Volume 68, No. 6/2007(December)
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 Clinical Nephrology
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Reviews
Inflammation from sterile dialysis solutions and the longevity of the peritoneal barrier
Abstract
M.F. Flessner
University of Mississippi Medical Center, Jackson, MS, USA
There now exists a significant amount of evidence from both animal and human studies that commercially-available dialysis solutions result in the changes of the peritoneal barrier. Mesothelial cells undergo an epithelial-to-mesenchymal transition after less than one year of dialysis. After more than 6 years of peritoneal dialysis, there is extensive fibrosis and vasculopathy in the submesothelial compact zone. Clinical studies demonstrate that the structural changes apparently correlate with alterations in transport function and progressive ultrafiltration failure. The possible mechanisms of inflammation include macrophage peroxide production, acidic dialysis solutions, glucose and its degradation products, the presence of a foreign body, and the integrated signaling of the chemokine-cytokine cascade of the peritoneal cellular immune response in conjunction with biofilm on the peritoneal catheter. Basic and translational research efforts are discussed to portray our current knowledge in this area and to outline the remaining questions.Correspondence to:
M.F. Flessner, MD, PhD, Division of Nephrology Department of Medicine, University of MS Medical Center, 2500 North State Street, Jackson, MS 39216-4505, USA
Email: mflessner@umsmed.edu
Reviews
Prescription writing: CAPD and PD plus
Abstract
J.A. Diaz-Buxo
Fresenius Medical Care North America, Waltham, MA, USA
The formulations of prescriptions for CAPD and PD plus are based on the theoretical constructs of equilibration dialysis and automated PD. There is good correlation between the predicted clearances and net ultrafiltration and those observed in clinical practice, particularly for patients with average peritoneal transport. Higher dialysate flows prescribed during APD to enhance small solute clearances and net ultrafiltration often result in reduced sodium removal due to sodium sieving. Sodium sieving can be minimized with APD through optimal prescriptions. The evidence supports the use of PD plus when adequacy targets cannot be achieved with CAPD.Correspondence to:
J.A. Diaz-Buxo, MD, FACP, Fresenius Medical Care NA, 1001 Morehead Square Drive, Suite 407, Charlotte, NC 28203, USA
Email: jose.diaz-buxo@fmc-na.com
Reviews
Dialysis membrane and diffusion of metastatic cancer cells
Abstract
S. Basso Ricci
Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
From a critical review of series of patients on hemodialysis for chronic renal failure and operated for renal neoplasms, it appears there is a low incidence of metastases compared to series of patients operated for malignant renal neoplasms and who have not undergone hemodialysis. In patients on hemodialysis, there are various elements that can influence the diffusion of metastatic cells, such as cytokines, tumor necrosis factor-a, anticoagulants and bisphosphonates. However, particular reference must be made to the possibility of the dialysis membrane in the blocking or inactivation of tumor cells.Correspondence to:
Dr. S. Basso Ricci, Via C. Goldoni 57, 20129 Milan, Italy
Originals
Prevalence of neurovascular compression in patients with essential and secondary hypertension
Abstract
A. Goldmann, T. Herzog, J. Schäffer, M. Mühling, B. Haubitz, H. Haller, H. Becker and J. Radermacher
1Boxbergweg, Neuenkirchen, 2Department of Neuroradiology, Hannover Medical School, Hannover 3Werderstraße, Peine, 4Department of Neurosurgery, 5Department of Nephrology, Hannover Medical School, Hannover, and 6Department of Nephrology, Klinikum Minden, Minden, Germany
Aims: There are discrepant data on the prevalence of vascular compression of the rostral ventrolateral medulla, discussed as a possible cause of essential hypertension, in patients with essential and secondary hypertension. We therefore evaluated the comparative prevalence of neurovascular compression in two large and well defined patient groups with severe essential and secondary hypertension. Patients and methods: 121 patients with long-standing severe (requiring at least three antihypertensive agents for adequate control of blood pressure) essential or secondary hypertension and extensive examination for causes of secondary hypertension were recruited. The presence of neurovascular compression was assessed independently by a neuroradiologist and a neurosurgeon in MRI images for all patients. The subgroup of patients with the highest prevalence of neurovascular compression was identified by CART-analysis. Results: 5 of 121 formerly included patients (4.1%) were excluded for diverging MRI assessments. Neurovascular compression was diagnosed in 50 of 68 patients (73.5%) with essential hypertension and 6 of 48 patients (12.5%) with secondary hypertension. The odds ratio for diagnosis of neurovascular compression in patients with essential hypertension was 19.4 (95%-confidence interval 7.9 – 47.9) compared to patients with secondary hypertension. CART-analysis identified the highest prevalence of neurovascular compression in patients with severe essential hypertension younger than 67.5 years. Conclusions: Since successful decompression or implantation of a carotid sinus stimulator in patients eligible for surgery may lead to substantial improvement in blood pressure in patients in whom blood pressure could not be lowered below 140/90 mmHg by antihypertensive treatment alone MRI screening for the presence of neurovascular compression is justified in patients meeting all of the following three criteria: exclusion of secondary hypertension after extensive examination; hypertension uncontrollable with antihypertensive treatment alone, and age younger than 67.5 years.Correspondence to:
Dr. J. Radermacher, Department of Nephrology, Klinikum Minden, Friedrichstrasse 17, 32427 Minden, Germany
Email: Joerg.Radermacher@klinikum-minden.de
Originals
Molecular analysis of the CLCN5 gene in Dent’s disease: first mutation identified in a patient from South America
Abstract
E. Ramos-Trujillo, V. Garcia-Nieto, H. Gonzalez-Acosta, J. Vara, V. Pérez-Diaz, I. Nadal, R. Oliveros and F. Claverie-Martin
1Unidad de Investigación, 2Unidad de Nefrología Pediátrica, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, 3Unidad de Nefrología Infantil, Hospital Universitario 12 de Octubre, Madrid, 4Servicio de Nefrología, Hospital Universitario de Valladolid, 5Servicio de Pediatría, Hospital Virgen del Camino, Pamplona and 6Nefrología Infantil, Hospital de Cruces, Baracaldo, Spain
Background: Dent’s disease is a rare renal tubular disorder characterized by low-molecular weight proteinuria, hypercalciuria, nephrocalcinosis, nephrolithiasis, rickets and eventual renal failure. The selective loss of low-molecular weight proteins points to a defect of the proximal tubule, where filtered proteins are normally reabsorbed by endocytosis. The disease tends to present in childhood or early adult life, and males are more severely affected than females. The disease is caused by mutations in CLCN5 or OCRL1, both on the X chromosome, which code for the chloride/proton exchange transporter ClC-5 and the phosphatidylinositol-4,5-biphosphate-5-phosphatase, respectively. Methods: Mutational analysis of CLCN5 gene from 4 unrelated patients diagnosed with Dent’s disease and their relatives, 3 from Spain and 1 from Bolivia, was performed by PCR and automatic DNA sequencing. Results: In the current study, we report the identification of 4 mutations in CLCN5 of 1 family from Bolivia and 3 families from Spain. Two of the mutations are novel and consist of 1 nonsense mutation, Y502X, and 1 missense mutation, L225P, affecting ClC-5 α-helix F, one of the helices involved in formation of the chloride selectivity filter. Conclusions: Our results add to the expanding spectrum of mutations in CLCN5. This is the first report of a CLCN5 mutation in a Dent’s disease patient of South American origin.Correspondence to:
F. Claverie-Martín, PhD, Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
Email: fclamar@gobiernodecanarias.org
Originals
Under-recognition of chronic kidney disease in elderly outpatients
Abstract
R. Ouseph, P. Hendricks, J.A. Hollon, B.D. Bhimani and E.D. Lederer
1University of Louisville, Kidney Disease Program, and
2Louisville Veterans Administration Medical Center, Louisville, KY, USA
The elderly are the fastest growing segment of the United States population. Age is a key predictor of chronic kidney disease (CKD). A major obstacle in the recognition of CKD in the elderly is the reliance on serum creatinine measurements as an estimation of glomerular filtration rate (GFR). We hypothesized that early stages of CKD would not be recognized by primary care clinicians providing care to elderly men in a highly structured setting. This study was a retrospective study of outpatients 70 years and older seen in VISN 9 at Veterans Administration Medical Centers from 1/1/2001 thru 12/31/2003. GFR was estimated using the MDRD formula. We abstracted demographic and medical data from the electronic medical record. The population consisted primarily of elderly white male (7,289 men; 91% Caucasian). In CKD Stage 2, 3, and 4, men had a diagnosis code reflecting kidney disease in 1.2%, 20%, and 74.6% of the charts. Despite declining kidney function, nephrology consults were requested in fewer than 5%. In summary, we have shown in a large outpatient population of elderly men that CKD is frequently under-recognized, but most pronounced in CKD Stages 2 and 3. Stages 2 and 3 may be the stages in which the most beneficial effects of interventions can be obtained.Correspondence to:
R. Ouseph, University of Louisville, 615 South Preston St, Louisville, Ky 40202, USA
Email: Rouseph@louisville.edu
Originals
Dose-response to a jelly preparation of calcium polystyrene sulfonate in patients with hyperkalemia – changes in serum potassium levels with or without a RAAS inhibitor
Abstract
Y. Tomino, T. Yamazaki, I. Shou, T. Tsuge, K. Satake, Y. Takeda, A. Ohtani, T. Nishitani, A. Kurusu, C. Hamada, S. Horikoshi, K. Maeda, Y. Tanaka, H. Fukuda, M. Wakabayashi and T. Seto
1Department of Internal Medicine, Division of Nephrology, Juntendo University School of Medicine, 2Division of Nephrology, Juntendo Nerima Hospital, Tokyo, 3Division of Nephrology, Juntendo Shizuoka Hospital, Nagaoka, Izunokuni City, Shizuoka, Japan
Aims: In this study, dose-response of the serum potassium-lowering effect of a calcium polystyrene sulfonate (PS) preparation was investigated. Changes in the serum potassium level were also examined with or without application of a RAAS inhibitor, which is said to increase the serum potassium level. Subjects and methods: 23 patients diagnosed to have hyperkalemia associated with chronic renal failure were enrolled in this study. The study drug, a PS-Ca jelly preparation (Argamate jelly), was started at a daily dose of 1 preparation (5 g as PS-Ca), and the dose was increased by 1 preparation every month to finally reach 3 preparations per day. Blood samples were collected once a month and serum levels of creatinine and electrolytes were measured. Results: PS-Ca jelly decreased serum potassium levels in a dose-dependent manner. Decreases were 0.67 mEq/l at 5 g of PS-Ca/day, 1.06 mEq/l at 10 g/d, and 1.33 mEq/l at 15 g/d. Irrespective of the use of the RAAS inhibitor, serum potassium levels decreased significantly in a dose-dependent manner. Furthermore, no major change in serum creatinine levels occurred in subjects in which the RAAS inhibitor was used, although in subjects in which the RAAS inhibitor was not used, serum creatinine level tended to gradually increase. Conclusion: Serum potassium levels were reduced in a dose-dependent manner by administration of 5 �?? 15 g/d of PS-Ca, and it appeared that together with control of serum potassium levels, renal function should be maintained by continuous administration of RAAS inhibitor.Correspondence to:
Dr. Y. Tomino, Division of Nephrology, Department of Internal Medicine, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo 113-8421, Japan
Email: yasu@med.juntendo.ac.jp
Originals
A randomized, double-blind, crossover design study of sevelamer hydrochloride and sevelamer carbonate in patients on hemodialysis
Abstract
J. Delmez, G. Block, J. Robertson, S. Chasan-Taber, A. Blair, M. Dillon and A.J. Bleyer
1Washington University School of Medicine, St. Louis, MO, 2Denver Nephrologists, PC, Denver, CO, 3Apex Research of Riverside, Riverside, CA, 4Genzyme Corporation, Waltham, MA and 5Section on Nephrology, Wake Forest University Winston-Salem, NC, USA
Aims: Sevelamer carbonate is an anion exchange resin with the same polymeric structure as sevelamer hydrochloride in which carbonate replaces chloride as the anion. The study investigated the effects of sevelamer carbonate and sevelamer hydrochloride on serum phosphorus, lipids and bicarbonate levels in hemodialysis patients. Materials and methods: This was a double-blind, randomized, crossover study. 79 hemodialysis patients were randomly assigned to either sevelamer carbonate or sevelamer hydrochloride for 8 weeks followed by a crossover to the other regimen for an additional 8 weeks of treatment. Results: The mean serum phosphorus was 4.6 ± 0.9 and 4.7 ± 0.9 mg/dl during sevelamer carbonate and sevelamer hydrochloride treatment, respectively. Sevelamer carbonate and sevelamer hydrochloride were equivalent in controlling serum phosphorus, the geometric least square mean ratio was 0.99 (90% CI, 0.95 – 1.03). Mean total and LDL cholesterol were 144.0 ± 33.9 and 59.5 ± 24.9 mg/dl, respectively, during sevelamer carbonate treatment and 139.0 ± 33.6 and 56.0 ± 23.3 mg/dl, respectively, during sevelamer hydrochloride treatment. Serum bicarbonate levels increased by 1.3 ± 4.1 mEq/l during sevelamer carbonate treatment. There were fewer gastrointestinal adverse events with sevelamer carbonate. Conclusions: Sevelamer carbonate and sevelamer hydrochloride were equivalent in controlling serum phosphorus and serum bicarbonate levels increased with sevelamer carbonate. Lipid profiles for both were well-below the levels suggested by KDOQI. Sevelamer carbonate may have advantages over sevelamer hydrochloride in the treatment of hyperphosphatemia in hemodialysis patients.Correspondence to:
J. Delmez, MD, Washington University School of Medicine,
660 South Euclid Avenue, Box 8129, St Louis, MO 63110, USA
Email: jdelmez@wustl.edu
Originals
Cardiac biomarkers are influenced by dialysis characteristics
Abstract
C. Sommerer, S. Heckele, V. Schwenger, H.A. Katus, E. Giannitsis and M. Zeier
1Department of Nephrology, University Department of Cardiology,
University Hospital of Heidelberg, Germany
Introduction: The cardiac biomarkers cardiac Troponin T (cTNT) and NT-proBNP tend to be elevated in nearly all hemodialysis patients. The high percentage and magnitude of these increased molecules is associated with cardiovascular morbidity and mortality in hemodialysis patients. This study investigates the impact of the dialysis procedure itself on cardiac biomarkers. Methods: Standard chronic hemodialysis lasting 4 – 5 hs 3 times weekly and using polysulfone dialyzers (high-flux and low-flux) was performed. Blood flow rates varied between 250 – 350 ml/min. The cTNT levels of 49 chronic hemodialysis patients were measured twice (interval of 6 weeks) before and after a hemodialysis session by a third-generation assay (Elecsys Analyzer, Roche Diagnostics, Mannheim, Germany). NT-proBNP levels were measured with polyclonal antibodies capable of recognizing the N-terminal fragment of BNP. In a follow-up period of 42 months, cardiovascular events and death were assessed. Results: The median concentration of cTNT prior to hemodialysis was 0.024 ng/ml (< 0.001 – 0.703). All dialysis patients presented high plasma levels of NT-proBNP (median 4,885 pg/ml). Oligoanuric patients had significantly higher cTNT and NT-proBNP levels prior to dialysis compared to patients with normal diuresis (p < 0.0001). cTNT and NT-proBNP levels increased significantly during the hemodialysis sessions in which a low-flux dialyzer was used (p < 0.0001) but remained unchanged when a high-flux dialyzer was utilized. Neither the predialytic nor the interdialytic changes in cTNT and NT-proBNP levels were influenced by blood flow. NT-proBNP levels increased markedly during hemodialysis sessions (p < 0.005) utilizing the low-flux dialyzer. Patients with a non-native fistula had significantly higher predialysis cTNT and NT-proBNP levels (p < 0.05). Patients with cardiovascular events had a significantly higher cTNT and NT-proBNP at the beginning of the study. Conclusion: Asymptomatic chronic hemodialysis patients have significantly higher levels of the cardiac biomarkers cTNT and NT-proBNP relative to the general population. The levels are associated with the time of measurement (before and after a hemodialysis session). Dialysis modalities like high-flux dialyzers influence cTNT and NT-proBNP levels and should be taken into account, particularly in patients with acute onset of cardiac ischemia. The elevation of cTNT and NT-proBNP levels after hemodialysis using a low-flux dialyzer are partly due to hemoconcentration. The significant association of cTNT and NT-proBNP with non-native fistulas (catheter or graft) may be due to the chronic inflammation commonly caused by these devices. Both cardiac biomarkers are of prognostic value determining cardiovascular events and death.Correspondence to:
Dr. C. Sommerer, Department of Nephrology, University Hospital of Heidelberg, Im Neuenheimer Feld 162, 69120 Heidelberg, Germany
Email: Claudia.Sommerer@med.uni-heidelberg.de
Originals
Effect of educational hospitalization on chronic kidney disease (CKD) patients
Abstract
K. Yamaji, A. Kurusu, M. Okamoto, Y. Sekiguchi, S. Horikoshi and Y. Tomino
Department of Internal Medicine, Division of Nephrology, Juntendo University School of Medicine, Tokyo, Japan
Although dietary control is recommended to chronic kidney disease (CKD) patients, improvement of compliance and education of outpatients are very difficult. The purposes of the present study are to estimate the dietary intake of sodium (Na) and protein by measuring urinary Na and urea nitrogen (UN) excretion, and to evaluate the efficacy of educational hospitalization. Methods: 70 patients (41 men and 29 women) with a mean age of 58.7 ± 15.8 years participated in the present study. Most patients had chronic kidney disease (CKD, Stage 3 or 4). Patients were hospitalized to learn about their diseases and dietary restrictions for 1 week. Patients were given low salt (less than 6 g/day) and low protein (0.6 – 1.0 g/standard body weight kg/day) diet. 24-hour urine samples were collected at the start (Day 2) and on completion (Day 7) of hospitalization. Salt and protein intakes were estimated using patients’ 24-hour urine samples. Results: Estimated salt intake was significantly decreased on completion of the hospitalization (Day 7) (p < 0.05). Estimated protein intake was also decreased slightly, but this was not statistically significant. There were significant differences in the changes of body weight, body mass index (BMI), and systolic and diastolic blood pressure between the start (Day 2) and completion (Day 7) of hospitalization. 89% of the patients showed an improved blood pressure without changes of antihypertensive drugs. Conclusions: It appears that short-term hospitalization is an effective program for achieving dietary and blood pressure control in CKD patients.Correspondence to:
Prof. Y. Tomino, MD, Division of Nephrology, Department of Internal Medicine, Juntendo University School of Medicine, Hongo 2-1-1, Bunkyo-ku Tokyo, Japan
Email: yasu@med.juntendo.ac.jp
Case Reports
Thrombotic microangiopathy in a 17-year-old patient: TTP, HUS or a bit of both?
Abstract
J. Gerth, M. Busch, F. Oyen, R. Schneppenheim, T. Keller, U. Budde, H.-J. Groene and G. Wolf
1Klinik für Innere Medizin III der Friedrich-Schiller-Universität Jena, 2Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, 3Helios-Klinikum Erfurt, 4Coagulation Laboratory, Laboratory Association Professor Arndt and Partners, Hamburg, 5Department Cellular and Molecular Pathology, German Cancer Research Center, Heidelberg, Germany
Thrombotic microangiopathies are characterized by the development of hyaline thrombi in small vessels resulting in thrombocytopenia, microangiopathic hemolysis, and organ dysfunction. Thrombotic-thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) are two major clinical syndromes of thrombotic microangiopathies. Although differential diagnosis between TTP and HUS is commonly determined in the clinical setting, recent evidence suggests major pathophysiological differences between the two diseases. Autoimmune inhibitors or genetic mutations of a von Willebrand factor (VWF) cleaving metalloprotease (ADAMTS13) leads to the accumulation of unusually large multimeric forms of VWF in TTP, facilitating adherence of platelets and development of microthrombi. In contrast, classic HUS is caused by infection with verocytotoxin-producing bacteria. This toxin induces endothelial injury, apoptosis and inflammation. Endothelial injury results in increased shear-stress, fostering cleavage of VWF, but thrombosis eventually develops. One would assume that measurement of ADAMTS13 activity and/or detection of verocytotoxin could easily contribute to the differential diagnosis of TTP or HUS. We report on a case of a young patient with thrombotic microangiopathy and renal involvement with low ADAMTS13 concentrations which did not respond well to plasmapheresis therapy, but subsequent to the detection of verocytoxin producing E. coli with the serotype O157:H7, reacted well to antibiotic treatment. Sequencing of the ADAMTS13 gene revealed no mutations and no anti-ADAMTS13 antibodies could be detected. This case shows overlapping presentations as well as etiologies for both TTP and HUS, a finding also underscored by a recent animal model in which verocytoxin triggered development of TTP in ADAMTS13-deficient mice.Correspondence to:
Prof. G. Wolf, Klinik für Innere Medizin III, University Hospital Jena, Erlanger Allee 101, 07747 Jena
Email: gunter.wolf@med.uni-jena.de
Case Reports
Focal segmental glomerulosclerosis associated with polycythemia vera:
report of a case and review of the literature
Abstract
S. Okuyama, K. Hamai, M. Fujishima, H. Ohtani, A. Komatsuda, K. Sawada and H. Wakui
1Third Department of Internal Medicine, Akita University School of Medicine and 2Nakadoori General Hospital, Akita, Japan
A 69-year-old female with a 3-year history of polycythemia vera (PV) developed nephrotic syndrome. A renal biopsy showed focal and segmental glomerulosclerosis (FSGS). The patient was treated with prednisolone and myelosuppressive agents. Thereafter, parallel improvement of the two conditions was observed. After 4-year treatment, proteinuria disappeared. To our knowledge, there are five reported cases of FSGS associated with PV. Among them, three patients suffered from progressive azotemia. We suggest that steroid therapy with myelosuppressive agents can resolve the renal lesion in patients with PV.Correspondence to:
H. Wakui, MD, Third Department of Internal Medicine, Akita University School of Medicine, 1-1-1 Hondo, Akita City, Akita 010-8543, Japan
Email: wakui@med.akita-u.ac.jp
Case Reports
Chronic renal insufficiency in a boy with cystic renal lymphangiectasia: morphological findings and long-term follow-up
Abstract
S. Ueda, H. Yanagida, K. Sugimoto, S. Fujita, K. Yagi, M. Okada and T. Takemura
Dpartment of Pediatrics, Kinki University School of Medicine, Osaka-Sayama, Japan
Cystic renal lymphangiectasia (CRL) is a rare malformation of lymphatics that can present in childhood and adulthood. Symptoms and radiologic features are relatively well defined, but clinical evolution and prognosis remain unclear. We treated a boy with CRL who developed chronic renal insufficiency. The first manifestation was abdominal swelling associated with an umbilical hernia noted incidentally at 1.6 years. Computed tomography with intravenous contrast administration demonstrated perirenal cysts with fluid collection, suggesting CRL. Intractable ascites resisted pharmacologic treatments such as diuretics. After approximately 7 years, the ascites resolved spontaneously, but the perirenal cysts persisted. At 11 years, proteinuria was noted. A renal biopsy specimen showed interstitial abnormalities consistent with CRL, glomeruli showed a focal segmental mesangial increase. Proteinuria persisted despite administration of an angiotensin-converting enzyme inhibitor, increasing as obesity and hypertension worsened. Renal function gradually declined in the ensuing years. Polycythemia coexisted with a normal serum erythropoietin concentration. A follow-up renal biopsy specimen disclosed glomerular enlargement together with focal segmental mesangial expansion, suggesting obesity-related glomerulopathy. Our observation suggest that under some specific circumstances like our patient CRL may exacerbate. Management of complicating obesity and hypertension are likely to be important for maintaining normal renal function, especially in the diffuse bilateral type of CRL present in our patient.Correspondence to:
T. Takemura, MD, Department an Pediatrics, Kinki University School of Medicine 377-2 Ohno-higashi, Osaka-Sayama, 589-8511, Japan
Email: tsukasa@med.kindai.ac.jp
Case Reports
Xanthogranulomatous pyelonephritis complicated by emphysematous pyelonephritis in a hemodialysis patient
Abstract
Y.K. Wen and M.L. Chen
1Division of Nephrology, Department of Medicine and 2Department of Pathology, Changhua Christian Hospital, Changhua, Taiwan
Xanthogranulomatous pyelonephritis and emphysematous pyelonephritis are two uncommon variants of pyelonephritis. The combined occurrence is very rare and has not been described in dialysis patients. We report a 78-year-old woman with end-stage renal disease receiving chronic hemodialysis who presented with a one-week history of vague abdominal pain. During the previous 4 months, she had experienced four episodes of urinary tract infection presenting with fever and pyuria which were improved by antibiotic therapy. The urine cultures yielded Klebsiella pneumoniae at all events. Abdominal computed tomography showed the right kidney replaced by multiple hypodense masses. A kidney biopsy demonstrated characteristic pictures of xanthogranulomatous pyelonephritis. Subsequent computed tomography showed gas bubbles formation in the right renal masses suggestive of emphysematous pyelonephritis. Because the patient refused surgical nephrectomy, percutaneous needle aspiration with prolonged antibiotic treatment was done. Follow-up computed tomography demonstrated dramatic regression of the renal mass. This case suggests that xanthogranulomatous pyelonephritis can be complicated by emphysematous pyelonephritis. Furthermore, the unique features in end-stage renal disease patients make the diagnosis of xanthogranulomatous pyelonephritis more difficult.Correspondence to:
Dr. Y.K. Wen, Division of Nephrology, Department of Medicine, Changhua Christian Hospital, 135 Nansiao St., Changhua, 500, Taiwan
Email: 45440@cch.org.tw
Letters to the Editor
Comment on Komenda et al.
Abstract
S. Shaldon
Monte Carlo, Monaco
Correspondence to:
S. Shaldon MA, MD, FRCP, 25 Le Michelangelo, 7 Avenue des Papalins, Monaco 98000
Email: stanley.shaldon@libello.com
Letters to the Editor
Massive hydrothorax complicating peritoneal dialysis in hemolytic uremic syndrome with diarrhea
Abstract
S. Fujinaga, Y. Ohtomo, T. Someya, T. Shimizu, Y. Yamashiro and K. Kaneko
1Division of Nephrology, Saitama Children
Correspondence to:
S. Fujinaga, MD, PhD, Division of Nephrology, Saitama Children
Email: f_shuich@d2.dion.ne.jp
