Volume 69, No. 4/2008(April)
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 Clinical Nephrology
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Review
Hypervolemia, arterial hypertension and cardiovascular disease: a largely neglected problem in peritoneal dialysis
Abstract
R. Brunkhorst
Department Nephrology, Klinikum Hannover, Germany
Here we review the existing data on hypertension, volume overload and volume control in peritoneal dialysis (PD) patients and comment on the impact of these factors on residual renal function and cardiovascular disease in PD patients.Correspondence to:
Prof. Dr. R. Brunkhorst; Department Nephrology, Klinikum Hannover, Podbielskistraße 380, 30659 Hannover, Germany
Email: reinhard.brunkhorst@krk.eu
Originals
Prevalence of cryoglobulinemia and autoimmunity markers in renal-transplant patients
Abstract
S. Faguer, N. Kamar, A. Boulestin, L. Esposito, D. Durand, A. Blancher and L. Rostaing
1Nephrology, Dialysis, and Multiorgan Transplant Unit, University Hospital, and 2Laboratory of Immunology, CHU Rangueil, Toulouse, France
Aims: To examine the prevalence of cryoglobulinemia (Cryo) and autoimmune markers in renal-transplant recipients in a stable condition, and to determine its risk factors and impact upon allograft function. Patients and methods: In May, 2006, 117 kidney-transplant (KT) recipients, aged 31 – 76 years, were tested for cryoglobulinemia, hepatitis B and C, complement C3, C4, CH50, antinuclear (ANAs), anticytoplasmic nuclear (ANCAs) and anticardiolipid antibodies, rheumatoid factor (RF), and lymphocyte subpopulations. Renal, liver, and hematological tests were also performed. Immunosuppressive regimens were based on calcineurin inhibitors (82%). Results: Cryo was positive in 47 patients (Cryo(+): 40.2%), of whom 13 were HCV+ (27.7%), with characteristics of Type II in 21.2% and Type III in 78.8%. Cryo was positive in 13/16 (81.2%) of HCV+/RNA+ patients vs. 34/101 (33.6%, p = 0.0003) of HCV-negative patients. Cryo(+) RT patients had been recipients of a graft for longer (142 months) than Cryo(-) patients, i.e., 95 months (p = 0.02). Creatinine clearances were similar in the two groups (56 vs. 50 ml/mn, p = 0.5), as were microalbuminuria and albuminemia. There was no difference between Cryo(-) and Cryo(+) patients in terms of age, sex, HLA mismatch, daily steroid doses, liver and hematological tests, ANAs, anticardiolipid antibodies, serum complement, and lymphocyte subpopulations. RF occurred in all Cryo(+) patients and in 82.8% of Cryo(-) patients, with higher titers in the Cryo(+) group (23 vs. 9 UI/ml, p = 0.012). ANCA occurred in nine Cryo(-) but in no Cryo(+) patients (p = 0.013). Finally, a multivariate analysis was not able to determine any predictive factor associated with cryoglobulinemia. Conclusion: Cryoglobulinemia is frequent after KT, and is associated with HCV markers, RF, and absence of ANCA.Correspondence to:
Prof. L. Rostaing; CHU Rangueil, Service de Néphrologie, Transplantation d’Organes, Hémodialyse, 1 av. Jean Poulhès, TSA 50032, 31059 Toulouse Cédex 9, France
Email: rostaing.l@chu-toulouse.fr
Originals
A single-center experience with BK virus nephropathy
Abstract
U. Ott, T. Steiner, M. Busch, J. Gerth and G. Wolf
1Department of Internal Medicine III and
2Department of Urology, Friedrich Schiller University, Jena, Germany
Background: BK virus nephropathy has an increasing role in renal transplant dysfunction, since new, highly potent immunosuppressive drugs have been introduced into therapy following renal transplantation. Diagnosis of acute impairment of renal transplant function is complicated by difficulty in differentiating BK virus nephropathy from acute rejection. Patients and methods: We retrospectively described the findings and therapeutic approaches of 6 consecutive patients with BK virus nephropathy in our transplantation center (75 – 80 transplantations/ year). BK virus nephropathy was classified according to Drachenberg et al. [2004]. Results: We observed an incidence rate of < 1% for BK nephropathy in our center. Four patients had a pattern B whereas 2 patients revealed a pattern C of BK virus nephropathy. Focal C4d-positive staining of peritubular capillaries were found in 2 of the 6 cases. For earlier detection of BK nephropathy, a diagnostic algorithm for each patient after renal transplantation was established. Urine was continuously monitored by cytology for decoy cells and PCR for BK virus DNA. If PCR was also positive for the BK virus in plasma, biopsy of the renal allograft was performed. Thereby diagnosis could be confirmed sooner. For treatment of BK nephropathy in our center, we reduced immunosuppressive agents and initiated a virustatic treatment with cidofovir in the first 3 cases. However, results were not satisfactory and two allografts were lost. We then reconsidered our therapeutic approach and switched the immunosuppressive treatment to leflunomide with consistent lowdose steroids. We use therapeutic drug monitoring for leflunomide and aim at a target level of 40 – 100 mg/ml. We lost no allograft with BK nephropathy since using this therapeutic approach. Conclusion: In our center, leflunomide therapy, but not cidofovir, was effective in patients with BK virus nephropathy of the renal allograft.Correspondence to:
G. Wolf, MD; Department of Internal Medicine III, University Hospital Jena, Erlanger Allee 101, 07740 Jena, Germany
Email: gunter.wolf@med.uni-jena.de
Originals
Postdialysis outcomes associated with consistent anemia treatment in predialysis patients with chronic kidney disease
Abstract
J.B. Wish, G.M. Nassar, K. Schulman, M. del Aguila and R. Provenzano
1Case Western Reserve University, Cleveland, OH, 2Renal Research Institute, Houston, TS, 3Thomson Medstat, Cambridge, MA, 4Roche Laboratories Inc., Nutley, NJ, 5St. John Hospital, Detroit, MI, USA
Aims: Anemia and cardiovascular (CV) events are major complications of chronic kidney disease (CKD) during dialysis. We conducted a retrospective observational study in CKD patients with anemia to evaluate the association between predialysis use of erythropoiesis-stimulating agents (ESAs) and postdialysis CV outcomes. Methods: The study analyzed claims data on incident hemodialysis patients aged >= 18 years (identified between January 2000 and November 2005). Patients were identified as anemic and ESA-treated prior to dialysis. ESA treatment was categorized into 4 consistency groups (from least to most consistent ESA use). Results: Of 5,848 hemodialysis patients, 52% were identified as anemic prior to onset of dialysis. Predialysis ESA treatment was received by 62% of anemic patients, with only 23% receiving the most consistent treatment. The risk of a CV event was significantly lower for the ESA-treated compared with ESA-untreated patients (relative risk (RR) 0.70, 95% (95% confidence intervals (CI) 0.61 – 0.82)). Compared with ESA-untreated, those who received ESAs had significantly lower risk of acute myocardial infarction (RR 0.65 (95% CI 0.44 – 0.95)) or inpatient mortality (RR 0.52 (95% CI 0.40 – 0.68)). ESA-treated patients in each of the 4 consistency groups had significantly lower risk of CV events compared with ESA-untreated patients, with the greatest benefit seen in patients who received most consistent ESA (RR 0.61 (95% CI 0.48 – 0.76)). Conclusions: This analysis suggests consistent ESA use to treat anemia of CKD in the predialysis period is associated with improved cardiovascular outcomes in postdialysis patients.Correspondence to:
Dr. J. Wish; Division of Nephrology, Case Western Reserve University, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106, USA
Email: jaywish@earthlink.net
Originals
Idiopathic retroperitoneal fibrosis: a role for mycophenolate mofetil
Abstract
R.D. Swartz, A.M. Lake, W.W. Roberts, G.J. Faerber and J.S. Wolf Jr.
1Division of Nephrology, Department of Internal Medicine and
2Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
Purpose: Idiopathic retroperitoneal fibrosis (IRPF) is an unusual progressive illness for which consistent therapeutic recommendations have not been devised. The present report describes a collaborative nephrology and urology approach to distinguish IRPF from secondary disease and then combine necessary acute surgical or radiological intervention with short-term corticosteroid and with mycophenolate mofetil (MM) to facilitate steroid tapering and long-term management. Materials and methods: 21 patients have been evaluated and followed over a 7-year period, 16 with characteristic IRPF and 5 with secondary retroperitoneal disease. IRPF patients initially received high-dose corticosteroid and MM. We report clinical follow-up along with imaging studies of the retroperitoneum and related organs, serologic markers for systemic disease, and nonspecific acute-phase reactants as indicators of ongoing disease activity. Results: Among IRPF patients, uniform success in stabilizing clinical signs and symptoms, radiological disease in the retroperitoneum and associated organs, and inflammatory indicators have been observed. Corticosteroid therapy can be limited to 6 months or less and MM to approximately 2 years, all with substantial impact on the natural history of IRPF. Conclusions: This is not a randomized, controlled trial, and patients were often referred with prior complications and/or treatments, however, the systematic approach and consistent results support the utility of MM as a safe and effective choice for long-term stabilization in IRPF.Correspondence to:
R.D. Swartz, MD; Division of Nephrology, Department of Internal Medicine,
3914 Taubman Center, Box 0364, University of Michigan Health System, Ann Arbor, MI, 48109-0364, USA
Email: rswartz@umich.edu
Originals
An assessment of cinacalcet HCl effects on bone histology in dialysis patients with secondary hyperparathyroidism
Abstract
H.H. Malluche, M.-C. Monier-Faugere, G. Wang, J.M. Frazão, C. Charytan, J.W. Coburn, D.W. Coyne, M.R. Kaplan, N. Baker, L.C. McCary, S.A. Turner and W.G. Goodman
1University of Kentucky, Division of Nephrology, Bone and Mineral Metabolism, Lexington, KY, USA, 2Nephrology Research and Development Unit, School of Medicine, Porto University, Portugal, 3New York Hospital Medical Center of Queens, Flushing, NY, 4VA Greater Los Angeles Health Care System, Los Angeles, CA, 5Washington University School of Medicine, St. Louis, MO, 6Nephrology Associates, Nashville, TN, 7Amgen, Thousand Oaks, CA, 8David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Aims: Cinacalcet lowers plasma parathyroid hormone (PTH) levels in patients with secondary hyperparathyroidism (sHPT), but the bone histologic response has not been described. This prospective, double-blind, placebo-controlled trial assessed the effects of cinacalcet on bone histology and serum markers of bone metabolism in dialysis patients with sHPT. Methods: Patients with intact PTH (iPTH) >= 300 pg/ml were randomly assigned 2:1 to receive cinacalcet or placebo with concurrent vitamin D and/or phosphate binder therapy. Cinacalcet (30 – 180 mg/day) was used to achieve iPTH levels <= 200 pg/ml. Bone biopsies were performed before and after one year of treatment. Results: Baseline and end-of-study data were available from 32 patients (19 cinacalcet, 13 placebo). Baseline bone turnover was elevated in 27, reduced in 3 and normal in 2 patients. Serum bone-specific alkaline phosphatase (BSAP) and N-telopeptide (NTx) were elevated. Cinacalcet treatment decreased PTH and diminished activation frequency, bone formation rate/bone surface, and fibrosis surface/bone surface. Adynamic bone was observed in three patients receiving cinacalcet; in two of these, PTH levels were persistently low (< 100 pg/ml). The histomorphometric parameter changes in bone corresponded to PTH, BSAP and NTx reductions. Bone mineralization parameters remained normal. Conclusions: Treatment with cinacalcet lowered PTH and reduced bone turnover and tissue fibrosis among most dialysis patients with biochemical evidence of sHPT.
Correspondence to:
H.H. Malluche, MD; Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Room MN 564, 800 Rose Street, Lexington, KY 40536-0084, USA
Email: hhmall@uky.edu
Originals
In-center daily on-line hemodiafiltration: a 4-year experience in children
Abstract
M. Fischbach, C. Dheu, L. Seuge, S. Menouer and J. Terzic
Nephrology Dialysis Transplantation Children’s Unit, Strasbourg, France
Our daily dialysis program was started in September 2002: in-center daily on-line hemodiafiltration (DIH) was carried out in 3-hour sessions, 5 – 6 times weekly, on-line assessment KT/Vurea of minimal 1.5 per session, polysulfone membranes. 12 children were included: median age 7.4 years (2.10 – 16.8 years), renal residual function less than 3 ml/min/1.73 m2 (Kcreat + Kurea/2), vascular access central catheter (n = 4) or fistula (n = 8), 7/12 being converted from peritoneal dialysis to DIH. Median follow-up on DIH was 11 months (4 – 43 months), endpoint was kidney transplantation (11/12) or transfer to another center (1/12). Monthly assessments of dialysis parameters (KT/Vurea, predialysis phosphatemia), diet survey (3 consecutive days), medications (number of antihypertensive drugs, phosphate chelators, potassium chelators) and statural growth were performed. At start of DIH, diet intake due to medical prescription and limited appetite was restrictive with limitation in water, salt (20 mmol/day), potassium and proteins (median 35 g/day, range 20 – 80 g); only 2/12 children were free of antihypertensive drugs, all received phosphate and potassium chelators, and growth retardation occurred (7/12 in prepubertal children, median height SDS –1.52) despite rhGH therapy (5/12 patients). At the end of DIH, diet was free, protein intake high (2 – 3 g/kg/day, range 30 – 100), 10/12 children were free of antihypertensive drugs, 4/12 received potassium chelators, 1/12 received phosphate chelators. All the prepubertal children at inclusion (n = 7) showed catch-up growth with a median growth rate of 0.8 cm/month (0.5 – 1.6 cm/ month). DIH allowed to maintain predialysis phosphatemia in a low normal range (median 1.23 mmol/l, range 1.65 – 0.63), without (11/12 children) need of phosphate chelators. Thanks to DIH children, parents and team care discovered during DIH a new way of life with motivated children, showing natural compliance (no diet restriction, no or few drugs), and most of all children developing with catch-up of growthCorrespondence to:
Prof. M. Fischbach; Nephrology Dialysis Transplantation Children’s Unit University Hospital Hautepierre, Avenue MoliPre, 67098 Strasbourg, France
Email: Michel.Fischbach@chru-strasbourg.fr
Case Reports
Remission of a B cell CLL-associated membranoproliferative glomerulonephritis Type I with rituximab and bendamustine
Abstract
C. Bartel, N. Obermüller, M.J. Rummel, H. Geiger and I.A. Hauser
1Department of Nephrology, University Hospital of Frankfurt/Main and
2Department of Hematology and Oncology, University Hospital of Giessen, Germany
In a 56-year-old white male patient, a membranoproliferative glomerulonephritis Type I was diagnosed after a 12-month history of low grade B cell lymphoma (Binet A). HIV, Hepatitis B and C serology were negative. Due to an impairment of renal function despite chemotherapy with COP, an immunochemotherapy consisting of rituximab (6 cycles) and bendamustine (4 cycles) was given. This therapeutic approach caused a complete remission of the nephrotic syndrome. Renal function and arterial hypertension improved markedly. In addition, urinary sediment became normal and proteinuria disappeared completely.Correspondence to:
Prof. Dr. I.A. Hauser; Department of Nephrology, University Hospital Frankfurt, Medical Clinic III, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
Email: Ingeborg.Hauser@KGU.de
Case Reports
Pauci-immune necrotizing and crescentic glomerulonephritis in a patient with systemic lupus erythematosus
Abstract
A. Fayaz, Y. Pirson, J.-P. Cosyns, J. Yango and M. Lambert
Divisions of 1General Internal Medicine, 2Nephrology and 3Pathology, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
We report a case of pauci-immune proliferative necrotizing and crescentic glomerulonephritis in a patient with systemic lupus erythematosus (SLE) who presented with a nephrotic syndrome, while SLE was clinically and serologically quiescent. Immunofluorescence and electron microscopy examination of the kidney biopsy failed to reveal any significant deposit of immunoglobulins as well as of complement C3 and C1q, excluding lupus nephritis as the determinant of crescentic glomerulonephritis. Anti-myeloperoxydase (MPO) as well as anti-proteinase 3 (PR3) antibodies were absent in the serum. An immunosuppressive regimen including corticosteroids and IV cyclophosphamide led to a dramatic decrease of proteinuria. We conclude that necrotizing glomerulonephritis unrelated to lupus nephritis may occur in a patient with quiescent SLE. An underlying dysfunction of cell-mediated immunity might explain the association of pauci-immune crescentic glomerulonephritis and SLE.Correspondence to:
Prof. Y. Pirson; Division of Nephrology, St. Luc University Hospital, 10 Avenue Hippocrate, 1200 Brussels, Belgium
Email: pirson@nefr.ucl.ac.be
Case Reports
Successful treatment of nephrotic syndrome due to systemic AL amyloidosis after autologous stem cell transplantation: renal response is an important therapeutic end point
Abstract
O.M. Akay, G. Sahin, S. Kabukcuoglu, A.U. Yalcin and Z. Gulbas
1Department of Hematology, 2Department of Nephrology and 3Department of Pathology, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey
Primary systemic (AL) amyloidosis involves vital organs from the early phase of illness, resulting in poor prognosis. Today, high-dose melphalan followed by autologous peripheral blood stem cell transplantation is an effective treatment for systemic AL amyloidosis. We report a patient with nephrotic syndrome due to systemic AL amyloidosis, who was successfully treated with autologous peripheral blood stem cell transplantation. At follow-up 36 months from ASCT, the patient showed a significant improvement in the signs of peripheral neuropathy and reduction in proteinuria without further organ involvement. Due to poor prognosis with conventional therapy, autologous stem cell transplantation should be considered for treatment in patients with systemic AL amyloidosis, and favorable outcome is ensured with achievement of renal response after ASCT.Correspondence to:
O.M. Akay, MD; Department of Hematology, Eskisehir Osmangazi University Medical Faculty, 26480, Eskisehir, Turkey
Email: melhak@hotmail.com
Case Reports
Rapidly deteriorating renal function with membranoproliferative glomerulonephritis Type 1 associated with hepatitis C treated successfully with steroids and antiviral therapy: a case report and review of literature
Abstract
M.S. Ahmed, C.F. Wong, H. Shawki, N. Kapoor and B.K. Pandya
1Department of Nephrology, 2Department of Gastroenterology, Aintree University Hospital Foundation Trust and 3Department of Renal Histopathology, Royal Liverpool University Hospital, Liverpool, UK
Introduction: The hepatitis C virus (HCV) infection is associated with several renal diseases including mixed essential cryoglobulinemia, membranoproliferative glomerulonephritis (MPGN) and less frequently membranous nephropathy and crescentic glomerulonephritis. We present a case of HCV-associated cryoglobulin-negative, MPGN Type 1 with features of early crescents and rapidly deteriorating renal function requiring urgent treatment. Case: A 35-year-old male was admitted with history of arthralgia and erythematous rash. His past medical history included being an intravenous drug abuser. Biochemistry test showed raised serum creatinine of 150 µmol/l. He had nephrotic range proteinuria of 6 g/day and a serum albumin of 23 g/l. Viral serology for hepatitis B and HIV was negative but confirmed evidence of HCV infection with genotype 3A and viral load of 151,014 copies. He had a renal biopsy and histology demonstrated features of crescentic MPGN Type 1. His renal function deteriorated rapidly with his serum creatinine rising to 300 µmol/l over 2 days. We commenced treatment with intravenous methylprednisolone, 500 mg once daily (o.d.) for 3 days, followed by oral prednisolone 40 mg o.d. Concurrently, pegylated Interferon- (IFN) α was commenced. After a 2-week treatment, his renal function showed remarkable recovery with creatinine reduced to 140 µmol/l. After 3 months, ribavirin was added when his renal function remained stable. He had tolerated his treatment without any major side effects. At 6 months follow-up clinic, his renal function was normal with serum creatinine of 69 µmol/l, 24-h urinary protein had dropped to 0.35 g/day, serum albumin increased to 38 g/l and HCV PCR was negative. Discussion: The current treatment strategy of HCV-associated renal diseases includes targeting viral trigger HCV with interferon and ribavirin. Both IFN-α and ribavirin have their limitation and adverse effects. In a clinical scenario where there is evidence of rapidly deteriorating renal function with crescentic glomerulonephritis, cautious use of immunosuppressive therapy may well be essential in the acute stage to halt the progression of kidney damage. Literature review of the treatment strategy for MPGN Type 1, cryoglobulin-negative with early features of crescents associated with HCV showed that there was no report or guideline available. Conclusions: To our knowledge, this is the first case in the literature of rapidly progressing MPGN Type 1 associated with HCV and nephrotic syndrome treated successfully with antiviral drugs and steroids concurrently. Our case highlights an important treatment strategy and may be beneficial to nephrologists facing this clinical scenario in the future. However, a randomized controlled trial is required to evaluate the efficacy of this treatment combination before it can be a standard treatment.Correspondence to:
M.S. Ahmed, MD; Aintree University; Hospital Foundation Trust, Department of Nephrology, Lower Lane, Liverpool, L9 7AL, United Kingdom
Email: msahmed@doctors.org.uk
Case Reports
Severe episodes of extra cellular dehydration: an atypical adult presentation of cystic fibrosis
Abstract
J.-F. Augusto, J. Sayegh, M.-C. Malinge, F. Illouz, J.-F. Subra and P.-H. Ducluzeau
1Service de Néphrologie-Dialyse-Transplantation, 2Service de Génétique Médicale, 3Service d’Endocrinologie-Diabétologie-Nutrition, and 4UPRES EA 3863, Centre Hospitalier et Universitaire Angers, Université Angers, UPRES EA 3863, Angers, France
Cystic fibrosis (CF) is usually diagnosed during childhood by respiratory or gastro-intestinal symptoms. Hyponatremic hypochloremic dehydration with metabolic alkalosis is a rare but typical presentation of CF in infants. In contrast, only 3 cases have been described in adults. We report a case of CF in a 33-year-old Caucasian female presenting with a severe sodium and chloride depletion caused by inappropriate sweating. She experienced three episodes of severe dehydration before the diagnosis was suspected. Sweat chloride test was pathological and mild pulmonary involvement was found on CT scan. DeltaF508 mutation and a rare mutation (3849+40 A/G) on the intron 19 of CFTR gene were found. Interestingly, our patient has a heterozygote twin sister, carrier of the same mutations of CFTR gene who also developed CF but with a different phenotype. We suspect modifier genes to be implicated in the differences observed between the two phenotypes. We discuss the physiopathology of electrolyte disturbance and review the other similar adults cases.Correspondence to:
Prof. J.-F. Subra; Service de Néphrologie-Dialyse-Transplantation, CHU d’Angers, 49933 Angers cedex 9, France
Email: jfsubra@chu-angers.fr
Case Reports
Hypokalemic quadriparesis associated with renal tubular acidosis in a patient with Sjögren’s syndrome
Abstract
B. Aygen, F.E. Dursun, A. Dogukan, I.H. Ozercan and H. Celiker
1Department of Nephrology and 2Department of Pathology, Firat University Medical Faculty, Elazig, Turkey
Sjögren’s syndrome is an autoimmune exocrinopathy that involves both glandular and extra-glandular systems. We report a 25-year-old woman who had rapidly progressive quadriparesis. Biochemical investigations showed severe hypokalemia with hyperchloremic metabolic acidosis diagnosed as distal renal tubular acidosis. Salivary gland biopsy revealed Sjögren’s syndrome as the underlying cause. She recovered following from quadriparesis potassium and alkali replacement.Correspondence to:
Dr. B. Aygen; Firat Universitesi Firat Tip Merkezi, Nefroloji Bilim Dali, 23200, Elazig, Turkey
Email: btaygen@yahoo.com
Case Reports
The reversed ratio of 1-84 PTH (whole PTH)/intact PTH in a patient on hemodialysis associated with primary hyperparathyroidism
Abstract
Y. Mizumura, Y. Mukaiyama, H. Osada, O. Hida, M. Nishimiya and Y. Nakamura
1Division of Nephrology and Dialysis, Eight Nine Medical Clinic, Ageo,
2Department of Internal Medicine, 3Department of Pathology,
4Department of Otolaryngology,
5Department of Radiology, Ageo Central General Hospital, Ageo, Japan
Intact PTH measures not only 1-84 PTH, but also other fragments such as 7-84 PTH. Lately, a measurement of 1-84 PTH has been available as whole PTH assay and the ratio of whole PTH/intact PTH is considered to be between 0.5 and 0.7 in patients on hemodialysis. Therefore, intact PTH should be higher than whole PTH. We present a 57-year-old male with chronic renal failure on hemodialysis whose whole PTH was higher than intact PTH (the reversed ratio of whole PTH/intact PTH). He showed one enlarged parathyroid gland by an ultrasonic test, CT examination and RI subtraction study. After this gland was removed by surgery, the ratio of whole PTH/intact PTH normalized. The size of the resected gland was 22 × 15 × 11 mm. The histologic examination revealed adenoma. This indicates that, if patients with chronic renal failure showed the reversed ratio of whole PTH/intact PTH, the possibility that they could have primary hyperparathyroidism in addition to secondary hyperparathyroidism should be considered.Correspondence to:
Y. Mizumura, MD, PhD; Division of Nephrology and Dialysis, Eight Nine Medical Clinic, Shosan Plaza 6F, 2-1-1, Yatsu, Ageo, Saitama, 362-0042, Japan
Email: mizumura@ach.or.jp
Case Reports
Two consecutive episodes of acute hepatitis C with different genotypes in a hemodialysis patient responsive to PEG-interferon monotherapy
Abstract
S. Lederer, R. Zachoval, U. Hasholzner and H. Schiffl
1KfH Nierenzentrum München-West and Campus Ingolstadt, Nephrologisches Zentrum, Klinikum der Universität München, 2Campus Großhadern, Medizinische Klinik und Poliklinik II, Klinikum der Universität München and 3Medizinisches Versorgungszentrum im Sonnenblock, München, Germany
We report the case of a 63-year-old male patient on long-term hemodialysis who suffered two consecutive episodes of persistent hepatitis C virus infection with different genotypes and was successfully treated with pegylated IFN-α monotherapy each time.Correspondence to:
PD Dr. med. S. Lederer; KfH Nierenzentrum München-West, Elsenheimerstraße 63, 80687 München, Germany
Email: stephan.lederer@kfh-dialyse.de
Letter to the Editor
Cardiac arrest following injection of concentrated trisodium citrate
Abstract
C.D. Punt and W.E. Boer
