Volume 72, No. 3/2009(September)
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 Clinical Nephrology
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Lead Article
IgA nephropathy in the triethnic population of New Mexico
E.G. Fischer, A.A. Harris, B. Carmichael, S.L. Lathrop and L.A. Cerilli
Abstract
E.G. Fischer1, A.A. Harris1, B. Carmichael1, S.L. Lathrop2 and L.A. Cerilli1
1Department of Pathology, Division of Surgical and Renal Pathology, and 2Office of the Medical Investigator, University of New Mexico, Albuquerque, NM, USA
Aims: IgA nephropathy (IgAN) is the most frequent glomerulonephritis around the globe, but its incidence in the United States is unknown. The disease has a preponderance for certain racial/ethnic groups. Our goals were to retrospectively analyze a series of IgAN biopsies from the state of New Mexico and to calculate an estimated incidence. Then we compared the racial/ethnic composition of our patient cohort to the composition of the New Mexico population and examined the three main racial/ethnic groups for differences in clinical and pathologic parameters. Materials and methods: Renal biopsies and clinical data from IgAN cases newly diagnosed in New Mexico between 2000 and 2005 were reviewed. We compared the racial/ethnic composition of our patient cohort to the demographic composition of the New Mexico population. Demographic, clinical, and histopathologic variables were analyzed with respect to the patients’ race/ethnicity. Results: The incidence of IgAN in New Mexico was 10.2 cases per million persons per year (9.3 when Henoch-Schönlein purpura cases were excluded). American Indians were twice as frequent in our patient cohort when compared to their demographic representation, with the reverse finding for Non-Hispanic Whites. Hispanics more frequently had nephrotic range proteinuria than Non-Hispanic Whites and American Indians. On renal biopsy, endocapillary proliferative glomerulonephritis was the most common glomerular abnormality, followed by the focal segmental glomerulosclerosis (FSGS)-like pattern. The FSGS-like pattern was more frequent in American Indians and Hispanics than in Non-Hispanic Whites. Conclusions: This is the first report of an incidence figure of IgAN for an entire state in the US. American Indian and Hispanic patients had a stronger representation in our cohort than Non-Hispanic Whites, when compared to the general New Mexico population.Correspondence to:
E.G. Fischer, MD, PhD
Department of Pathology, MSC08 4640
University of New Mexico
Albuquerque, NM 87131, USA
Email: efischer@salud.unm.edu
Original
Low-flux hemodialysis suppresses interferon-gamma production: the possible role of beta2-microglobulin
G. Lonnemann, F.H. Bahlmann, J. Freise, B. Hertel and C.A. Dinarello
Abstract
G. Lonnemann1, F.H. Bahlmann2,3, J. Freise4, B. Hertel2 and C.A. Dinarello5
1Group Practice Nephrology/Dialysis, Langenhagen, 2Division of Nephrology, Medizinische Hochschule Hannover, 3Department of Medicine IV, University of the Saarland, Homburg/Saar, 4Division of Respiratory Medicine, Medizinische Hochschule Hannover, Germany, and 5Department of Infectious Diseases, University of Colorado Denver, Aurora, CO, USA
Interferon-gamma (IFN-gamma) is required for the acquired immune response involving maturation and activation of antigen-presenting cells (APC); both IFN-gamma production and activation of APC are impaired in ESRD patients on low-flux hemodialysis (HD). High levels of uremic toxins including beta2-microglobulin (beta2M) are thought to play a role in immunosuppression. Patients and methods: To test this hypothesis, we conducted an A-B-A crossover study to examine the influence of high-flux HD (A) versus low-flux HD (B) in ESRD patients (n = 14) using biocompatible synthetic dialyzer membranes (Polyamix®, Gambro, Hechingen, Germany) and ultrafiltered bicarbonate-buffered dialysis fluid. Each study period lasted 6 months and at the end of each period, Kt/V urea, plasma levels of albumin, C-reactive protein (CRP) and beta2M were determined. In addition, production of IFN-gamma induced by heat-killed Staphylococcus epidermidis (Staph epi) was performed in whole blood cultures. Results: Kt/V urea (mean ± SEM) was 1.45 ± 0.06 in Period A, 1.36 ± 0.07* in Period B, and 1.51 ± 0.07 in Period A’ (*p < 0.01). beta2M resting levels increased from 26.6 ± 1.42 mg/l in Period A to 34.7 ± 2.30* mg/l in Period B, and decreased to 21.6 ± 1.07 mg/l at the end of Period A’ (*p < 0.0001). Albumin and CRP levels did not differ significantly. Staph epi-induced IFN-gamma production was 1.2 ± 0.39 ng/1,000 PBMC at the end of Period A, 0.34 ± 0.10 ng/1,000 PBMC* in Period B, and 2.71 ± 0.67 ng/1,000 PBMC at the end of Period A’ (*p < 0.05). There was an inverse correlation between b2M levels and whole blood IFN-gamma production (R2 = 0.26). Conclusion: High levels of uremic toxins such as beta2M suppress IFN-gamma production in ESRD patients under low-flux HD. High-flux HD reduces beta2M levels by 30% and improves IFN-gamma production suggesting an improved cellular immune response in ESRD patients.Correspondence to:
G. Lonnemann, MD
Gemeinschaftspraxis Nephrologie/Dialyse
Eickenhof 15
30851 Langenhagen, Germany
Email: Lonnemann@eickenhof-dialyse.de
Original
Immediate pain sensation is less with subcutaneous epoietin-beta compared to subcutaneous darbepoietin-alpha
P.M. ter Wee, Y. de Koter, O. van der Veer and M.H. van Vliet
Abstract
P.M. ter Wee, Y. de Koter, O. van der Veer and M.H. van Vliet
Department of Nephrology, Vrije Universiteit University Medical Center, Amsterdam, The Netherlands
Although immediate pain sensation at the injection site is reported by patients, only limited data on comparison of pain at the injection site between erythropoiesis stimulating agents are available. Therefore, we compared the effect of subcutaneous epoietin-beta on immediate pain sensation to that of subcutaneous darbepoietin-alpha in a double blind, randomized controlled study. Adult patients, aged 18 – 75 years, treated with peritoneal dialysis or with stage 4 chronic kidney disease who in our unit are treated with subcutaneous darbepoietin-alpha for renal anemia for at least 3 months, were eligible for the study. After informed consent, patients received on one day four subcutaneous injections, two in each upper leg, in a fixed sequence, blinded to the patient and blinded to the investigator. Injections contained in a random order single dose epoietin-beta (0,3 ml = 4000 IU), darbepoietin-alpha (0,5 ml = 20 µg) and volume matched saline 0.9% placebo injections. Immediately after the four injections, whilst remaining sitting, the subject was requested to fill out one pain scale (Visual Analogue Scale (VAS)) and to verbally evaluate the pain experience (Verbal Pain Score (VPS)). Finally, the subject was requested to rank the four injections from least to most painful (Treatment Ranking). A total of 42 patients (22 male) participated in the study with a mean age of 56.8 ± 1.9 years. The average VAS was lower for epoietin-beta (26.8 ± 4.5 mm) compared to darbepoietin-alpha (58.1 ± 4.6 mm; p < 0.01). Mean VAS for epoietin-beta did not differ from that of the two placebo saline solutions (0,3 ml 26.3 ± 4.4 mm; 0,5 ml 18.4 ± 3.2 mm). Mean VAS for darbepoietin-alpha was significantly higher than placebo (both p < 0.01). Similar observations were obtained for VPS (mean for epoietin-beta 1,3 ± 0.2 and for darbepoietin-alpha 2.9 ± 0.2; p < 0.01) and Treatment Ranking (mean for epoietin-beta 2.0 ± 0.2 and for darbepoietin-alpha 3.2 ± 0.2; p < 0.01). From the results it can be concluded that subcutaneous epoietin-beta caused statistically significant less pain sensation immediately after injection compared to subcutaneous darbepoietin-alpha . The pain caused by subcutaneous epoietin-beta injection was similar to that caused by placebo control injections whereas subcutaneous darbepoietin-alpha injection was significantly more painful than subcutaneous placebo injections.Correspondence to:
P. ter Wee, MD
Department of Nephrology
Vrije Universiteit University Medical Center
De Boelelaan 1117
1081 HV Amsterdam, The Netherlands
Email: pm.terwee@vumc.nl
Original
Slower decline of renal function after initiation of rosiglitazone in diabetics – a pilot study
H. Trivedi, N. Lu, B.T. Andresen and A. Whaley-Connell
Abstract
H. Trivedi1, N. Lu2, B.T. Andresen3 and A. Whaley-Connell3
1Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO, 2Medical College of Wisconsin, Milwaukee, WI, and 3University of Missouri-Columbia, Columbia, MO, USA
Background: To translate laboratory data to the bedside, we hypothesized that initiation of a thiazolidinedione would reduce the rate of progression of renal insufficiency in diabetic subjects. Methods: We included subjects initiated on rosiglitazone for control of diabetes who had at least two consecutive serum creatinine values >= 1.5 mg/dl that were at least 4 weeks apart. We used slope estimates of reciprocal of creatinine vs. time (days) from linear models to derive the rate of decline of renal function before (Phase 1) and after (Phase 2) rosiglitazone initiation. The adjusted rate of decline of renal function was derived using repeated measure models weighted by inverse variances adjusting for hemoglobin A1C and mean blood pressure. Results: There were 114 subjects (113 men, 1 woman; mean age 66.8 ± 9.4 years). The mean duration of Phase 1 was 586.2 ± 275.6 days and Phase 2 was 613.2 ± 281.7 days (p = 0.47). The mean unadjusted Phase 1 slope of reciprocal creatinine vs. time was –0.00015 ± 0.00021 and the Phase 2 slope was –0.00009 ± 0.00021. The mean slope difference (Phase 2 – Phase 1) was 0.00005 ± 0.00031 (p < 0.0001 for Wilcoxon signed rank test and p = 0.0023 for t-test). The adjusted difference in the mean slope was 0.00007 ± 0.00042 (p = 0.0135). Conclusion: There was a slower rate of decline of renal function after initiation of rosiglitazone in diabetic subjects with renal insufficiency. These findings warrant confirmation by a prospective randomized trial.Correspondence to:
H. Trivedi, MD
9200 W. Wisconsin Ave.
Milwaukee, WI 53226, USA
Email: trivedi8@hotmail.com
Original
Acute kidney injury requiring hemodialysis in patients with anicteric leptospirosis
F.P. Hurst,, R.T. Neff, A.R. Katz, A.E. Buchholz, D.M. Sasaki, B.W. Berg, and K.C. Abbott
Abstract
F.P. Hurst1,2,3, R.T. Neff1,2, A.R. Katz4, A.E. Buchholz5, D.M. Sasaki5, B.W. Berg3,6 and K.C. Abbott1,2
1Nephrology Service, Walter Reed Army Medical Center, Washington, DC, 2Uniformed Services University of Health Sciences, F. Edward Hebert School of Medicine, Bethesda, MD, 3Department of Medicine, Tripler Army Medical Center, Honolulu, HI, 4Department of Public Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honululu, HI, 5Hawaii Department of Health, Disease Outbreak Control Divison, and 6Telehealth Research Institute, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
Background: Leptospirosis is an infrequent disease in the US, with most cases reported in the state of Hawaii. Renal involvement is common (44 – 67%), ranging from a mild prerenal azotemia in anicteric disease to renal failure requiring dialysis in Weil’s syndrome (severe leptospirosis with jaundice, renal failure, and hemorrhage). Methods: To describe the pattern of leptospiral renal disease at our institution, we performed a retrospective analysis (1992 – 2004) of all hospitalized cases of laboratory confirmed leptospirosis presenting with acute kidney injury (AKI), defined as a presenting serum creatinine > 1.5 mg/dl. Results: During this time period, 18 patients were hospitalized with laboratory confirmed leptospirosis. Among these patients, 12 had AKI on presentation, and hemodialysis was required in 3 patients. Renal biopsies were performed in 2 of these patients, revealing acute tubulointerstitial nephritis. Interestingly, the patients who required dialysis did not have Weil’s syndrome. They did not exhibit jaundice or hemorrhage, and serum AST (mean 51.7 U/l (range 36 – 60)), ALT (mean 51.0 U/l (range 38 – 64)), and total bilirubin (mean 1.2 mg/dl (range 0.8 – 1.8)) were either within normal limits or only slightly elevated, despite having the worst renal disease. Conclusions: This series adds to other evidence that severe AKI (requiring dialysis) can complicate anicteric leptospirosis in contrast to the notion that the AKI in anicteric disease is typically mild and prerenal. Leptospirosis should be considered in all patients who present with fever and AKI, especially if associated with thrombocytopenia or travel to an endemic area.Correspondence to:
F.P. Hurst, MD
Department of Nephrology
Walter Reed Army Medical Center
6900 Georgia Ave NW
Washington, DC 20307, USA
Email: frank.hurst@us.army.mil
Original
Anticardiolipin antibodies in hemodialysis patients with hepatitis C and their role in fistula failure
S. Ozmen, R. Danis, D. Akin and S. Batun
Abstract
S. Ozmen1, R. Danis1, D. Akin1 and S. Batun2
1Department of Nephrology and 2Department of Biochemistry, Dicle University School of Medicine, Diyarbakir, Turkey
Background/Aims: Several conflicting results are presently reported regarding raised IgG and IgM-anticardiolipin antibodies (ACA) titers in hemodialysis (HD) patients and their role in vascular access dysfunction. We aimed to determine the prevalence of both IgM and IgG-ACA titers and to analyze retrospectively their role in primary and secondary arteriovenous fistula (AVF) failure in a homogeneous group of HD patients with chronic hepatitis C. Methods: This study included 103 adults on maintenance hemodialysis with chronic hepatitis C infection. All participants had blood samples drawn predialysis and after an overnight fast. Analysis included biochemistry, IgG and IgM ACA, Anti-HCV, HBsAg, serum HCV RNA and HCV genotyping. Results: The prevalence of IgG-ACA was 14.6% (15/103). No patient had a positive value of the IgM-ACA test. HCV replication was detected in 52 of 76 patients. The most common HCV genotype was genotype 1 (90%). The percentage of females was higher in ACA(+) group (p = 0.038). There were no significant differences between subjects with and without ACA-IgG regarding other parameters studied. No difference in regard to AVF survival was detected between ACA(+) and ACA(–) groups (p > 0.05). Conclusion: We found no significant differences in primary or secondary AVF failure between patients with elevated and normal ACA. Therefore, we conclude that AVFF may be caused by factors other than ACA in these patients. More prospective studies are needed to confirm this observation.Correspondence to:
Dr. S. Ozmen
Dicle University School of Medicine
Department of Nephrology
21280 Diyarbakir, Turkey
Email: drozmen@gmail.com
Original
Improvement in secondary hyperparathyroidism due to drug adherence monitoring in dialysis patients
M. Pruijm, D. Teta, G. Halabi, G. Wuerzner, V. Santschi and M. Burnier
Abstract
M. Pruijm, D. Teta, G. Halabi, G. Wuerzner, V. Santschi and M. Burnier
Service of Nephrology and Hypertension, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
Background: Poor medication adherence is a frequent cause of treatment failure but is difficult to diagnose. In this study we have evaluated the impact of measuring adherence to cinacalcet-HCl and phosphate binders in dialysis patients with uncontrolled secondary hyperparathyroidism. Methods: 7 chronic dialysis patients with iPTH-levels >= 300 pg/ml despite treatment with >= 60 mg cinacalcet-HCl were included. Medication adherence was measured using the “Medication Events Monitoring System” during 3 months, followed by another 3-month period without monitoring. The adherence results were monthly discussed with the patients, as well as strategies to improve them. Results: During monitoring, the percentage of prescribed doses taken was higher for cinacalcet-HCl (87.4%) and sevelamer (86.3%) than for calcium acetate (76.1%), as was the taking adherence (81.9% vs. 57.3% vs. 49.1%) but not the percentage of drug holidays (12.3% vs. 4.5% vs. 3.6%). Mean PO4 levels (from 2.24 ± 0.6 mmol/l to 1.73 ± 0.41 mmol/l; p = 0.14) and Ca++ × PO4 product (4.73 ± 1.43 to 3.41 ± 1.04 mmol2/l2; p = 0.12) improved and iPTH-level improved significantly from 916 ± 618 pg/ml to 442 ± 326 pg/ml (p = 0.04), without any change in medication. However, as drug monitoring was interrupted, all laboratory parameters worsened again. Conclusions: Assessment of drug adherence helped to document episodes of non-compliance and helped to avoid seemingly necessary dose increases.Correspondence to:
M. Burnier, MD
CHUV, Lausanne
Service of Nephrology – CHUV
Rue du Bugnon 17
1011 Lausanne, Switzerland
Email: michel.burnier@chuv.ch
Case Report
Nephrotic syndrome as paraneoplastic manifestation of a primary pulmonary lymphoepithelioma-like carcinoma
M.D. Arenas, M.T. Gil, T. Malek, J. Farré, F.J. Fernández Morejón, J.M. Arriero, I. Aranda, A. Moledous and F. Álvarez-Ude
Abstract
M.D. Arenas1, M.T. Gil1, T. Malek1, J. Farré3, F.J. Fernández Morejón3, J.M. Arriero4, I. Aranda2, A. Moledous1 and F. Álvarez-Ude5
1Servicio de Nefrologia, 2Servicio de Anatomía Patológica, Hospital Perpetuo Socorro, Alicante, 3Servicio de Anatomía Patológica, Hospital San Jaime, Torrevieja (Alicante), 4Servicio Neumología, Hospital de San Juan de Alicante, 5Servicio de Nefrología, H. General de Segovia, Spain
We present a case of nephrotic syndrome secondary to a membranous glomerulonephritis (MG), in a nonsmoking female with a solitary pulmonary nodule, which did not show growth during 2 years of followup. A biopsy by videothoracoscopy showed a granulomatous non-neoplastic process with giant multinucleated cells. The appearance of a nephrotic syndrome and its interpretation as paraneoplastic revealed the existence of a primary pulmonary lymphoepithelioma-like carcinoma (LELC), a very rare pulmonary tumor. After resection of tumor there was a complete recovery from the nephrotic syndrome. This case highlights how the investigation of paraneoplastic syndromes can help in the early diagnosis of some malignancies.Correspondence to:
M.D. Arenas
Hospital Perpetuo Socorro
Plaza Dr Gómez Ulla, 15
03013 Alicante, Spain
Email: lola@olemiswebs.com
Case Report
Acute on chronic subdural hematoma as a rare complication in a microscopic polyangiitis patient receiving antithrombotic treatment
N. Takahashi, H. Kimura, R. Kitai, M. Sato, M. Yoneda, C. Yamamoto, D. Mikami, M. Kuriyama, T. Kubota, H. Itoh and H. Yoshida
Abstract
N. Takahashi1, H. Kimura1, R. Kitai2, M. Sato3, M. Yoneda3, C. Yamamoto1, D. Mikami1, M. Kuriyama3, T. Kubota2, H. Itoh4 and H. Yoshida1
1Department of General Medicine, Division of Nephrology, School of Medicine, Faculty of Medical Sciences, 2Department of Sensory and Locomotor Medicine, Division of Neurosurgery, 3Second Department of Internal Medicine (Neurology), and 4Department of Pathological Sciences, Division of Tumor Pathology, School of Medicine, Faculty of Medical Sciences, University of Fukui, Japan
We report a 56-year-old man with microscopic polyangiitis (MPA) who developed acute exacerbation of a chronic subdural hematoma (SDH). Laboratory data demonstrated elevation of myeloperoxidase antineutrophil cytoplasmic antibody (MPOANCA) and rapidly progressing renal dysfunction. Renal biopsy showed crescentic glomerulonephritis (GN) with membranous nephropathy (MN). He was treated with corticosteroids, antithrombotic agents, and an immunosuppressant. One month after initiation of treatment, he had a mild headache. One month later, he developed acute SDH. Although he recovered completely after the operation, he finally died of bacterial infection. On autopsy, a scar of vasculitis was confirmed in the leptomeninges as well as in the kidney and lung. Although SDH is a rare complication in MPA, nephrologists must pay more attention to the initial symptoms before a hematoma attack such as headache, especially in patients using antithrombotic agents.Correspondence to:
H. Yoshida, MD, PhD, Professor
Division of Nephrology
Department of General Medicine
School of Medicine
Faculty of Medical Sciences
University of Fukui
Fukui, 910-1193, Japan
Email: hayoshi@u-fukui.ac.jp
Case Report
Minimal-change nephrotic syndrome due to occupational mercury vapor inhalation
G. Campbell, D. Leitch, A.J.P. Lewington, P.I. Dargan and R.J. Baker
Abstract
G. Campbell1, D. Leitch2, A.J.P. Lewington1, P.I. Dargan3 and R.J. Baker1
Departments of 1Nephrology and 2Pathology, St. James University Hospital, Leeds, and 3Guy’s and St. Thomas’ Poisons Unit, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
A 25-year-old man developed nephrotic syndrome and severe hypertension following occupational exposure to mercury vapor whilst working at a fluorescent light factory. A renal biopsy confirmed minimal-change disease on light microscopy, immunofluorescence and electron microscopy. He was also noted to be polycythemic which was initially treated with venesection. His blood and urinary mercury levels were elevated and so he was given chelation therapy with 2,3-dimercaptopropane-1-sulfonate (DMPS), along with steroids for his minimal-change disease, resulting in full resolution of his nephrotic syndrome within 6 weeks. He remains well with normal renal function, blood pressure and normal blood and urine mercury concentrations.Correspondence to:
Dr. G. Campbell
Renal Unit
St. James University Hospital
Beckett Street, Leeds, LS9 7TF, UK
Email: garycampbell730@aol.com
Case Report
Cardiac tamponade following insertion of an internal jugular vein catheter for hemodialysis
Y.-M. Lee, H.-J. Kim, J.-E. Lee, J.-H. Song, M.K. Lee, S.Y. Lee and S.H. Ahn
Abstract
Y.-M. Lee1, H.-J. Kim1, J.-E. Lee1, J.-H. Song1, M.K. Lee2, S.Y. Lee2 and S.H. Ahn1
1Departments of Internal Medicine, 2Thoracic and Cardiovascular Surgery, Wonkwang University School of Medicine, Iksan, Republic of Korea
Central venous cannulation is widely used in patients with end-stage renal disease when venous access was not adequately created in advance to be functioning when replacement therapy is required. As with all invasive procedures, central venous cannulation is associated with a number of complications. Cardiac tamponade is a well-recognized complication of this procedure and its mortality is high. It is thought to arise from the guide-wire, dilator and venous cannulation perforating the right atrium, right ventricle and, on rare occasions, the superior vena cava. In this study we describe a case of cardiac tamponade that was caused by perforating the inferior vena cava (IVC) via the guide-wire while attempting internal jugular vein (IJV) catheterization under echographic guidance.Correspondence to:
S.-H. Ahn, MD, PhD, Associate Professor
Department of Internal Medicine
Wonkwang University School of Medicine
344-2 Shinyong-dong
Iksan 570-180, Korea
Email: ashneph@wonkwang.ac.kr
Case Report
Renal amyloidosis in intravenous heroin addicts with nephrotic syndrome and renal failure
I. Manner, S. Sagedal, M. Røger and I. Os
Abstract
I. Manner1, S. Sagedal1, M. Røger2 and I. Os1,3
1Department of Nephrology, 2Department of Pathology, Ullevål University Hospital, and 3University of Oslo, Oslo, Norway
Background: Renal amyloidosis has emerged as an important differential diagnosis when heroin addicts are admitted to renal clinics with proteinuria and nephrotic syndrome. Material: We present nine heroin addicts with renal AA amyloidosis, a condition previously not encountered in Norway, who were admitted to our renal clinic during the last 3.5 years. In the same time period a total of 209 patients were biopsied from native kidneys. Results: Heroin abuse was associated with 70% of all biopsy-verified renal AA amyloidosis during this time period. Renal amyloidosis was found in 9 of the 12 heroin addicts that were biopsied. 6 of the 9 heroin addicts with amyloidosis required dialysis within 13 months after admission. Conclusion: Renal AA amyloidosis among heroin addicts seems to be associated with chronic suppurative skin infections. AA amyloidosis should always be considered in chronic heroin addicts presenting with proteinuria and renal impairment.Correspondence to:
Dr. I. Manner
Department of Nephrology
Ullevål University Hospital
0407 Oslo, Norway
Email: iwma@online.no
Case Report
Cryptococcal pleuritis developing in a patient on regular hemodialysis
K. Kinjo, S. Satake and T. Ohama
Abstract
K. Kinjo, S. Satake and T. Ohama
Department of Internal Medicine, Okinawa Prefectural Hokubu Hospitla, Okinawa, Japan
A 64-year-old male on regular hemodialysis who was a human T lymphotrophic virus Type I (HTLV-I) carrier developed cryptococcal pleuritis. The initial manifestations of the present case were a persistent cough and the accumulation of unilateral pleural effusion. A culture of the pleural fluid of the patient grew cryptococcus neoformans and a test for antigens against cryptococcus neoformans in the pleural fluid was also positive, therefore, cryptococcal pleuritis was diagnosed. Pleural cryptococcosis per se is rare and it is extremely rare for a dialysis patient to develop pleural cryptococcosis. To our knowledge, only a few cases of cryptococcal pleuritis have so far been reported in patients on dialysis. Furthermore, an isolated occurrence of cryptococcal pleuritis with no cryptococcal pulmonary parenchymal lesions, as was seen in the present case, is rare because cryptococcal pleuritis is usually associated with underlying cryptococcal pulmonary parenchymal lesions. Patients on chronic dialysis are susceptible to developing pleural effusion from many etiologies such as congestive heart failure, infection (tuberculosis, bacterial, viral, parasitic, fungal), collagen vascular disease, drug reaction, metastasis, or uremia itself. Cryptococcal pleuritis developing in a dialysis patient is extremely rare, but physicians should consider cryptococcal infection as a possible cause when pleural effusion develops in a dialysis patient and no other cause is identified, as occurred in the present case.Correspondence to:
Kazushi Kinjo, MD
2-12-3 Onaka
Nago City, Okinawa 905-8512, Japan
Email: keikinjo@yahoo.co.jp
Case Report
Renal infarction after cocaine abuse: a case report and review
W. Hoefsloot, R.A. de Vries, R. Bruijnen and F.H. Bosch
Abstract
W. Hoefsloot1,3, R.A. de Vries3, R. Bruijnen2 and F.H. Bosch1
1Departments of Internal Medicine, 2Radiology, 3Hepato-Gastroenterology, Rijnstate Hospital, Arnhem, The Netherlands
A 36-year-old male presented with sudden pain in the left lower abdomen caused by a left renal infarction. Cocaine metabolites were found in the urine and a cocaine-induced renal infarction was diagnosed. Cocaine-induced renal infarction is not frequently reported in the literature. Pathophysiologic mechanisms include direct cocaine-induced platelet activation in combination with vasoconstriction and endothelial damage. There is no proven therapy for this complication.Correspondence to:
W. Hoefsloot
Radboud University Nijmegen Medical Center
Department of Pulmonary Diseases (454)
6500 HB Nijmegen, The Netherlands
Email: W.Hoefsloot@long.umcn.nl
Case Report
Aliskiren corrects recurrent hyperreninemia and hyperaldosteronism in autosomaldominant polycystic kidney disease
P. Amico, S. Kalbermatter and D. Kiss
Abstract
P. Amico, S. Kalbermatter and D. Kiss
Department of Internal Medicine, University of Basel, Division of Nephrology, Kantonsspital, Liestal, Switzerland
A 47-year-old woman with family history of autosomal-dominant polycystic kidney disease (ADPKD), who underwent living-donor kidney transplantation in 2000, presented with recurrent edema, hyperreninemia, and hyperaldosteronism. Since 2002, her antihypertensive therapy comprised ramipril and spironolactone. The post-transplantation kidney function was stable. Based on the clinical picture and reports of renin secretion by renal cysts in ADPKD, we performed a trial of aliskiren therapy (300 mg/day). The patient showed excellent blood pressure control and reduction of edema, with aldosterone levels normalizing within 2 months. This is a novel report of aliskiren therapy for treatment of edema, hyperreninemia, and hyperaldosteronism in ADPKD.Correspondence to:
D. Kiss, MD
Division of Nephrology
Kantonsspital
4410 Liestal, Switzerland
Email: denes.kiss@ksli.ch
Case Report
Profound thrombocytopenia associated with piperacillin in a hemodialysis patient
M.-T. Yan, H.-Y. Chu, T. Chau and S.-H. Lin
Abstract
M.-T. Yan1, H.-Y. Chu1, T. Chau2 and S.-H. Lin2
1Division of Nephrology, Department of Medicine, Ren-Ai Branch, Taipei City Hospital, Taipei, and 2Division of Nephrology, Department of Medicine,Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Piperacillin-induced thrombocytopenia, albeit reversible, is a life-threatening hematological emergency but easily overlooked. We describe a 78-year-old uremic man on regular hemodialysis who received intravenous administration of piperacillin (2 g) 3 times a day to treat nosocomial pneumonia. On the eighth day of therapy, isolated profound thrombocytopenia with a nadir value of 3 × 103/mm3 was noticed. Physical examination revealed multiple bruises over puncture sites and petechiae over bilateral lower extremities. An exhaustive search for potential causes of thrombocytopenia was unrevealing. Upon withdrawal of piperacillin and immediate high-flux hemodialysis, platelet count rapidly normalized up to 215 × 103/ mm3 in 3 days. With the widespread use of piperacillin, early recognition of piperacillin-induced immune thrombocytopenia and prompt withdrawal of the causative antibiotic may achieve less morbidity.Correspondence to:
S.-H. Lin, MD
Division of Nephrology
Department of Medicine
Tri-Service General Hospital
Number 325, Section 2
Cheng-Kung Road, Neihu 114, Taipei, Taiwan
Email: shihhualin@yahoo.com
Letter to the Editor
Influence of darbepoetin-alpha therapy on HbA1c values in hemodialysis patients
T. Okada, T. Nakao, T. Yamanaka and T. Tamekuni and Ikeda
Abstract
T. Okada, T. Nakao, T. Yamanaka and T. Tamekuni and Ikeda
