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Abstract

G.L. Bakris and E. Ritz on behalf of the World Kidney Day Steering Committee

Abstract

T. Anothaisintawee¹, S. Rattanasiri², A. Ingsathit²,³, J. Attia⁴ and A. Thakkinstian²

¹Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, ²Clinical Epidemiology Unit, Faculty of Medicine, Ramathibodi Hospital, Bangkok, ³Department of Medicine, Division of Nephrology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand and ⁴Department of Medicine, John Hunter Hospital Newcastle, New South Wales, Australia
Aims: Many studies have estimated the prevalence of chronic kidney disease (CKD) but results have varied due partly to the type of equation used to estimate GFR, type of subjects, and ethnicity. This review aimed to estimate the prevalence of CKD Stage III, accounting for these factors. Methods: 403 studies were identified from Medline using the PubMed search engine, of which 34 studies were eligible. Data were independently extracted by two reviewers, and heterogeneity was assessed using metaregression. Results: The pooled prevalence was estimated using a random effects model. In the general population, the prevalences of CKD Stage III using MDRD equation were 3.6% (95% CI: 2.5, 4.8), 10.7% (95% CI: 4.5 – 16.9%), and 16.3% (95% CI: 2.1 – 30.5%) for age groups <= 50, 50 – 60 and > 60 years. The prevalence was about double using the Cockcroft-Gault equations, i.e. 7.5% (95% CI: 6.9 – 8.2%) and 34.9 (95% CI: 25.9 – 44.8%) in age <= 50 and > 50 years, respectively. The prevalence was similar in Caucasians and Asians aged <= 60, i.e. 9.9 versus 9.3%. The prevalence was also higher in the diabetic population than in the general population, i.e. 18.2% versus 10.6%. Conclusions: The pooled prevalence of CKD in the general population varied according to age groups. The prevalence is similar in Caucasians and Asians within age 60 years or younger but other age groups need more studies in order to pool. Individual patient meta-analysis would be appropriate to resolve the causes of heterogeneity.Correspondence to:
A. Thakkinstian, PhD; Clinical Epidemiology Unit,
Faculty of Medicine, Ramathibodi Hospital, Rama 6 Road, Rachatevi, Bangkok, Thailand 10400
Email: raatk@mahidol.ac.th

Abstract

M. Kamalesh¹, S. Campbell², C.K. Chong³, A. Gipson³, N. Patel³, C. Ng¹, G.J. Eckert⁴, M. Meda² and S. Sawada¹

¹Division of Cardiology, ²Department of Medicine, ³Division of Nephrology and ⁴Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
Background: Metabolic syndrome (MS) and chronic kidney disease (CKD) are both strongly associated with coronary artery disease (CAD). Components of MS also cause CKD. The incremental effect of CKD on CAD prevalence in MS patients referred for stress imaging studies is unknown. Methods: From January to December 2005, consecutive subjects referred for a stress imaging study were prospectively enrolled. CAD was defined as fixed or reversible defects on nuclear imaging and as resting or stress-induced wall motion abnormalities on echocardiography. MS was defined using NCEP-ATP III criteria. CKD definition was based on calculated glomerular filtration rate. The independent effect of CKD on stress results was assessed using multiple variable logistic regression. Stepwise model selection was used for variable reduction, and areas under the receiver operating characteristic curves (ROC) were calculated. Results: Of 1,122 patients enrolled (mean age 61.4 years, 97% male), 535 (47%) had MS. Among MS patients, 156/535 (29%) had CKD while 116/587 (19%) subjects without MS had CKD. Subjects with CKD were older (p < 0.001) in subjects with and without MS. The presence of CKD affected prevalence of CAD in the non-MS group only, almost doubling it (20% vs. 38%, p < 0.001). Further, using the ordered nature of the 5 CKD stages, worsening severity of CKD had greater prevalence of CAD, in non-MS subjects only (p < 0.001). Conclusions: MS attenuates the effect of CKD on CAD prevalence, regardless of CKD severity. CKD almost doubles the prevalence of CAD in non-MS subjects. CKD severity is associated with greater CAD burden in the non-MS group.Correspondence to:
M. Kamalesh, MD; Indiana University School of Medicine, 1481 W 10th St., Indianapolis, IN 46202, USA
Email: Masoor.kamalesh@med.va.gov

Abstract

J. Benjamin¹, S. Moldavsky¹, J. Lee¹ and R. Rubin²

¹Department of Nephrology and ²Department of Hematology and Thrombosis, Temple University School of Medicine, Philadelphia, PA, USA
Aims: Heparin-induced antibody formation and thrombocytopenia are well-established complications of heparin use and may be associated with thromboembolic events. Our study aimed to establish the prevalence of heparin-induced antibodies (HIA), otherwise known as platelet factor 4 (PF4) antibodies, and their relationship to thrombocytopenia and thrombotic events in a group of predominantly African-American hemodialysis patients over 12 months. For comparison, the prevalence of HIA in thrombocytopenic patients with serum creatinine of less than 2.0 mg/dl tested for the antibody in the same period was evaluated. Methods: 36 hemodialysis patients on thrice-weekly, in-center treatments receiving heparin on dialysis were selected to have blood drawn predialysis for PF4 heparin antibodies (HIA). Complete blood counts (CBC) were also checked that day and monthly for the next 3 months. Outpatient records were reviewed for thromboembolic events, including thrombosis of dialysis access lines, grafts and fistulas. The HIA results for the dialysis patients were compared with HIA performed at the same lab for non-dialysis thrombocytopenic patients during the same period. Results: 17 out of 36 (47%) hemodialysis patients had detectable HIA. There were no differences in gender, ethnicity, disease states, or duration of hemodialysis. None of the patients had thrombocytopenia, and the incidence of thromboembolic events was statistically not different from patients without HIA. The non-CKD thrombocytopenic group had a lower incidence, 16/88 (18%) of positive HIA. Conclusions: Heparin-induced antibodies are relatively common in patients receiving hemodialysis. However, their presence does not appear to be associated with clinical consequences. Therefore, testing for HIA should be done only if a clinical indication is present.Correspondence to:
J. Benjamin, MD; Division of Nephrology, 3322 N.Broad Street, Philadelphia, PA 19140, USA
Email: benjam@temple.edu

Abstract

H. Fehmi¹, Y. Osman¹, S. Bhat¹, K. Nguyen¹, O. Daramola², T. Cantor³, M.-C. Monier-Faugere⁴, J. Yee¹ and H.H. Malluche⁴

¹Henry Ford Health System, Detroit, Michigan, ²CFA Kidney and Hypertension Center, Longwood, FL, ³Scantibodies Laboratory, Santee, CA and ⁴Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
Background: Secondary hyperparathyroidism is a frequent complication of chronic kidney disease (CKD). The goal of treatment is to achieve circulating levels of parathyroid hormone (PTH) associated without oversuppression of bone turnover. This is commonly achieved by treatment with vitamin D analogs. Doses of vitamin D compounds are usually monitored by measurement of circulating levels of PTH. Study design: To prospectively assess the effects on bone histology of two different protocols for dosing vitamin D. Setting and participants: African-American patients from the same geographic area, managed by the same team of physicians in three dialysis clinics were studied. Patients were treated with vitamin D for 3 years and underwent bone biopsies for assessment of bone turnover. Dosing of vitamin D during the 3 years prior to the biopsy was done following two different guidelines. One group was treated following K/DOQI guidelines adapted to the bio-intact PTH assay (Protocol A), the other group was managed (Protocol B) following K/DOQI guidelines for intact PTH and/or the ratio of PTH-(1-84)/N-terminally truncated fragments (PTH ratio). Predictor: Levels of circulating PTH and/or PTH ratio. Outcome: Prevalence of low bone turnover. Measurements: Qualitative and quantitative assessment of bone histology after tetracycline labeling. Results: 7 out of 22 patients managed following Protocol A were found to have low bone turnover (32%) by bone histology. None of the 21 patients managed by Protocol B for guidance of vitamin D therapy, had low bone turnover. Limitations: Lack of bone biopsy at the beginning of study. Conclusions: This report indicates that the additional information provided by the PTH ratio represents a distinct advantage in avoiding low bone turnover over the use of a single PTH assay to guide vitamin D dosing in African-American patients with CKD Stage 5 on dialysis.Correspondence to:
H.H. Malluche, MD, FACP; Division of Nephrology, Bone and Mineral Metabolism, Room MN 564, University of Kentucky Medical Center, 800 Rose Street, Lexington, KY 40536-0084, USA
Email: hhmall@uky.edu

Abstract

Haiyang Zhou and Chenggang Xu

Department of Nephrology, Changzheng Hospital, Second Military Medical University, Shanghai, China
Background: Controversy exists regarding the optimal route and mode of calcitriol administration in the treatment of secondary hyperparathyroidism (SHPT). The aim of this study is to compare the efficacy and adverse reaction of calcitriol in the same mode (intermittent) but different route (intravenous versus oral) in the treatment of SHPT. Methods: Electronic databases including Medline, Embase, Cochrane-controlled trials register, China Biological Medicine Disk (updated February 2008), and manual bibliographical searches were conducted. A meta-analysis of all randomized controlled trials (RCTs) comparing intermittent intravenous with intermittent oral calcitriol in the treatment of SHPT was performed. Results: 6 studies from 5 countries were finally considered for the meta-analysis, including a multicenter trial. The results of meta-analyses showed that there were no significant differences between the two routes in suppressing iPTH, AKP and rising Ca, P. In sensitivity analyses (baseline iPTH >= 600 pg/ml, baseline iPTH < 600 pg/ml, and excluding the multicenter trial), the results were similar to those of the overall analyses. Results of the descriptive analysis showed that there were no significant differences between the two routes in the incidence of hypercalcemia and hyperphosphatemia. Conclusions: Our analysis indicated that there were no significant differences between intermittent intravenous and oral calcitriol in the treatment of SHPT, both in their efficacy and adverse reaction. Since the present studies had several limitations in methodological design and sample size, largescale and long-term comparisons of intermittent intravenous and oral treatment need to be done in a randomized, double-blind, placebo-controlled design to accurately evaluate their relative efficacy and safety.Correspondence to:
Prof. C. Xu; Department of Nephrology, Changzheng Hospital, Second Military Medical University, No. 415, Fengyang Road, Shanghai, 200003, PR China
Email: xx911280@hotmail.com

Abstract

A.J. Hutchison¹, M.E. Barnett², R. Krause³, J.T.C. Kwan⁴ and G.A. Siami⁵, on behalf of the Lanthanum Carbonate Study Group

¹Manchester Royal Infirmary, Manchester, UK, ²Barnett Research and Communications, Torrance, CA, USA, ³KfH Nephrological Center Moabit, Berlin, Germany, ⁴St. Helier Hospital, Carshalton, UK, and ⁵Vanderbilt University, Nashville, TN, USA
Aims: The efficacy and tolerability of the phosphate binder, lanthanum carbonate, have been evaluated in long-term comparative studies and subsequent open-label extensions. Animal studies show that lanthanum has a very low bioavailability and absorbed lanthanum is primarily excreted in bile. A specified subset of data from four Phase III clinical trials and subsequent extension studies is presented, in order to assess the effects of lanthanum carbonate on the liver. Methods and materials: Hepatic biochemical tests for alanine transaminase, aspartate aminotransferase, alkaline phosphatase and bilirubin were performed. Adverse events classified as “liver and biliary system events” were recorded. Results: In the four initial clinical trials, lanthanum carbonate was not associated with any adverse changes in transaminases or bilirubin. The incidence and nature of adverse events associated with the liver during lanthanum carbonate treatment was similar to that in the comparator groups. For patients who enrolled into the subsequent long-term follow-up study (up to 6 years of treatment), changes in transaminases were not clinically relevant and mean values were similar to those observed in the earlier trials. Overall, there was no increase in the incidence of adverse events associated with the liver reported after up to 6 years of treatment when compared with the results of the initial studies. Conclusions: There was no evidence of adverse effects of lanthanum carbonate on the liver in patients who received treatment for up to 6 years.Correspondence to:
Dr. A.J. Hutchison; Consultant Nephrologist, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
Email: alastair.hutchison@cmmc.nhs.uk

Abstract

G. Seyffart¹,³, T. Schulz² and S. Stiller³

¹Dialysis Center Bad Homburg, Department of Surgery Frankfurt, ²Markus Hospital and ³Interneph, Aachen, Germany
Over the past almost 50 years several calcium concentrations in the dialysate (CaD) have been used to balance calcium in hemodialysis (HD) patients but a consensus as to which is most appropriate has not been established. Moreover, since the late 1980s, further confusion has been caused following the use of calcium salts as intestinal phosphate binders. This paper reports results of 387 chronic HD patients with respect to secondary hyperparathyroidism (sHPT) and renal osteodystrophy (ROD) of a single center over 20 years. The most important therapeutic measures applied were use of only 2 CaD, 1.5 and 1.75 mmol/l, with very few exceptions, administration of either calcium-containing or calcium-magnesium-containing and/or calcium-free phosphate binders, no dietary restrictions and continuous compensation of uremic acidosis via dialysate and oral supplements of bicarbonate. Using one of the two CaD and selective administration of different phosphate binders for fine adjustment of serum calcium through this combination, we were able to maintain in the long term almost physiological conditions. With exception of the phosphate metabolism, most physiological functions with regard to sHPT and ROD returned close to normal. As a result, the incidence of hypercalcemia, hypocalcemia, extraosseous, extravascular calcification, bone pain and spontaneous bone fractures was extremely low. We conclude that the clinical advantages of the therapeutic measures, above all precise balance of calcium homeostasis, in our investigation were demonstrated by high survival rates (92% after the first year on HD, 82% after 2, and 55% after 5 years), low incidence of cardiovascular fatalities (about 25%), and very low incidence of sHPT (mostly normal parathyroid hormone levels, 1 parathyrdoidectomy within 20 years).Correspondence to:
G. Seyffart, MD; Am Urseler Weg 4, 61440 Oberursel, Germany
Email: gseyffart@gmx.de

Abstract

H.E. Yim¹, K.H. Yoo¹, N.H. Won², Y.S. Hong¹ and J.W. Lee¹

¹Department of Pediatrics and ²Department of Pathology, College of Medicine, Korea University, Seoul, Korea
Churg-Strauss syndrome (CSS) is a rare systemic vasculitis associated with asthma and eosinophilia. Withdrawal of corticosteroids in asthmatic patients is known to be a powerful trigger for the development of CSS. Renal involvement in patients with CSS is commonly manifested as antineutrophil cytoplasm antibody-associated necrotizing crescentic glomerulonephritis, however, concomitant CSS and the nephrotic syndrome or IgA nephropathy are rare. We report a 12-year-old boy with CSS associated with IgA nephropathy that developed while tapering oral steroids. The patient had a history of the nephrotic syndrome and asthma.Correspondence to:
K. H. Yoo, MD, PhD; Department of Pediatrics, Guro Hospital, Korea University Medical Center #80, Guro-Dong, Guro-Gu, Seoul 152-703, Korea
Email: guroped@korea.ac.kr

Abstract

Y.K. Wen¹ and M.L. Chen²

¹Division of Nephrology, Department of Internal Medicine and ²Department of Pathology, Changhua Christian Hospital, Changhua, Taiwan
We report a 70-year-old man who presented with cervical lymphadenopathy, hypercalcemia, and acute renal failure. Lymph node biopsy revealed caseating granulomas. Renal biopsy showed immune complex-mediated diffuse proliferative glomerulonephritis with crescentic formation. Ultrastructural features of the glomerular disease were compatible with the description in infectious glomerulonephritis. Disseminated tuberculosis was diagnosed when sputum, urine, and bone marrow cultures confirmed the presence of Mycobacterium tuberculosis. Successful treatment with antituberculous agents accompanied by recovery of renal function. As far as we know, the association of tuberculosis with glomerulonephritis appears to be exceedingly rare. In addition to describing this case, we also review cases of tuberculosis-associated glomerulonephritis retrieved from the literature.Correspondence to:
Dr. Y.K. Wen; Division of Nephrology, Department of Internal Medicine, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua, 500, Taiwan
Email: 45440@cch.org.tw

Abstract

G. Pérez-Suárez¹, J.M. Raya², A. Alvarez¹, A. Martín³, H. Alvarez-Arguelles³, M. Hernández-Garcia² and D. Hernández¹

Department of ¹Nephrology, ²Hematology and ³Histopathology, Hospital Universitario de Canarias, Tenerife, Spain
Light-chain deposition disease (LCDD) is an uncommon condition in which monoclonal light chains are deposited in different organs causing varying degrees of tissue damage. We report the case of a 56-year-old male with progressive renal failure as the first manifestation of LCDD without initial evidence of monoclonal immunoglobulin protein in either serum or urine. The patient later developed severe systemic disease with rapid multiple organ involvement. Finally, he died 2 months after diagnosis, despite steroid and cyclophosphamide therapy.Correspondence to:
G. Pérez Suárez, MD; Nephrology Section, Hospital Universitario de Canarias, Ofra s/n., 38320 La Laguna, Tenerife, Spain
Email: gpersuarez@gmail.com

Abstract

V. Wong¹, J. Adams¹, M.I. Jones¹, N. Dutt², J.B. Dibble¹ and S.A. Jayawardene¹

¹Department of Nephrology, ²Department of Histopathology, Kings College Hospital, London, United Kingdom
We describe a case of acute renal failure with crescentic glomerulonephritis, due to pneumococcal infective endocarditis on an endoprosthetic pulmonary valve. The patient’s renal insufficiency subsequently improved following eradication of the microbe with antibiotics alone. Moreover, this is the first description of pneumococcal PVE leading to a crescentic glomerulonephritis.Correspondence to:
V. Wong, MD; Locum Renal Consultant, Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
Email: Vincent.Wong@kch.nhs.uk

Abstract

K. Höpker¹*, M.C. Liebau¹*, C. Friederichsohn², R. Waldherr³ and T. Benzing¹

¹Renal Division, Department of Medicine and Centre for Molecular Medicine Cologne, University of Cologne, ²Nephrologisches Zentrum, Villingen-Schwenningen and ³Gemeinschaftspraxis für Pathologie, Heidelberg, Germany
Alport syndrome is a progressive hereditary renal disease. Mutations in the genes encoding for three members of the type IV collagen protein family have been found to be the cause of the disease. Alport syndrome is often associated with sensorineural hearing loss and ocular abnormalities, and patients suffering from typical Alport syndrome usually develop end stage renal disease during adolescence or young adulthood. Here we report on a family with atypical Alport disease initially presenting as hereditary focal and segmental glomerulosclerosis. Genetic testing identified a previously undescribed COL4A5 mutation as cause of the disease.Correspondence to:
Prof. Dr. med T. Benzing; University Hospital Cologne, Department of Medicine IV, Kerpener Straße 62, 50937 Cologne, Germany
Email: thomas.benzing@uk-koeln.de

Abstract

R.M. Venzin, C.D. Cohen, M. Maggiorini and R.P. Wüthrich

Clinic for Nephrology, and Medical Intensive Care Unit, University Hospital, Zurich, Switzerland
We report the first case of acute renal failure with hyperkalemia associated with the recently marketed direct renin inhibitor aliskiren. To optimize blood pressure control, the antihypertensive medication of a 76-year-old hypertensive female patient was changed from the angiotensin II receptor antagonist irbesartan to aliskiren. Spironolactone was continued, as serum creatinine and potassium levels were initially normal. Two weeks later the patient presented with acute oliguric renal failure, symptomatic hyperkalemia and metabolic acidosis, necessitating emergency dialytic treatment. Unrecognized pre-existing renal insufficiency (CKD Stage 2 – 3) and the continuation of spironolactone were identified as predisposing risk factors.Correspondence to:
R.P. Wüthrich, MD, FACP, FASN; Clinic for Nephrology, University Hospital, Rämistrasse 100, 8091 Zurich, Switzerland
Email: rudolf.wuethrich@usz.ch

Abstract

H.J. Zhao, H.P. Chen, Z.Y. Meng and Q. Wang

Department of Nephrology, Central Hospital of Weifang, Shandong, China
A 73-year-old nephrotic female developed acute renal failure (ARF) with serum creatinine to 586 umol/l after 4 days of therapy with hydroxyethyl starch (HES). Renal biopsy demonstrated that the histopathological appearance was mesangioproliferative glomerulonephritis with tubulointerstitial changes resembling acute tubulointerstitial nephritis. “Pulse” therapy with methylprednisolone, hemodialyses and other symptomatic treatment were performed in the patient during the oliguric phase of the disease. There was no worsening of her renal function, and subsequently it recovered fully. After 6 months of follow-up she had a serum creatinine of 112 umol/l, proteinuria had declined to 0.18 g/day and she is now doing well. Our findings suggest that an immune disease due to a hapten induced by HES may be a possible factor in the pathogenesis of ARF. Therefore, it is important for clinicians to bear in mind the possibility of ARF due to HES and it has been proposed that, whenever possible, HES should not be used in idiopathic nephritic syndrome patients to avoid severe complications.Correspondence to:
Dr. H.J. Zhao; Department of Nephrology, Weifang Central Hospital, No. 666, Weizhou Road, Wei fang city, Shandong 261041, P.R. China
Email: dayizhaoshi@163.com

Abstract

J.Y. Jung, C. Lee, H. Ro, H.S. Kim, K.W. Joo, Y. Kim, C. Ahn, J.S. Han, S. Kim, K.-H. Oh

Division of Nephrology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
Objective: To report a sequential occurrence of life-threatening hypokalemia and rebound hyperkalemia following barbiturate coma therapy. Case history: A 53-year-old man was admitted to the division of nephrology due to sudden development of severe hypokalemia. The patient had been treated following a clinical diagnosis of traumatic subarachnoid hemorrhage and subdural hematoma. Barbiturate coma therapy had been performed on this patient. He developed fatal hypokalemia 10 hours after the start of thiopental administration which did not respond to potassium supplementation. The lowest potassium level following barbiturate coma therapy was 1.0 mmol/l. Severe bradycardia and cardiac arrest developed, which necessitated cardiac massage and treatment with epinephrine and atropine. He recovered from cardiac arrest. When thiopental infusion was suddenly stopped, the potassium level increased to 8.9 mmol/l, which required quick administration of calcium gluconate and infusion of glucose solution mixed with regular insulin. Despite such management, he developed asystole. After direct current cardioversion and emergency hemodialysis, he recovered from cardiac arrest and his serum potassium level was stabilized. Conclusion: We recommend that clinicians must be aware of the potential occurrence of severe hypokalemia, which is rare but fatal, following barbiturate coma therapy. Rebound hyperkalemia, which is fatal, may also occur following cessation of thiopental infusion. Clinicians should also be aware of this potential complication. Further studies are needed to elucidate the precise mechanism of this clinical event.Correspondence to:
K.-H. Oh, MD, PhD; Department of Internal Medicine, Seoul National University Hospital, 28 Yongon-Dong, Chongno-Gu, Seoul, 110-744, Seoul, Republic of Korea
Email: ohchris@hanmail.net

Abstract

N. Illner¹, J. Gerth¹, R. Pfeiffer², T. Bruns³ and G. Wolf¹

¹Department of Internal Medicine III, ²Department of Internal Medicine I and ³Department of Internal Medicine II, Friedrich Schiller University Jena, Germany
A 22-year-old man presented with dichromate intoxication in a suicidal attempt. He exhibited signs of liver and renal toxicity and very high serum chromium levels. Since it has been reported in the literature that hemodialysis and hemoperfusion are not sufficient to remove chromium, we tried plasmapheresis considering the fact that chromium salts bind to protein. Five plasmapheresis treatment sessions significantly lowered his serum and urinary chromium concentrations. The patient survived without organ damage despite ingestion of a lethal dichromate dose and high serum chromium concentration. Thus, plasmapheresis should be considered as a potential therapeutic option to reduce chromium concentrations.Correspondence to:
Prof. G. Wolf; University of Jena, Department of Medicine, Erlanger Allee 101, 07740 Jena, Germany
Email: Gunter.Wolf@med.uni-jena.de

Abstract

A. Capitanini, A. Tavolaro, M. Rosellini and A. Rossi

Division of Nephrology, Civil Hospital of Pescia (Pistoia), Italy
Aims: Spontaneous hemorrhage in the kidney, also known as Wunderlich Syndrome, is a rare clinical problem. The most common cause of spontaneous renal hemorrhage is tumor. Other causes are rupture of a renal cyst, vasculitis, hydronephrosis, preeclampsia, and kidney infections. Case history: A 67-year-old man was admitted complaining left flank colic pain. A contrast CT scan showed the presence of a subcapsular hematoma of the left kidney extending from the upper to the lower pole. He had no history of trauma and immunological screening tests for vasculitis were normal. His current therapy included acetylsalicylic acid (100 mg/daily) and lisinopril (20 mg/ daily). The patient was hospitalized for 4 days and his circulatory state remained stable. Nine months later an ultrasound examination showed complete resolution of the hematoma. One year later the patient was admitted again because of a spontaneous right calf hematoma and a thoroughly investigation of his coagulation pattern was carried out. Laboratory finding revealed a platelet defect, as the number of adenine nucleotides and other marker related to platelet activation were increased: ADP 1 mcM lack 2º wave, ADP 2 mcM lack 2º wave, Adrenalina 5 mcM lack 2º wave, Adrenalina 10 mcM lack 2º wave. Platelet activation markers: Gp53 in lysosomal membrane 0.48 Dpar (0 – 0.26). Conclusion: Our case describes the recurrence of spontaneous hemorrhages (perirenal and intramuscular hematoma) as a result of an underlying platelet aggregation defect worsened by administration of acetylsalicylic acid. In patients on antiplatelet treatment with a history of excessive bleeding a thorough investigation of coagulation status appears beneficial.Correspondence to:
A. Capitanini, MD; Division of Nephrology, Civil Hospital of Pescia, 51017 Pescia (Pistoia), Italy
Email: drcapitanini@excite.it

Abstract

T. Saito¹, Y. Ubara¹, T. Suwabe¹, Y. Higa¹, Y. Higa¹, S. Nakanishi, J. Hoshino¹, N. Sawa¹, H. Katori¹, F. Takemoto¹, R. Marui¹, M. Nakamura¹, S. Tomikawa¹, S. Hara¹, H. Tohbai² and K. Takaichi¹

¹Nephrology Center and Department of Obstetrics and ²Gynecology, Toranomon Hospital, Tokyo, Japan
Because pregnancy is rare in women with end-stage renal disease, dialysis patients have not been reported to present with acute abdominal symptoms related to pregnancy including ectopic pregnancy. A 41-year-old woman treated with hemodialysis for over 18 years was brought to the emergency room at our institution because of acute abdominal pain. Ultrasonography detected an abdominal fluid collection, and her anemia had worsened (hematocrit 18%). Emergency laparoscopic exploration disclosed a hemorrhagic corpus luteum of pregnancy, causing ovarian bleeding on the left. Coagulation of bleeding points was carried out. At this time, pregnancy at 7 weeks of gestation was discovered. After the procedures, hemodialysis frequency was increased to 5 times weekly, and an erythropoietin derivative was administered to maintain a hematocrit above 30%. The patient developed no hypertension. At 33 weeks of gestation, cesarean section was performed because of a decrease in amniotic fluid and frequent late deceleration of the fetal heart rate. A live baby girl weighing 1,422 g was born. The successful pregnancy reflects remarkable progress in dialysis technology. Pregnancy, then, can underlie an acute abdomen in childbearing-age women (14 – 44 years old) undergoing long-term dialysis.Correspondence to:
Y. Ubara, MD, PhD; Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Kajigaya, Takatsu, Kawasaki, Kanagawa 213-0015, Japan
Email: ubara@toranomon.gr.jp

Abstract

M.S. Ahmed¹, C. Nistal², R. Jayan³, M. Kuduvalli⁴ and H.K.I. Anijeet¹

¹Department of Nephrology, ²Department of Microbiology, ³Department of Nuclear Medicine, Royal Liverpool University Hospital and ⁴Department of Cardiothoracic Surgery, Cardiothoracic Center, Liverpool, UK
Introduction: Dialysis catheter-related infection is a major cause of morbidity and mortality in patients on dialysis. In recent years, there have been reported cases of infections with opportunistic environmental organism, Achromobacter xylosoxidans (AX) causing bacteremia in patients on dialysis. However, no previous such reports on prosthetic valve endocarditis in a dialysis patient with Achromobacter xylosoxidans were found after a Medline search. We report such a case and review the literature. Case: A 69-year-old diabetic man with bioprosthetic aortic valve replacement developed end-stage renal disease following infective endocarditis with Staphylococcus epidermidis. Even though he was treated successfully for his endocarditis, he developed further bacteremia with AX from his peripherally inserted central catheter (PICC) and the line was removed. He had further episodes of bacteremia with AX while having dialysis with tunneled line and the line was also removed. He was re-admitted with pyrexia and vegetations both in mitral and prosthetic aortic valve confirmed with transesophageal echo. His antimicrobial therapy with etrapenum, tigecycline and cotrimoxazole failed. He had both mitral and prosthetic aortic valve replacements but postoperatively developed multiorgan failure and died despite the intensive support. Discussion: Achromobacter xylosoxidans is an aerobic, Gram-negative bacillus and considered to be an opportunistic pathogen with low virulence. Infective endocarditis is a potentially lethal complication of bacteremia. The choice of appropriate antibiotic is crucial in these cases. AX strains are highly resistant to antibiotics. The organism is usually susceptible to antipseudomonal penicillins, carbapenems and trimethoprim-sulfamethoxazole. Conclusion: AX is an emerging pathogen in catheter-related infection in the dialysis population and, therefore, needs vigilance and prompt treatment. Antimicrobial treatment should include susceptibility and synergy testing. Removal of central intravenous catheter should also be considered at the time of early presentation in patients at high risks of developing infective endocarditis.Correspondence to:
Dr. M.S. Ahmed; Department of Nephrology, Link 6-C, Royal Liverpool, University Hospital, Prescott Street, Liverpool L7 8XP, UK
Email: msahmed@doctors.org.uk

Abstract

L. Labriola¹, B. Vandercam², D. Swinne³ and M. Jadoul¹

Departments of ¹Nephrology and ²Internal Medicine, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium, ³Laboratory of Mycology, Institute of Public Health, Brussels, Belgium
Paecilomyces lilacinus is a saprophytic mould which rarely causes infection in humans. We report a case of Paecilomyces lilacinus catheter-related fungemia in a chronic hemodialyzed patient. Blood cultures remained positive for 8 weeks. The infection was cured after eventual acceptance by the patient of oral voriconazole treatment for 6 weeks and removal of the tunneled catheter. The literature on Paecilomyces fungemia in humans is reviewed.Correspondence to:
Prof. M. Jadoul, MD; Department of Nephrology, Cliniques Universitaires St Luc, Université Catholique de Louvain, 1200 Brussels, Belgium
Email: michel.jadoul@uclouvain.be

Abstract

K. Polner¹, G. Gosi², S.I. Vas†, I. Kalina² and G. Acsády²

¹Nephrocentrum Foundation Budapest and ²Semmelweis University, Department of Cardiovascular Surgery, Budapest, Hungary
We present the case of a 76-year-old male patient, who – after 2.5 years of CAPD treatment – underwent aorto-biiliac aneurysm reconstruction for aorto-biiliac aneurysm by bifurcational stent-graft implantation. To our knowledge this is the first case presentation of a stent-graft implantation and uninterrupted continuation of CAPD treatment in a patient on peritoneal dialysis.Correspondence to:
K. Polner, MD; Nephrocentrum, Foundation Budapest, 132 Becsi Street, Budapest 1032,
Hungary
Email: polner.kalman@hotmail.com

Abstract

J. Heinz, U. Domröse, C. Luley, S. Westphal, S. Kropf, K.H. Neumann and J. Dierkes

Abstract

P.A. Davis, P. Mormino and L.A. Calò

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Volume 71, No. 3/2009(March)