epoetin-b injection compared with 16% of those receiving darbepoetin-a. The percentage of individuals perceiving moderate or important pain was significantly greater with darbepoetin-a (38%) compared with epoetin-b (5%, p = 0.0005) and placebo (14%). Pain evaluation at T1 showed no difference between treatment groups. Local tolerance was excellent except for a small hematoma with epoetin-b at T1 and with darbepoetin-a at T0 which persisted at T1. Conclusion: In healthy volunteers, s.c. injection of epoetin-b was significantly less painful than with darbepoetin-a and comparable with placebo. No significant pain was apparent at T1 in any group.Correspondence to:
F. Berthoux, MD
Department of Nephrology, Dialysis and Renal Transplantation
Hôpital Nord CHU de Saint-Etienne
42055 Saint-Etienne Cedex 2, France
Email: francois.berthoux@chu-st-etienne.fr
Original
Significance of Tei-index alterations induced by acute preload reduction with hemodialysis
K. Yakabe, S. Ikeda, J. Urata, S. Koga, R. Chijiwa, A. Ninomiya, F. Fukukawa, K. Taura and S. Kohno
Abstract
K. Yakabe1, S. Ikeda2, J. Urata2, S. Koga2, R. Chijiwa2, A. Ninomiya1, F. Fukukawa1, K. Taura1 and S. Kohno2
1Department of Internal Medicine, Nagasaki Municipal Medical Center, 2Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan
Aim: The load dependence of Tei-index, an index to estimate combined systolic and diastolic ventricular functions, remains controversial. Moreover, its significance in the setting of acute preload reduction including hemodialysis (HD) remains unknown. Therefore, we examined the significance of the Tei-index in HD patients. Patients and methods: Doppler echocardiographic parameters of 42 patients with normal left ventricular ejection fraction (LVEF) were evaluated before and after HD. Based on the index of body water excess calculated using a Crit-Line monitor, the patients were assigned to Group A (normal hydration ~ overhydration) and Group B (risk of pulmonary congestion). Results: Group A was younger and had a shorter isovolumic relaxation time (IRT) than Group B before HD. Hemodialysis significantly increased the Tei-index of Group A, which was derived from prolonging IRT and isovolumic contraction time and shortening the ejection time without changing LVEF. Changes in the Tei-index (DTei-index) significantly correlated with the rate at which blood volume decreased. They were derived from graphs generated using the Crit-Line monitor. Furthermore, the DTei-index inversely correlated with the Tei-index before HD. Conclusion: These findings suggest that the Tei-index is preload-dependent, which is related to changes in volume and speed. Thus, the Tei-index should be cautiously interpreted according to various hemodynamic situations. However, the correlation between the DTei-index and the Tei-index before HD implies that the latter could be a good indicator of effective fluid removal by HD.Correspondence to:
S. Ikeda, MD
Second Department of Internal Medicine
Nagasaki University School of Medicine
1-7-1 Sakamoto
Nagasaki 852-8501, Japan
Email: sikeda@nagasaki-u.ac.jp
Original
Sexual function in women undergoing hemodialytic treatment assessed using the female sexual function index (FSFI) and the somatic inkblot series (SIS) test
F. Sogni, M. Zacchero, A. Parola, F. Carboni, C. Terrone and P. Gontero
Abstract
F. Sogni1, M. Zacchero1, A. Parola2, F. Carboni2, C. Terrone1 and P. Gontero1
1Clinica Urologica, Università del Piemonte Orientale, 2Dipartimento di Psicologia Clinica, Ospedale “Maggiore della Carità”, Novara, Italy
Aims: Female sexuality in end-stage renal disease has so far only been explored using non-validated tools. The aim of this study was to compare sexual function among hemodialyzed (HD) patients and healthy controls using validated questionnaires. Material: Two internationally validated tests have been administrated: the female sexual function index (FSFI) questionnaire and a set of tables from the somatic inkblot series (SIS) test which focus specifically on the area of sexuality. Methods: 25 consecutive HD patients were assessed for sexual function using the FSFI. Nine SIS inkblots concerning sexuality were also administered to obtain more detailed information about the psychological component of sexuality. An equal number of control healthy volunteers perfectly matched for age, marital status and educational level underwent the same evaluations, and the results of the two groups were compared. Results: HD patients had significantly lower scores than the controls for all FSFI domains except sexual desire even when stratified by age and marital status. All sexually related thematic areas of the SIS except body perception were significantly affected in the HD group compared to the control group. Conclusions: Chronic renal failure requiring HD treatment adversely affects female sexual function. The psychological impact on patients is significant when compared to an age-matched control group. Both the FSFI questionnaire and the SIS test may be considered useful tools for an integrated medical and psychological screening of FSD.Correspondence to:
F. Sogni, MD
Reparto Urologia
Ospedale Maggiore della Carità,
C.so Mazzini 18,
28100 Novara, Italy
Email: vivienne70@libero.it
Case Report
Crescentic glomerulonephritis associated with totally implantable central venous catheter-related Staphylococcus epidermidis infection
T. Kusaba, M. Nakayama, H. Kato, H. Uchiyama, K. Sato and Y. Kajita
Abstract
T. Kusaba1, M. Nakayama2, H. Kato2, H. Uchiyama2, K. Sato2 and Y. Kajita2
1Division of Nephrology, 2Division of Internal Medicine, Nantan General Hospital, Nantan, Japan
A 59-year-old woman was admitted to our hospital for treatment of acute renal insufficiency. She had been under home intravenous hyperalimentation therapy through a totally implantable central venous catheter for 2 years because of post-radiation enteritis. Clinical examination on admission revealed severe renal insufficiency complicated with hypocomplementemia, marked proteinuria and hematuria. Chest roentgenography demonstrated moderate pulmonary congestion. Hemodialysis was initiated and her pulmonary congestion improved. On the 14th and 21st hospital day, blood culture revealed Staphylococcus epidermidis colonization. Cefazolin was administered and C-reactive protein decreased, however, renal insufficiency and hypocomplementemia did not improve. To investigate the genesis of renal insufficiency, renal biopsy was performed. Light microscopic findings of the kidney revealed severe crescentic glomerulonephritis complicated with moderate tubulointerstitial damage. Immunofluorescence-microscopic findings of the kidney revealed positive IgG, IgM, C3 deposition along the capillary lumen. From these laboratory findings and the clinical course, we diagnosed her renal disease as crescentic glomerulonephritis induced by catheter-related bloodstream infection, and the central venous catheter was removed. After removal, urinary output and hypocomplementemia remarkably improved, however, unfortunately, her renal dysfunction did not improve and maintenance hemodialysis needed to be continued. Although her renal disease was not caused by ventriculo-atrial shunt but by central venous catheter-related bloodstream infection, we supposed that the pathogenesis was a closely similar entity to shunt nephritis.Correspondence to:
T. Kusaba, MD
Division of Nephrology
Nantan General Hospital
25 Yagi-Ueno Yagi-cho Nantan-city,
Kyoto, 629-0197, Japan
Email: fwnk5760@mb.infoweb.ne.jp
Case Report
Simultaneous and sustained remission of intractable myasthenia gravis and focal segmental glomerulosclerosis with tacrolimus treatment
S. Chung, C.W. Park, J. Song, J.A. Kim, S.J. Shin and Y.S. Chang
Abstract
S. Chung, C.W. Park, J. Song, J.A. Kim, S.J. Shin and Y.S. Chang
Division of Nephrology, Department of Internal Medicine, St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
Nephropathies associated with thymoma or myasthenia gravis (MG) have rarely been observed. Furthermore, among the renal pathology of patients presenting with thymic and renal disease, focal segmental glomerulonephritis (FSGS) is the uncommon type. Herein, we report a case of a 50-year-old woman who suffered from intractable MG and FSGS resistant to standard therapy. After the start of low-dose tacrolimus treatment, the patient showed simultaneous and significant improvement of myasthenic symptoms and proteinuria. Although a satisfactory explanation of the underlying mechanism has not been offered yet, T cell dysfunction involved in both diseases might explain their association and improvement. This case suggests that low-dose tacrolimus treatment appears to be effective not only for improving intractable myasthenia symptoms but also for obtaining complete remission of FSGS.Correspondence to:
Y.S. Chang, MD
Division of Nephrology
Department of Internal Medicine
St. Mary’s Hospital
The Catholic University of Korea
62, Yeoeuido-dong, Yeongdeungpo-gu
Seoul 150-713, Republic of Korea
Email: ysc543@unitel.co.kr
Case Report
Familial Mediterranean fever and IgA nephropathy: case report and review of the literature
F. Gok, E. Sari, O. Erdogan, D. Altun and O. Babacan
Abstract
F. Gok1, E. Sari1, O. Erdogan2, D. Altun1 and O. Babacan1
1Department of Pediatrics, Division of Pediatric Nephrology, Gulhane Military Medical Academy School of Medicine, Etlik, Ankara and 2Department of Pediatric Nephrology, Dr. Sami Ulus Childrens Hospital, Ankara, Turkey
Familial Mediterranean fever (FMF) is the most common form of autoinflammatory syndromes and is characterized by recurrent inflammatory attacks of fever and serositis. Amyloidosis is the most common renal complication of FMF. In addition to amyloidosis, many renal lesions have been anecdotally reported in patients with FMF and other hereditary periodic fevers. We report a Turkish child with FMF presenting with hematuria during attacks, in whom kidney biopsy documented the presence of mesangial IgA deposits and the absence of amyloidosis. Kidney biopsy should be performed in patients showing microscopic or gross hematuria during attacks of familial Mediterranean fever in order to gain additional epidemiological data about specific features of renal involvement and to allow adequate treatment.Correspondence to:
F. Gok MD,
Associate Professor
Department of Pediatric Nephrology
Gulhane Military Medical Academy
School of Medicine
06018 Etlik, Ankara, Turkey
Email: faysalgok@yahoo.com
Case Report
Nephrotic syndrome complicating chronic visceral leishmaniasis: re-emergence in patients with AIDS
S. Alexandru, C. Criado, M.L. Fernández-Guerrero, M. de Górgolas, V. Petkov, A. Garcia Perez, J. Egido, A. Barat, F. Manzarbeitia, C. Caramelo and A. Ortiz
Abstract
S. Alexandru1, C. Criado2, M.L. Fernández-Guerrero2, M. de Górgolas2, V. Petkov1, A. Garcia Perez1, J. Egido1, A. Barat3, F. Manzarbeitia3, C. Caramelo1 and A. Ortiz1
1Departments of Nephrology, 2Internal Medicine and 3Pathology, Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Spain
Leishmania infection may be associated with immunecomplex-mediated glomerular injury. Contrary to immune-competent individuals, leishmaniasis in HIV patients is a chronic, relapsing disease. Despite the increasing frequency of the Leishmania/ HIV co-infection, there is a paucity of information on the effects of such co-infection in the kidney. We present a patient with AIDS and refractory, relapsing visceral leishmaniasis who developed nephrotic syndrome associated with renal involvement by Leishmania in the absence of immunecomplex glomerular deposition. For the first time, the relapsing nature of renal injury in this context is documented.Correspondence to:
Dr. A. Ortiz
Unidad de Diálisis
Fundación Jiménez Díaz
Av Reyes Católicos 2
28040 Madrid, Spain
Email: aortiz@fjd.es
Case Report
Long-term (7-year-) treatment with lamivudine monotherapy in HBV-associated glomerulonephritis
M. Mesquita, L. Lasser and P. Langlet
Abstract
M. Mesquita1, L. Lasser2 and P. Langlet2
1Nephrology and Dialysis Unit, 2Hepatogastroenterology Unit, Department of Internal Medicine, CHU-Brugmann, Université Libre de Bruxelles, Belgium
Glomerulonephritis (GN) is an uncommon but well-described complication of chronic hepatitis B virus (HBV) infection. HBV-related membranous nephropathy (MN) may lead to renal failure in 1/3 of the patients and spontaneous remission is rare. There is no standard therapy for HBV-associated MN. We report a case of a 28-year-old man with HBV-associated MN due to pre-core HBV mutant with complete remission under an ongoing 7-year lamivudine monotherapy.Correspondence to:
Dr. M. Mesquita
Department of Nephrology and Dialysis
CHU Brugmann
Bruxelles, Belgium
Email: maria.mesquita@chu-brugmann.be
Case Report
Isolated ventricular noncompaction in patients with chronic renal failure
N.S. Markovic, N. Dimkovic, T. Damjanovic, G. Loncar and S. Dimkovic
Abstract
N.S. Markovic1, N. Dimkovic2, T. Damjanovic2, G. Loncar1 and S. Dimkovic1
1Cardiology Department and 2Center for Renal Disease, Zvezdara University Medical Center, Belgrade, Serbia
Isolated ventricular noncompaction is a rare congenital disorder characterized by the presence of numerous prominent trabeculations and deep intratrabecular recesses which communicate with the ventricular cavity. This disease has a very bad prognosis. Two cases of isolated ventricular noncompaction in patients with chronic renal failure have been described. The first case is a 65-year-old male, on regular hemodialysis for 3.5 years due to mesangioproliferative glomerulonephritis. He was symptomless regarding signs of congestive heart failure, angina pectoris, systemic embolization or arrhythmia. The second case is a patient with chronic renal failure (due to renal calculosis) admitted because of non-ST elevation acute myocardial infarction. In both cases echocardiography revealed an enlarged left ventricle, with extremely thickened walls with two layers: a thin, compacted myocardium on the epicardial side, and a thicker noncompaction endocardial layer. Ratio between noncompaction part of the wall and compaction part was 2.56 in the first and 4.94 in the second case. Blood flow from the left ventricular cavity into recesses was recorded with Color Doppler. Oral anticoagulation therapy was introduced in both of them. Holter ECG in the first patient revealed an intermittent right bandle branch block and in the second patient, premature ventricular contractions. Neurological examination findings were normal in both patients. Echocardiography of first-degree relatives was performed in the first case and it was normal in all 5 relatives. In the second case it was not performed due to technical reasons (relatives live abroad). Regular echocardiographic follow-up of all patients with chronic renal failure is necessary in order to diagnose cardiovascular comorbidities including this rare abnormality and its complications.Correspondence to:
N.S. Markovic, MD, PhD
Assistant Professor
Zvezdara University Medical Center
Cardiology Department
D. Tucovic 161,
11000 Belgrade, Serbia
Email: natmarkovic@yahoo.com
Case Report
Predictable removal of anticardiolipin antibody by therapeutic plasma exchange (TPE) in catastrophic antiphospholipid antibody syndrome (CAPS)
T. Zar and A.A. Kaplan
Abstract
T. Zar and A.A. Kaplan
Department of Medicine, Division of Nephrology, University of Connecticut Health Center, Farmington, CT, USA
Catastrophic antiphospholipid antibody syndrome (CAPS) is a rare life-threatening variant of antiphospholipid antibody syndrome (APS), with an associated mortality rate of > 50%. Treatment recommendations are aggressive and consist of intravenous heparin, steroids, immunoglobulins and/or therapeutic plasma exchange (TPE). At present, insufficient data exist to make precise recommendations regarding the most effective therapy for CAPS. Accumulating evidence over recent years is encouraging and may lead to future guidelines. We report predictive and effective removal of pathological anticardiolipin antibody (aCL AB) in a patient with CAPS. The case report and discussion provide valuable insight into aCL AB production and its removal by first- order kinetics using TPE.Correspondence to:
A.A. Kaplan, MD
Professor of Medicine
Division of Nephrology
University of Connecticut Health Center
Rm L-4078, Farmington, CT 06030, USA
Email: Kaplan@nso.uchc.edu
Case Report
Hemophagocytic lymphohistiocytosis in a pancreas-kidney transplant recipient: response to dexamethasone and cyclosporine
J.M. González-Posada, D. Hernández, A. Martin, J.M. Raya, S. Pitti, A. Bonilla, I. Astigarraga and A. Alarcó
Abstract
J.M. González-Posada1, D. Hernández1, A. Martin2, J.M. Raya3, S. Pitti4, A. Bonilla4, I. Astigarraga5 and A. Alarcó2
1Department of Nephrology, 2Department of General Surgery, 3Department of Hematology, 4Department of Radiology, Hospital Universitario de Canarias, Tenerife and 5Department of Pediatrics, Hospital de Cruces, Barakaldo, Spain
We describe a severe case of hemophagocytic lymphohistiocytosis (HLH), secondary to a candida glabrata retroperitoneal abscess in a 41-year-old simultaneous pancreas-kidney transplantation (SPKT) recipient. Despite percutaneous abscess drainage and antifungal therapy, general status deteriorated with persistent fever, severe pancytopenia and liver dysfunction. Presence of hypertriglyceridemia, very high serum levels of ferritin and hemophagocytosis in a bone-marrow aspirate gave the diagnosis of HLH. Of note, change from tacrolimus to cyclosporine together with dexamethasone produced rapid response with status improvement. We concluded that HLH, a rare but often fatal condition characterized by excessive activation of lymphocytes and macrophages, is a diagnostic and therapeutic challenge in solid-organ transplanted patients and must be suspected in the presence of fever, blood cytopenia and liver dysfunction. Specific antiinfectious therapy together with cyclosporine and dexamethasone may be a therapeutic approach.Correspondence to:
J.M. Gonzalez-Posada, MD
Departament of Nephrology
Hospital Universitario de Canarias
Ofra s/n. La Laguna
38320 Santa Cruz de Tenerife, Spain
Email: jmgposada@hotmail.com
Letter to the Editor
Relapsing calciphylaxis in a young obese patient hemo-dialyzed in a 3- × 8-hour schedule with a favorable outcome after switching to a 6- × 4-hour schedule
G. Jean, T. Vanel, J.-C. Terrat, J.-M. Hurot, C. Lorriaux and C. Chazot
Abstract
G. Jean, T. Vanel, J.-C. Terrat, J.-M. Hurot, C. Lorriaux and C. Chazot
Letter to the Editor
Mycoplasmal pneumonia proceeding acute focal bacterial nephritis
H. Matsukura, T. Miyawaki, M. Miyamoto, Y. Suzuki, H. Kubota and S. Abe
Abstract
H. Matsukura1, T. Miyawaki2, M. Miyamoto3, Y. Suzuki4, H. Kubota5 and S. Abe6
