Volume 63, No. 6/2005(June)
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 Clinical Nephrology
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Originals
Implication of the peak serum level of mizoribine for control of the serum anti-dsDNA antibody titer in patients with lupus nephritis
Abstract
H. Tanaka, K. Tsugawa, T. Nakahata, M. Kudo, K. Suzuki and E. Ito
Department of Pediatrics, Hirosaki University School of Medicine, Hirosaki, Japan
Aim: Mizoribine (MZR) is a novel selective inhibitor of inosine monophosphatase dehydrogenase that was developed in Japan. We previously reported the efficacy and safety of oral MZR pulse therapy, which is associated with elevated peak serum MZR levels, in selected patients with lupus nephritis. However, only limited information is available as yet on the optimal peak serum level of MZR that would yield an enhanced clinical efficacy without serious toxicity in patients with lupus nephritis. Methods: A total of 11 patients with clinically stable lupus nephritis treated with oral MZR pulse therapy combined with low-dose prednisolone were enrolled in the cross-sectional study. The peak serum concentrations of MZR (as determined by HPLC) and the serum anti-dsDNA antibody titers (as determined by ELISA) were examined in the patients in order to evaluate the correlation between these two parameters. The correlation between the dose of MZR (mg/kg) administered orally as a single daily dose and the peak serum level of the drug was also examined. In two of the patients, serial measurements of the changes in the peak serum levels of MZR and anti-dsDNA titers could be conducted over 10 months. Results: A significant inverse correlation (r = –0.596, p = 0.0116) was observed between the peak serum levels of MZR and the serum anti-dsDNA antibody titers in the study participants, while the dose of prednisolone remained unchanged. The peak level of MZR in the serum was significantly correlated with the single dose of MZR (r = 0.509, p = 0.0371). In the two patients in whom serial measurements were conducted, the first patient who showed a peak serum MZR level of less than 2.5 – 3.0 mg/ml eventually developed an increase of the serum anti-dsDNA titer with hypocomplementemia and proteinuria. On the other hand, in the second patient who showed a peak serum MZR level in excess of 4.0 mg/ml, persistently low serum anti-dsDNA titers with normocomplementemia were observed. Conclusion: Although this study is only a preliminary study conducted on a small sample, we speculate from the results that a peak serum level of MZR of at least more than 2.5 – 3.0 mg/ml is necessary to achieve satisfactory clinical efficacy of the drug for the treatment of lupus nephritis. Further study is needed to confirm these preliminary findings.Correspondence to:
H. Tanaka, MD
Department of Pediatrics
Hirosaki University, School of Medicine
5 Zaifu-cho, Hirosaki 036-8562, Japan
Email: hirotana@cc.hirosaki-u.ac.jp
Originals
Antineutrophil cytoplasmic antibodies (ANCA) in Chinese patients with anti-GBM crescentic glomerulonephritis
Abstract
G. Yang, Z. Tang, Y. Chen, C. Zeng, H. Chen, Z. Liu and L. Li
Department of Nephrology, Jinling Hospital, Nanjing University, School of Medicine, Nanjing, P.R. China
Objective: To study the prevalence of ANCA and their target antigen in Chinese patients with anti-GBM crescentic glomerulonephritis (CGN), and to evaluate the possible role of ANCA in Chinese anti-GBM CGN patients with coexisting serum ANCA by studying clinicopathologic features of this disease. Material and methods: Twenty-three sera were collected from 23 renal biopsy-proven anti-GBM CGN patients. According to the standardized procedures, all of the sera were determined by both, indirect immunofluorescence (IIF) ANCA, and enzyme-linked immunosorbent assay (ELISA) MPO-ANCA, PR3-ANCA and BPI-ANCA. The patients were divided into two groups according to serum ANCA positivity (Group A) or negativity (Group B). Thirty-three ANCA-associated pauci-immune CGN patients were regarded as control group (Group C). Their clinicopathologic features were compared to reveal whether ANCA correlated with disease activity. Results: There were 11 (47.8%) cases with positive serum ANCA in 23 anti-GBM glomerulonephritis patients. There were 4/11 MPO-ANCA (one with positive PR3-ANCA and C-ANCA, three with negative IIF-ANCA), 1/11 PR3-ANCA (with positive MPO-ANCA and C-ANCA), 3/11 P-ANCA (with negative ELISA-ANCA) and 5/11 C-ANCA (one with positive PR3-ANCA and MPO-ANCA, and the other four with negative ELISA-ANCA). No BPI-ANCA was detected. No different clinicopathologic features were found between Groups A and B. Both were different from Group C in age, sex ratio, frequence of anuria and ESRD, variety of crescents, glomerular sclerosis, vessel lesion and prognosis. Conclusion: Our data demonstrate that ANCA in Chinese patients with anti-GBM CGN is not rare. The major target antigen of ANCA is MPO. ANCA seems not to be correlated with disease activity.Correspondence to:
Z. Tang, MD, PhD
Department of Nephrology
Jinling Hospital
305# East Zhongshan Road
Nanjing,
P.R. China (210002)
Email: tangdr@public1.ptt.js.cn
Originals
Lower serum magnesium levels are associated with more rapid decline of renal function in patients with diabetes mellitus type 2
Abstract
P.-C.T. Pham, P.-M.T. Pham, P.-A.T. Pham, S.V. Pham, H.V. Pham, J.M. Miller, N. Yanagawa and P.T.T. Pham
1Nephrology Division, Olive View-UCLA Medical Center, Sylmar, CA, 2Department of Medicine, Central Maine Medical Center, Lewiston, ME, 3Cardiology Division, Roseville Kaiser Permanente, Roseville, CA, 4Cardiology Division, Sacramento VA Medical Center, Ma
Aims: Hypomagnesemia has been implicated in adversely affecting diabetic complications. This is a retrospective study designed to determine whether there is any association between serum magnesium concentration [Mg2+] and the rate of renal function deterioration, as determined by the slope of serum creatinine reciprocals versus time (1/SCr-vs-t), in patients with diabetes mellitus type 2 (DM2). Materials and methods: DM2 patients without known kidney disease seen at Olive View-UCLA Medical Center for any reason during January – March 2001 were included. For each patient, all available data from our electronic database for [Mg2+], hemoglobin A1C (HbA1C), serum creatinine (SCr), lipid profiles, routine urinary analysis, as well as history of hypertension and pharmacy profiles were retrieved. The average of all parameters obtained and linear regression analyses for the slope of 1/SCr-vs-t plot were performed for each patient. Patients were stratified by gender and divided into four groups based on increasing [Mg2+]. Correlations between each parameter including the slope of 1/SCr-vs-t and the four magnesium groups were analyzed. Results: 252 males and 298 females with a mean follow-up of 62.6 ± 22.5 months were included. Patients belonging to lower [Mg2+] groups for both genders had significantly worse slopes of 1/SCr-vs-t plot independent of the presence of hypertension and use of ACEI/ARB, diuretics, HMG-CoA enzyme inhibitors or aspirin. In a multivariate regression analysis controlling for age, HbA1C and various components of the lipid profile, [Mg2+] remained an independent predictor for the slope of 1/SCr-vs-t. A trend for worse proteinuria based on routine urinary analysis was observed among patients belonging to the lowest [Mg2+] group. Conclusions: Lower [Mg2+] is associated with a faster renal function deterioration rate in DM2 patients.Correspondence to:
P.-C.T. Pham
Olive View-UCLA Medical Center
Department of Medicine
Nephrology Division
14445 Olive View Drive, 2B-182
Sylmar, CA 91342, USA
Email: pctp@ucla.edu
Originals
Epitope analysis of myeloperoxidase-specific antineutrophil cytoplasmic autoantibodies (MPO-ANCA) in childhood onset Graves’ disease treated with propylthiouracil
Abstract
M. Fujieda1, K. Suzuki2, H. Sato3, M. Hattori4, N. Wada5, M. Tsuchiya6, N. Okamoto7, T. Murata7, M. Matsudaira8, M. Shimizu9, K. Ohta9, K. Naruse1, S. Sugihara10 and H. Wakiguchi1
1Department of Pediatrics, Kochi University Medical School, Kochi,
2Department of Bioactive Molecules, National Institute of Infectious Disease, Tokyo, 3Division of Endocrinology, Chiba Children’s Hospital, Chiba, 4Department of Pediatric Nephrology, Tokyo Women’s Medical University, Tokyo, 5Department of Pediatric Nephrology, Shizuoka Children’s Hospital, Shizuoka, 6Department of Pediatrics and Child Health, Nippon Medical School Hospital, Tokyo, 7Department of Pediatrics, Osaka Medical College, Osaka, 8Department of Pediatrics, Nagasaki University, Graduate School of Biomedical Sciences, Nagasaki, 9Department of Pediatrics, Kanazawa University, Graduate School of Medical Science, Kanazawa, and 10Department of Pediatrics, Daini Hospital, Tokyo Women’s Medical University, Tokyo, Japan
Aim: This study aimed to elucidate the relationship between epitope profiles and clinical manifestations of patients with myeloperoxidase antineutrophil cytoplasmic autoantibodies- (MPO-ANCA) positive childhood onset Graves’ disease treated with propylthiouracil (PTU). Methods: Sixteen patients were studied. The patients were grouped into ten without clinical vasculitis and nephritis (non-vasculitis group) and six with biopsy-proven pauci-immune necrotizing crescentic glomerulonephritis (vasculitis group). Epitope analysis was performed on serum samples by an enzyme-linked immunosorbent assay (ELISA) using a panel of recombinant deletion mutants of MPO. Results: The high frequency sites were region upstream of Met341 (Ha region) near the N-terminus of the heavy chain, and regions downstream of Gly598 (Hf and Hg regions) near the C-terminus. Most patients in the non-vasculitis group had polyclonal MPO-ANCA recognizing both the above linear sites and other epitope sites of the heavy chain of MPO. Only one of ten patients in the non-vasculitis group, and four of six patients in the vasculitis group had MPO-ANCA recognizing only the linear sites of the heavy chain of the MPO molecule (Ha, Hf and/or Hg). Of the four patients in the vasculitis group, two had nephritis, like rapidly progressive glomerulonephritis and one had alveolar hemorrhage. Conclusion: These findings suggest that most patients with childhood onset Graves’ disease treated with PTU who manifest no vasculitis have polyclonal MPO-ANCA recognizing both the linear and other epitope sites of the heavy chain of MPO. However, some patients who develop nephritis have MPO-ANCA recognizing only the linear sites of the heavy chain of MPO. This clonality of MPO-ANCA may be a risk factor that induces clinical vasculitis and nephritis in patients treated with PTU. Therefore, patients exposed to PTU should be monitored for MPO-ANCA level and epitopes.Correspondence to:
M. Fujieda, MD
Department of Pediatrics
Kochi University
Medical School,
Kohasu, Oko-cho, Nankoku, Kochi 783-8505, Japan
Email: fujiedam@med.kochi-u.ac.jp
Originals
Influence of carvedilol on chronic renal failure progression in spontaneously hypertensive rats with adriamycin nephropathy
Abstract
D. Jovanovic, D. Jovovic, N. Mihailovic-Stanojevic, Z. Miloradovic, J. Dimitrijevic, N. Maksic and L. Djukanovic
1Clinic of Nephrology, 2Institute of Medical Biochemistry, Clinical Centre of Serbia, and 3Institute for Medical Research, Belgrade, Serbia and Montenegro
Background: In this study, the effects of carvedilol, antihypertensive (a-b blocker) agent with antiproliferative and antioxidative properties, on slowing down of chronic renal failure (CRF) progression in spontaneously hypertensive rats (SHR) with adriamycin (ADR) nephropathy were examined. Methods: Eighty adult (24 weeks) SHR were divided into four groups: Control group: 20 SHR; ADR group: 20 SHR treated with ADR (2 mg/kg i.v. twice in 20 days); ADR-C group: 20 SHR treated with ADR and with carvedilol (30 mg/kg/day); ADR-CC group: 20 SHR treated with carvedilol and captopril (60 mg/kg/day). Systolic blood pressure was measured every two weeks, renal blood flow (RBF), mean arterial pressure (MAP) and renal vascular resistance (RVR) were determined at Weeks 6 and 12, creatinine clearance and proteinuria at Weeks –3 (see measurements), 6 and 12. The rats were sacrificed at Weeks 6 and 12 after the second ADR injection. Glomerular sclerosis, tubulointerstitial and blood vessel changes were determined by semiquantitative scoring. Results: Carvedilol decreased systolic blood pressure. It decreased RVR and MAP, and increased RBF significantly. Carvedilol also significantly decreased interstitial infiltration in the early phase of the study, slowed down the development of interstitial fibrosis and tubular atrophy and decreased blood vessel changes. The hemodynamic and morphological effects of carvedilol were associated with slowing down the CRF progression as well as a mild decrease in proteinuria. Captopril addition to carvedilol improved its effects especially on prevention of tubulointerstitial changes. Conclusions: Results of this experimental study showed beneficial effect of carvedilol and its combination with captopril on CRF progression, indicating that clinical studies are warranted.Correspondence to:
Prof. Dr. D. Jovanovic
Akademska 8
11080 Zemun, Serbia and Montenegro
Email: dijanaj@EUnet.yu
Originals
Once-weekly intravenous paricalcitol in the treatment of secondary hyperparathyroidism in hemodialysis patients
Abstract
M.E. Staniforth, S.C. Cheng and D.W. Coyne
Department of Internal Medicine, Renal Division, and Chromalloy American Kidney Center at Washington University School of Medicine, St. Louis, MO, USA
Background: Paricalcitol, a vitamin D analog, is commonly administered three times weekly to control secondary hyperparathyroidism in hemodialysis patients. Less frequent dosing would be more convenient, require less nursing time, and be an option in other dialysis modalities. No studies have examined the efficacy of once-weekly dosing of paricalcitol. Methods: Chronic hemodialysis patients receiving a stable dose of paricalcitol three times weekly with intact PTH (iPTH) 100 – 500 ng/l were monitored during a two-week baseline, then were converted to a single mid-week paricalcitol dose equal to the previous cumulative weekly dose. Serum calcium and phosphorus were monitored weekly and iPTH levels determined during study Weeks 4 and 8. A single paricalcitol dose adjustment was made during study Week 5 based on iPTH to achieve a target value of 150 – 300 ng/l. Phosphate binders and calcium dialysate bath were kept constant during the study. Results: In the 25 patients, mean iPTH was 295 ± 107 ng/l at baseline, and not significantly different at Week 4 (307 ± 111 ng/l) or Week 8 (285 ± 98 ng/l). Paricalcitol dose increases mid-study were almost exclusively in patients with iPTH > 300 ng/l. Calcium, phosphorus, and calcium ´ phosphorus product were not significantly different on weekly therapy. (Only one patient developed a calcium > 2.55 mmol/l during the study.) Conclusion: Once-weekly dosing of paricalcitol is an effective option in treatment of secondary hyperparathyroidism. Less frequent dosing may better allocate nursing time and potentially benefit other patient populations with CKD and ESRD.Correspondence to:
D.W. Coyne, M.D.
Washington University School of Medicine
660 S. Euclid Ave.
Campus Box 8129
St. Louis, MO 63110, USA
Email: dcoyne@im.wustl.edu
Originals
Lanthanum carbonate (Fosrenol®) efficacy and tolerability in the treatment of hyperphosphatemic patients with end-stage renal disease
Abstract
S.-S. Chiang, J.-B. Chen and W.-C. Yang
1Shin Kong Wu Ho-Su Memorial Hospital, Taipei, 2Chang Gung Memorial Hospital at Kaohsiung, Niao Sung Hsiang, Kaohsiung Hsien, and 3Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, and National Yang-Ming University, School
Aims: High serum phosphorus levels are a common problem in patients receiving long-term dialysis treatment. Lanthanum carbonate (Fosrenol®) is a new non-aluminum, non-calcium phosphate binder developed for the treatment of hyperphosphatemia in patients with end-stage renal disease (ESRD). We report data from a recent trial, which, for the first time, assessed the efficacy and tolerability of lanthanum carbonate treatment, compared with placebo, in Chinese patients with ESRD. Patients and methods: Following a one- to three-week washout phase and a four-week, open-label lanthanum carbonate dose-titration phase, male and female hemodialysis patients were randomized (1:1) to receive either lanthanum carbonate or placebo for four weeks. The primary efficacy parameter of the study was the control of serum phosphorus levels (£ 1.8 mmol/l [£ 5.6 mg/dl]). Secondary endpoints included the profile of serum phosphorus during titration and parathyroid hormone, calcium, and calcium × phosphorus (Ca × P) product levels. The safety and tolerability of lanthanum carbonate were assessed by monitoring adverse events throughout the study. Results: Mean serum phosphorus level at the end of washout was 2.5 ± 0.5 mmol/l (7.7 ± 1.5 mg/dl; n = 73), and there was no evidence of a difference in levels between the treatment groups pre-randomization. At the end of the study, lanthanum carbonate-treated patients had significantly lower phosphorus levels (1.6 ± 0.5 mmol/l [5.1 ± 1.5 mg/dl]; n = 30) than those receiving placebo (2.3 ± 0.4 mmol/l [7.2 ± 1.3 mg/dl]; n = 31; p < 0.001). In addition, a significantly higher proportion of patients receiving lanthanum carbonate had controlled serum phosphorus levels (60%) compared with the placebo group (10%; p < 0.001). Ca × P product levels were also significantly lower in the lanthanum carbonate group at the end of randomized treatment (p < 0.001). Lanthanum carbonate was well tolerated; only one serious adverse event was reported, which was unrelated to treatment. Conclusions: Lanthanum carbonate was shown to be an effective and well-tolerated phosphate binder for the treatment of hyperphosphatemia in Chinese patients with ESRD. This finding supports the results of previous US and European studies, which have also shown that lanthanum carbonate treatment effectively controls serum phosphorus levels.Correspondence to:
W.-C. Yang, MD
Chief, Division of Nephrology
Department of Medicine
Taipei Veterans General Hospital
201 Shih-Pai Road, Section 2
Taipei 11217, Taiwan, R.O.C.
Email: wcyang@vghtpe.gov.tw
Case reports
Kidney disease associated with primary antiphospholipid syndrome: clinical signs and histopathological features in an experience of five cases
Abstract
A. Saracino, A. Ramunni, G. Pannarale and P. Coratelli
Department of Internal and Public Medicine, Division of Nephrology,
University of Bari, Italy
Background: The primary antiphospholipid syndrome (PAPS) is characterized by the presence of circulating antiphospholipid antibodies, clinically associated with blood hypercoagulability. Renal involvement in course of PAPS is very frequent, although the true prevalence of PAPS-correlated kidney disease is difficult to estimate. Materials and methods: We reviewed 270 consecutive renal biopsies examined in our Nephrology Division of Bari University Hospital between 1998 and 2004 to identify those performed in patients with PAPS. Results: We identified five biopsies performed in patients with PAPS. In three patients the diagnosis of PAPS was made at onset of the kidney disorder, while in the other two cases the initial diagnosis was primary focal segmental glomerulosclerosis (FSGS). In these cases the subsequent finding of positive antiphospholipid antibodies reoriented the diagnosis toward PAPS-correlated nephropathy. The clinical onset of kidney disease consisted of acute renal failure in three patients and urinary abnormalities in the other two. Histological examination of renal biopsies showed vascular lesions (intimal fibrous hyperplasia, arteriolar hyalinosis, double outline of the capillary walls) in four patients. Focal segmental glomerulosclerosis was present in four patients, two of whom showed double outline of the capillary walls. All patients had tubulo-interstitial lesions, while immunofluorescence was positive in only two patients. All patients preserved stable renal function throughout follow-up (mean value: 10.6 years, range 4 months – 24 years). The prevalence of PAPS-correlated nephropathy in our population was 1.85% Conclusion: Our data confirm that PAPS-associated nephropathy has slow progression and rarely leads to end-stage renal failure. The prevalence of PAPS-correlated nephropathy is likely underestimated because some patients with a diagnosis of primary focal sclerosis may actually be affected by PAPS.Correspondence to:
Dr. A. Saracino
Chair of Nephrology
Policlinico
Piazza Giulio Cesare 11
70125 Bari, Italy
Email: asaracino@inwind.it
Case reports
Poststreptococcal acute glomerulonephritis superimposed on bilateral renal hypoplasia
Abstract
Y. Naico-Yoshida, M. Hida, Y. Maruyama, N. Hori and M. Awazu
Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
An 8-year-old girl with preexisting chronic renal failure (CRF) due to bilateral renal hypoplasia presented with edema, gross hematuria and acute deterioration of renal function. The diagnosis of poststreptococcal acute glomerulonephritis (PSAGN) was made based on clinical presentation, red blood cell casts, low level of C3 and elevated antistreptolysin 0 titer. Her course was prolonged with serum creatinine increased from the baseline level of 1.1 mg/dl to 2.2 mg/dl, returning toward the baseline level (1.2 mg/dl) after one month. Serum creatinine then started to increase again. The slope of creatinine clearance over time became steeper after the episode of PSAGN. A severe course of PSAGN and subsequent deterioration of renal function have previously been reported in patients with diabetic nephropathy or focal glomerulosclerosis. The present case along with a literature review suggests that individuals with fewer nephrons are at higher risk of severe course and outcome of PSAGN. Conversely, patients with severe PSAGN may be born with fewer nephrons due to low birth weight, unrecognized renal hypoplasia or other unknown causes.Correspondence to:
M. Awazu, MD
Department of Pediatrics
Keio University School of Medicine
35 Shinanomachi
Shinjuku-ku, Tokyo 160-8582, Japan
Email: awazu@sc.itc.keio.ac.jp
Case reports
A case of gain-of-function mutation in calcium-sensing receptor: supplemental hydration is required for renal protection
Abstract
M. Suzuki, T. Aso, T. Sato, M. Michimata, I. Kazama, H. Saiki, R. Hatano, Y. Ejima, N. Miyama, A. Sato and M. Matsubara
1Division of Molecular Medicine, Center for Translational and
Advanced Animal Research, Tohoku University School of Medicine, Sendai, 2Division of Pediatrics, Yokosuka Kyousai Hospital, Yokosuka,
3Hakujikai Memorial Hospital, Tokyo, 4Sekisui Chemical,
Aims: The calcium-sensing receptor (CaSR) regulates the extracellular calcium level, mainly by controlling parathyroid hormon secretion and renal calcium reabsorption. In gain-of-function CaSR mutations, the genetic abnormalities increase CaSR activity leading to the development of such clinical manifestations as hypercalciuric hypocalcemia and hypoparathyroidism. We report a Japanese case of CaSR gain-of-function mutation and represent a therapeutic intervention based on the functional characteristics of CaSR in renal tubule. Methods and results (case): DNA sequence analysis revealed a heterozygous G to T mutation identified in a 12-year-old Japanese girl presenting with sporadic onset of hypercalciuric hypocalcemia and hypoparathyroidism. The mutation is located in the N-terminal extracellular domain of the CaSR gene, one of the most important parts for the three-dimensional construction of the receptor, resulting in the substitution of phenylalanine for cysteine at amino acid 131 (C131F) in exon 3. Based on the diagnosis of the gain-of-function mutation in the CaSR, oral hydrochlorothiazide administration and supplemental hydration were started in addition to calcium supplementation. The combination therapy of thiazide and supplemental hydration markedly reduced both renal calcium excretion and urinary calcium concentration from 0.4 – 0.7 to less than 0.1 mg/mg (urinary calcium/creatinine ratio) and from 10 – 15 to 3 – 5 mg/dl (urinary calcium concentration), respectively. This therapy stopped the progression of renal calcification during the follow-up period. Conclusion: Supplemental hydration should be considered essential for the following reasons: 1) calcium supplementation activates the CaSR in the kidney and suppresses renal urinary concentrating ability, 2) the thiazide has a diuretic effect, 3) as calcium supplementation increases renal calcium excretion, the supplemental hydration decreases urinary calcium concentration by increasing urinary volume, thereby diminishing the risk of intratubular crystallization of calcium ion.Correspondence to:
M. Matsubara, MD, PhD
Division of Molecular Medicine
Center for Translational Advanced Animal Research
Tohoku University School of Medicine
2-1 Seiryo-cho, Aoba-ku, Sendai 980-8575, Japan
Email: mmitsu2i@mail.tains.tohoku.ac.jp
Case reports
Critical renal artery stenoses may cause a spectrum of cardiorenal failure and associated thromboembolic events
Abstract
E. Svarstad, L. Urheim and B.M. Iversen
Renal Research Group, Institute of Medicine, University of Bergen, Bergen, Norway
A wide spectrum of acute or chronic heart failure and thromboembolic events may be causally related to high-grade uni- or bilateral renovascular hypertensive disease, and the variety of these potential interactions may be unrecognized in clinical practice. We present three cases that illustrate the clinical variability of cardiorenal failure and thromboembolic events seen in patients with significant renal artery stenoses. These are high-risk patients where severe morbidity and mortality are threatening. Our patients also demonstrate that the diagnosis often is delayed, and that recanalizing of occluded renal arteries may be highly cost-effective and life-saving in such patients.Correspondence to:
E. Svarstad
Renal Research Group
Medical Department
Haukeland University Hospital
5021 Bergen, Norway
Email: einar.svarstad@helse-bergen.no
Case reports
Obstructive icterus directly related to visceral artery aneurysm in a CAPD patient
Abstract
M.H. Sipahioglu1, B. Tokgöz1, Ö.I. Karahan2, E. Ok3, T. Sav1, O. Oymak1 and C. Utas1
Departments of 1Nephrology and 2Radiology, 3Department of Surgery, Erciyes University Medical School, Kayseri, Turkey
Visceral artery aneurysms (VAA) are uncommon pathologies. We report a case of the first CAPD patient with obstructive jaundice directly related to VAA. A 25-year-old man with a four-year history of hemodialysis followed by two years of CAPD was admitted due to jaundice. He had two episodes of peritonitis. An abdominal ultrasonogram and a selective common hepatic arteriogram confirmed the presence of a 5 cm saccular aneurysm supplied from the gastroduodenal artery and a 4 cm fusiform aneurysm supplied from the proximal part of the common hepatic artery. The gastroduodenal artery was responsible for the impression of the common bile duct. In the operation, the gastroduodenal artery aneurysm was completely excised after its proximal and distal ends were ligated. The proximal and distal ends of the hepatic artery were also ligated. A prosthetic graft (PTFE), which extended from the splenic artery to the distal portion of the hepatic artery, was placed. In this way, the arterial blood flow of the liver was re-established. Patients with VAAs present with a constellation of symptoms including abdominal pain, jaundice and shock (due to rupture of aneurysm). Pancreatitis, and atherosclerosis have been reported to be the most common causes of VAAs. In conclusion, when CAPD patients present with jaundice or hemorrhagic shock with abdominal pain, VAA should be considered in differential diagnosis, especially if patients have a history of frequent pancreatitis episodes, and severe risk factors for atherosclerosis.Correspondence to:
Dr. M.H. Sipahioglu
Erciyes University
Medical School
Department of Nephrology
Kayseri, Turkey
Email: murathsipahioglu@yahoo.com
Letter to the Editor
Cirrhosis and IgA nephropathy related to the PiSZ phenotype of a1-antitrypsin deficiency
Abstract
A. Showkat, B.M. Wall and C.R. Cooke
Letter to the Editor
Successful pregnancy complicated by microscopic polyarteritis nodosa
Abstract
K. Owada, T. Katoh, K. Asano, K. Watanabe, S. Shigetomi and T. Watanabe
Letter to the Editor
Immunoglobulin A nephropathy associated with cyclic neutropenia
Abstract
H. Matsukura, S. Watanabe, Y. Ito, H. Kanegane, T. Miyawaki and K. Shinozaki
