Volume 72, No. 4/2009(October)
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 Clinical Nephrology
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Lead article
The ratio between kidney volume and function increases with the progression of nephropathy in Type 2 diabetes
M. Giordano, T. Ciarambino, L. Gesuè, P. Castellino, M. De Simone, G. Rinaldi, M. D’Amora, G. Zito, G. Paolisso and L. Coppola
Abstract
M. Giordano1, T. Ciarambino1, L. Gesuè1, P. Castellino2, M. De Simone1, G. Rinaldi1, M. D’Amora1, G. Zito1, G. Paolisso1 and L. Coppola1
1Department of Geriatrics and Metabolism Diseases, Second University of Naples and 2Department of Internal Medicine, University of Catania, Catania, Italy
Objective: In Type 2 diabetes, it is not clear if renal size is constantly related to the glomerular filtration rate. In addition, it is not known if kidney volume (KV) is associated with an increased urinary albumin and IgG excretion. Methods: The relationship between kidney volume, creatinine clearance (CrCl), urinary albumin and IgG excretion in 95 Type 2 diabetic patients with different stages of nephropathy (1 – 4 Stage sec NKDF-QD) was elevated and compared to 85 non-diabetic subjects with similar degree of kidney function. Results: In Type 2 diabetic patients the KV/CrCl ratio was increased, in comparison with the control subjects, from about 15% in Stage 1 to 53% in Stage 4. In T2D subjects, significant correlations were found between KV and urinary albumin excretion (r = 0.665, p < 0.05), and between KV and urinary IgG excretion (r = 0.800, p < 0.001). Conclusion: The present study finds that Type 2 diabetic subjects, are characterized by an increased ratio between KV/CrCl, throughout the different progressive stages of nephropathy. In Type 2 diabetes relationships between KV and urinary albumin and between KV and IgG excretion also were found to be significant, suggesting a role for the impaired size selectivity of proteinuria as a possible determinant of KV.Correspondence to:
M. Giordano, MD, PhD
Associate Professor of Medicine
Second University of Naples
Department of Geriatrics and Metabolic Diseases
Policlinico SUN, P.zza L. Miraglia
80138 Naples, Italy
Email: mauro.giordano@unina2.it
Original
Lanthanum carbonate vs. sevelamer hydrochloride for the reduction of serum phosphorus in hemodialysis patients: a crossover study
S.M. Sprague, E.A. Ross, S.D. Nath, P. Zhang, R.D. Pratt and R. Krause
Abstract
S.M. Sprague1, E.A. Ross2, S.D. Nath3, P. Zhang4, R.D. Pratt4 and R. Krause5
1NorthShore University HealthSystem, Northwestern University Feinberg School of Medicine, Evanston, IL, 2University of Florida, Gainesville, FL, 3University of Texas Health Science Center at San Antonio, Medicine/Nephrology, San Antonio, TX, 4Shire Pharmaceuticals, Wayne, PA, USA, and 5Nephrological Center Moabit, KfH-Kuratorium for Dialysis and Kidney Transplantation, Berlin, Germany
Aims: The aim of this crossover study was to compare the reduction of serum phosphorus (SP) with fixed doses of the non-calcium-containing phosphate binders lanthanum carbonate (LC) and sevelamer hydrochloride (SH) in hemodialysis patients. Methods: Following washout (2 – 3 weeks), 182 patients with SP >= 6.0 mg/dl and calcium >= 8.4 mg/dl were randomized (1:1) to receive LC (2,250 to 3,000 mg/day) or SH (4,800 to 6,400 mg/day) for 4 weeks. Patients underwent a second washout (2 weeks) and switched to the alternative binder for 4 weeks. Results: At the end of treatment, LC had reduced SP by 1.7 ± 0.1 mg/dl, compared with 1.4 ± 0.1 mg/dl for SH; the difference was not statistically significant in the primary analysis (LOCF, p = 0.133). However, the reduction with LC was significantly greater than with SH in a prespecified key secondary analysis of patients who completed 4 weeks of treatment with each binder (0.5 mg/dl difference, p = 0.007). The reduction of SP was also greater with LC than SH after 1 week of treatment (p = 0.024). Conclusions: Although the primary analysis found no difference between LC and SH in the reduction of SP, a significant difference in favor of LC was observed in patients who completed treatment. The results of this study show interesting trends with respect to onset and duration of action that warrant further investigation in longer-term studies.Correspondence to:
S.M. Sprague, DO
NorthShore University HealthSystem
2650 Ridge Avenue
Evanston, IL 60201, USA
Email: stuartmsprague@gmail.com
Original
Clinical pattern of adult polycystic kidney disease in a northeastern region of Italy
V. Corradi, F. Gastaldon, G.M. Virzì, M. de Cal, S. Soni, C. Chionh, D.N. Cruz, M. Clementi and C. Ronco
Abstract
V. Corradi1, F. Gastaldon1, G.M. Virzì1, M. de Cal1, S. Soni1, C. Chionh1, D.N. Cruz1, M. Clementi2 and C. Ronco1
1Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, and 2Department of Pediatrics, Clinical Genetics University of Padova, Italy
Background: Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic renal disorder, with a prevalence of 1 : 500 to 1 : 1,000. ADPKD is genetically heterogeneous: the genes involved are PKD1 and PKD2. ADPKD occurs worldwide and in all ethnic groups and is an important cause of CKD Stage 5. Prevalence of ADPKD on renal replacement therapy (RRT) in Italy has been reported to be 8.2%. In the dialysis population of Vicenza, a province in Northeastern Italy, it accounts for 13.4%. The study aims to investigate reasons for the high prevalence of ADPKD in our region and to describe the clinical profile and genetics of these patients. Methods: Since April 2007, ADPKD patients have been enrolled. Patients from families not native to Vicenza have been excluded. The diagnosis of ADPKD is defined by ultrasound criteria. Complete clinical details have been recorded, including family history. We have used linkage analysis to identify the gene involved in each family. Results: We describe the first 100 patients recruited from a total of 42 families. 29 patients were in ESRD at the time of enrollment. Renal stones and hepatic cysts were present in 24% and 40%, respectively. The majority of the ADPKD patients (61%) were diagnosed either incidentally or by screening. Positive family history was recorded in 86 patients. The involved gene was PKD1 in 83.7% and PKD2 in 16.3% of the studied patients. PKD2 patients presented the common haplotype. Conclusions: It is the first epidemiological study from Northeastern Italy reporting clinical profile and genetic analysis of ADPKD patients. The clinical profile of the patients is similar to previous reports, but there is a high prevalence of ADPKD in our region. The presence of a common haplotype is in accordance with our hypothesis of a founder effect in our province, suggesting that a strong lineage-specific gene is present. If the sequence analysis confirms the same mutation, this might suggest a common ancestral origin and a segregation of a specific mutation.Correspondence to:
Prof. C. Ronco
Department of Nephrology, Dialysis and Transplantation
San Bortolo Hospital
Via Rodolfi, 37
36100 Vicenza, Italy
Email: cronco@goldnet.it
Original
Mycophenolate mofetil therapy for childhood-onset steroid dependent nephrotic syndrome after long-term cyclosporine: extended experience in a single center
S. Fujinaga, Y. Ohtomo, D. Hirano, N. Nishizaki, T. Someya, Y. Ohtsuka, K. Kaneko and T. Shimizu
Abstract
S. Fujinaga1, Y. Ohtomo2, D. Hirano1, N. Nishizaki1, T. Someya3, Y. Ohtsuka3, K. Kaneko4 and T. Shimizu3
1Division of Nephrology Saitama Children’s Medical Center, Saitama City, 2Department of Pediatrics, Juntendo Nerima Hospital, Tokyo, 3Department of Pediatrics, Juntendo University School of Medicine, Tokyo, and 4Department of Pediatrics, Kansai Medical University, Osaka, Japan
Background: Mycophenolate mofetil (MMF) is being used increasingly in children with steroid-dependent nephrotic syndrome (SDNS). However, there is limited information on the optimal therapeutic range for mycophenolic acid (MPA), the active metabolite of MMF, in these patients. Methods: 26 patients with SDNS (mean age 13.1 years, 19 with minimal change disease and 7 with focal segmental glomerulosclerosis) who had received MMF for at least 6 months after longterm cyclosporine (CsA, mean 56 months) at Saitama Children’s Medical Center between September 2002 and August 2008 were analyzed. MMF was introduced at an initial dose of 250 mg/12 h, adjusted to maintain target predose MPA at greater than 2 µg/ml (maximum 1 g twice daily) gradually over 4 weeks. After the introduction of MMF, the dosages of both CsA and prednisolone (PSL) were tapered off if possible. Results: The mean MMF dose required was 34 ± 6 mg/kg, which maintained the mean predose MPA levels of 3.1 mg/ml. In 26 patients, treatment with MMF for a mean follow-up period of 19 months (range 7 – 42), resulted in a reduction of the mean PSL dose from 0.33 ± 0.23 to 0.17 ± 0.11 mg/kg per day (p < 0.01) and mean CsA dose from 3.2 ± 1.7 to 1.3 ± 1.8 mg/kg per day (p < 0.01). The mean 12-monthly relapse rates decreased from 2.5 ± 1.4 to 0.8 ± 1.2 episodes (p < 0.01). In 20 patients treated with MMF (77%), the dose of PSL and/or CsA was successfully tapered with a reduction in the relapse rates. In 6 patients, however, CsA therapy was reintroduced or its dose was increased because of treatment failure. The patients whose average predose MPA levels were less than 3 µg/ml were significantly likely to have treatment failure (p < 0.05). 2 patients reduced the MMF dosage because of anemia or herpes labialis. However, no severe gastrointestinal discomfort was seen in any patients. Despite long-term CsA therapy, marked tubulointerstitial fibrosis developed during MMF therapy in surveillance biopsies of only one of these five patients. Conclusions: Therapy with MMF based on the predose MPA levels can be a less toxic alternative to CsA or in some cases a useful additional medication to allow for a reduction in the CsA and/or PSL dosage.Correspondence to:
S. Fujinaga, MD
Division of Nephrology
Saitama Children’s Medical Center,
2100 Magome, Iwatsuki-ku
Saitama-city Saitama 339 8551, Japan
Email: f_shuich@d2.dion.ne.jp
Original
Sodium-sensitive variability of the antiproteinuric efficacy of RAS inhibitors in outpatients with IgA nephropathy
T. Suzuki, Y. Miyazaki, A. Shimizu, Y. Ito, H. Okonogi, M. Ogura, Y. Utsunomiya, T. Kawamura and T. Hosoya
Abstract
T. Suzuki, Y. Miyazaki, A. Shimizu, Y. Ito, H. Okonogi, M. Ogura, Y. Utsunomiya, T. Kawamura and T. Hosoya
Division of Kidney and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Nishishinbashi, Minato-ku, Tokyo, Japan
Aims: Inhibition of the renin-angiotensin system (RAS) decreases proteinuria in IgA nephropathy and often retards disease progression. However, its antiproteinuric efficacy varies considerably among patients or different stages in a single patient. We sought for the factor(s) underlying the variation in urinary protein excretion in RAS inhibitor-treated outpatients with IgA nephropathy. Patients: 43 patients with biopsy-proven IgA nephropathy, moderate proteinuria (0.5 – 3.5 g/day), normal to moderately-low estimated GFR (eGFR) (28.6 – 114.2 ml/min/1.73 m2) and normal blood pressure, prehypertension or mild hypertension (systolic/diastolic blood pressures < 160/100 mmHg) were placed on RAS inhibitors following diagnosis. Method: Excretion of urinary protein (UprV) and sodium (UNaV), estimated protein intake (EPI) and the mean blood pressure (MBP) were determined on 12 consecutive visits for an average duration of 17.6 months. Analyses were performed to determine which factor(s) influenced the variation in UprV. Results: 14 patients (32.6%) showed a significant correlation between UprV and UNaV, whereas UprV correlated significantly with EPI or MBP in 7 (16.3%) and 3 patients (7.0%), respectively. The 14 patients were characterized by lower eGFR and more extensive glomerulosclerosis and tubulointerstitial damage at baseline than the other 29 patients. The UprV-UNaV correlation was significant in 8 of 12 patients (66.7%) with eGFR < 60 ml/min/1.73 m2 and in 6 of 29 patients (19.4%) with eGFR >= 60 ml/min/1.73 m2 (p < 0.05). The UprV/UNaV regression lines were significantly steeper with more extensive glomerulosclerosis (p < 0.05) and tubulointerstitial damage (p < 0.05) at baseline. The lines also tended to be steeper with lower baseline eGFR (p = 0.062). Conclusions: These results showed that the antiproteinuric effect of RAS inhibitors becomes susceptible to an increase in urinary sodium excretion as renal function and functioning nephron mass decline with the progression of renal histological damage. Stringent dietary sodium restriction is required to maximize the antiproteinuric effect of RAS inhibitors in outpatients with IgA nephropathy.Correspondence to:
Y. Miyazaki, MD, PhD
Division of Kidney and Hypertension
Department of Internal Medicine
Jikei University School of Medicine
3-25-8, Nishishinbashi, Minato-ku
Tokyo, 105-8461 Japan
Email: yoichimiyazaki@jikei.ac.jp
Original
Removal of vancomycin in sustained low-efficiency dialysis (SLED): a need for better surveillance and dosing
L. Golestaneh, A. Gofran, M.H. Mokrzycki and J.L. Chen
Abstract
L. Golestaneh1, A. Gofran1, M.H. Mokrzycki1 and J.L. Chen2
Department of Medicine, 1Divisions of Renal and 2Pharmacy Services, Montefiore Medical Center, The University Hospital for the Albert Einstein College of Medicine, Bronx, NY, USA
Aims: This study was designed to evaluate the extent of vancomycin removal from the blood compartment during sustained low-efficiency dialysis (SLED) and the efficacy of our current vancomycin dosing practice. Material: 10 ICU patients were selected. They all had oliguric renal failure requiring SLED and were on vancomycin therapy. SLED was provided with the Fresenius 2000K machine and used an AV400 polysulfone dialyzer (sieving coefficient for vitamin B12 = 1, and surface area = 0.7 m2). Method: SLED prescriptions were individualized for each patient but the duration for all was at least 8 hours. The blood flow rate (Qb) and dialysate flow rate (Qd) did not vary between patients by greater than 100 cc per minute. Blood samples were drawn at 0, 2, 4, and 8 hours to determine the extent of reduction in vancomycin level. Results: The total reduction of vancomycin was about 36% with an 8-hour treatment, when following a typical SLED prescription. Serum vancomycin levels dropped below the therapeutic window (< 15 mcg/ml) at the end of an 8-hour SLED session in almost half of the patients. Drug removal was greatest during the first 4 hours (29.5 ± 6.5%) compared to the last 4 hours (9.1 ± 7.4%) of SLED. Conclusions: Vancomycin removal during a typical 8-hour SLED treatment approaches 36%. SLED patients are at risk for undertreatment of their infections. A redosing strategy should be considered if the estimated or measured predialysis level is 20 – 30 mcg/ml. Vancomycin should be redosed with at least 500 mg in most patients at the completion of the SLED. Therapeutic drug monitoring (TDM) is an essential part of any dosing scheme, until further studies are done.Correspondence to:
L. Golestaneh, MD, MS
Assistant Professor of Medicine
Renal Division
Montefiore Medical Center
111 East 210th Street
Bronx, NY 10467, USA
Email: lgolesta@montefiore.org
Original
The phenomenon of hemoglobin variability with erythropoiesis stimulating agents in renal transplant patients
G. Fernández Fresnedo, A.L.M. de Francisco, C. Gomez Alamillo, J.C. Ruiz, E. Rodrigo and M. Arias
Abstract
G. Fernández Fresnedo, A.L.M. de Francisco, C. Gomez Alamillo, J.C. Ruiz, E. Rodrigo and M. Arias
Nephrology Service, University Hospital Marqués de Valdecilla, Santander, Spain
Treatment with erythropoiesis-stimulating agents (ESA) is often associated with fluctuation in hemoglobin (Hb) levels that has been considered a factor that influences morbidity/mortality in hemodialysis patients. Our aim was to describe the hemoglobin variability during ESA treatment and to study associated factors in kidney transplants. Hb variability (defined as fluctuations of Hb ± 1.5 g/dl) was assessed in 85 renal transplant patients treated with ESA for at least 3 months and with a minimum of 6 Hb measurements along 1 year. 58% of patients experienced Hb variability during follow-up. Although 71.3% of patients maintained Hb levels greater than 11 g/dl along the whole follow-up, only 3% of patients maintained stable Hb levels within the target range all the time (11 – 13 g/dl). By multivariate analysis, clinical factors associated with variability were changes in ESA dose (RR 2.92, p = 0.04), infectious events with hospitalization (RR 1.95, p = 0.03) and the use of sirolimus (RR 1.1, p < 0.05). Excluding dose changes and hospitalization in the analysis variability was an independent predictor of graft function deterioration. In conclusion, Hb variability is common in renal transplants treated with ESA. Only few patients maintained Hb levels in the therapeutic range (11 – 13 g/dl). Dose changes, inflammatory status and graft function deterioration are the determining factors.Correspondence to:
G. Fernández-Fresnedo
Servicio de Nefrología
Hospital Marqués de Valdecilla
Avda de Valdecilla
39008 Santander, Spain
Email: nefffg@humv.es
Original
End-stage renal disease in both husband and wife in Taiwan
C.-H. Chang, Y.-W. Fang and H.-S. Chen
Abstract
C.-H. Chang1,2, Y.-W. Fang1 and H.-S. Chen1
1Division of Nephrology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei and 2Department of Medicine, School of Medicine, Taipei Medical University, Taipei, Taiwan
Aim: The incidence and prevalence of end-stage renal disease (ESRD) are extremely high in Taiwan. It is an interesting fact that both the husband and wife in some families of Taiwan suffer from ESRD. Therefore, we attempted to identify the potential risk factors of such couples. Methods: This is a retrospective observational study. Six couples receiving maintenance dialysis in our hospital from 1996 to 2006 were enrolled in this study. Detailed medical history; drugs history including over-the-counter drugs (OCD), analgesics and herbal remedies; occupational history and onset of transitional cell carcinoma (TCC) were recorded. These data are correlated with pre-dialysis laboratory findings. The outcomes of dialysis and TCC were also recorded and analyzed. Results: Two males were Chinese herbal medicine practitioners. All the patients (12/12) had taken Chinese herbs and most of them (10/12) had also taken OCD (especially cold remedies and analgesics). We found all of them had bilateral contracted kidneys, mild proteinuria and trace glucosuria. One patient’s renal biopsy revealed Chinese herb nephropathy. Four patients (33%) suffered from TCC. Three patients expired during follow up due to hyperkalemia, extensive TCC and suicide, respectively. Conclusions: The prevalence of Chinese herbs or compound analgesics abuse is high in couples with ESRD. The clinical features and high incidence of TCC are compatible with drug related chronic tubulointerstitial nephritis. Abuse of offending agents should be considered as a risk factor in family members with ESRD.Correspondence to:
C.-H. Chang, MD
Division of Nephrology
Department of Internal Medicine
Shin Kong Wu Ho-Su Memorial Hospital
95, Wen-Chan Road
Taipei 111, Taiwan
Email: m001091@ms.skh.org.tw
Original
Dialysis dose and nutrition assessment by optical on-line dialysis adequacy monitor
M. Luman, J. Jerotskaja, K. Lauri and I. Fridolin
Abstract
M. Luman1, J. Jerotskaja2, K. Lauri2 and I. Fridolin2
1Department of Dialysis and Nephrology, North Estonia Medical Center and 2Department of Biomedical Engineering, Technomedicum, Tallinn University of Technology, Tallinn, Estonia
Aim: In light of the variability of dialysis sessions, on-line monitoring could improve hemodialysis (HD) adequacy. A new optical Dialysis Adequacy Monitor (DIAMON) prototype enables to estimate dialysis dose and protein nitrogen appearance (PNA) at every dialysis session. The aim of this study was to compare the adequacy of dialysis treatment and the patient’s nutritional status by pre-and post-dialysis blood samples, the DIAMON prototype and Total Dialysate Collection (TDC). Material and methods: Ten patients were monitored during three consecutive hemodialysis sessions during one week. Blood samples were drawn before the start of dialysis and at the end of dialysis. The DIAMON prototype was connected to the fluid outlet of the dialysis machine with all spent dialysate passing through during the on-line experiments, and TDC was performed for all dialysis treatments. Equilibrated Kt/V (eKt/V) values were estimated from blood-urea (eKt/Vb) and from DIAMON (eKt/Va), and normalized PNA (nPNA) values from TDC and DIAMON, respectively. The variable volume single pool urea kinetic modeling (VVSP UKM) was also utilized for single-pool Kt/V (spKt/V) and nPNA estimation. Results: The mean ± SD given by eKt/Vb was 1.08 ± 0.22 (n = 30), and eKt/Va 1.05 ± 0.21 (n = 28). The mean ± SD of nPNA was 0.73 ± 0.15 g/kg/day (n = 29) from TDC, and 0.73 ± 0.14 g/kg/day (n = 28) using DIAMON prototype. The mean values of eKt/V from blood samples and nPNA from TDC were not statistically different from the corresponding values estimated by DIAMON (p < 0.05). Generally the delivered dialysis dose and dietary protein intake of the patients observed during the study using the DIAMON prototype was very similar to that obtained by TDC and VVSP UKM. Conclusion: The optical dialysis adequacy sensor, DIAMON, provides continuous, on-line measurements of dialysis adequacy and permits longitudinal analysis of the delivered dialysis dose and patient’s nutritional status, and can immediately identify, and alert to, any deviations in dialysis treatment.Correspondence to:
M. Luman, MD
Department of Dialysis and Nephrology
North Estonia Medical Center
J. Sütiste tee 19
13419 Tallinn, Estonia
Email: merike.luman@regionaalhaigla.ee
Case Report
Renal AA amyloidosis secondary to morbid obesity?
E. Alsina, M. Martin, MJ. Panadés and E. Fernández
Abstract
E. Alsina, M. Martin, MJ. Panadés and E. Fernández
Hospital Universitari Arnau de Vilanova, Lleida, Spain
Systemic amyloidosis is characterized by extracellular deposits on different organs of insoluble fibrils compounded of low molecular weight subunits coming from a great diversity of serum proteins. Secondary amyloidosis AA is due to fibril deposition composed of fragments of the acute phase reactant serum amyloid A. We report a case of a young patient with morbid obesity and hypertension who was admitted to our hospital for acute renal insufficiency associated with nephrotic range proteinuria which developed while on antibiotic treatment for a respiratory infection. AA Amyloidosis was diagnosed by renal biopsy. Based on recent evidence we hypothesize that morbid obesity could be the underlying cause of the deposit disease.Correspondence to:
M. Martín, MD
Nephrology Section
Hospital Arnau de Vilanove
Av. Alcalde Rovira Roure, 80
25198 Lleida, Spain
Email: mmartin@arnau.scs.es
Case Report
Tubulointerstitial nephritis and uveitis with Fanconi syndrome in a patient with ankylosing spondylitis
Y.K. Wen
Abstract
Y.K. Wen
Division of Nephrology, Department of Medicine, Changhua Christian Hospital, Changhua, Taiwan
We report a 40-year-old man with ankylosing spondylitis who was referred to our hospital because of a 2-month history of general fatigue, anorexia, and weight loss. Laboratory findings showed anemia and renal dysfunction. Fanconi syndrome was suggested by multiple proximal tubular defects including renal glucosuria, hyperuricosuria, hyperphosphaturia, proximal renal tubular acidosis, and kaliuresis leading to hypokalemia. Renal biopsy showed acute tubulointerstitial nephritis. Furthermore, bilateral uveitis was diagnosed by an ophthalmologist. The patient was treated with systemic corticosteroids. The renal and proximal tubular function returned to normal and uveitis disappeared by 4 weeks after commencement of corticosteroid treatment. To our knowledge, tubulointerstitial nephritis and uveitis has rarely been associated with Fanconi syndrome and had not been reported in ankylosing spondylitis.Correspondence to:
Dr. Y.K. Wen
Division of Nephrology
Department of Medicine
Changhua Christian Hospital
135 Nanhsiao Street
Changhua, 500, Taiwan
Email: 45440@cch.org.tw
Case Report
A bitter pill to swallow
S. David, S. Merscher, H. Schmidt-Guertler, J. T. Kielstein, T. Kirchhoff and M. Meier
Abstract
S. David1, S. Merscher2, H. Schmidt-Guertler2, J. T. Kielstein1, T. Kirchhoff3 and M. Meier1,2
1Department of Nephrology, Medical School Hannover 2Clinic of Nephrology and Hypertension, Hannover and 3Department of Diagnostic Radiology, Medical School Hannover, Germany
Foreign body aspiration can be a life-threatening emergency requiring immediate intervention. However, unlike in children, clinical presentation of foreign bodies in adults often varies with regard to symptoms and signs and occurs without asphyxia. We here describe the case of a 65-year-old man on maintenance hemodialysis who developed dyspnea and left chest aspiration pneumonia after swallowing one tablet of the phosphate binder sevelamer. This case illustrates that elderly patients with swallowing complaints should be taken serious when they complain about their subsequent frustration of ingestion of their pills.Correspondence to:
M. Meier, MD
Department of Nephrology
Medical School Hannover
Carl-Neuberg-Straße 1
30625 Hannover, Germany
Email: matthmax@yahoo.de
Case Report
An unusual non-immunological cause of renal pulmonary syndrome
S. Aithal, N. Marley and G. Venkat-Raman
Abstract
S. Aithal1, N. Marley2 and G. Venkat-Raman2
1Morriston Hospital, Swansea, and 2Queen Alexandra Hospital, Portsmouth, UK
A 38-year-old Caucasian male presented with a 4-week history of nose bleeds, gross hematuria and blurred vision. He was a smoker, who had used cannabis and cocaine previously. At presentation, he had features of malignant hypertension (blood pressure 220/120 mmHg), was hypoxic on room air, with no signs of fluid overload or heart failure. He had acute renal failure with radiological evidence of alveolar hemorrhage. Renal biopsy showed extensive ischemic collapse of glomeruli and severe fibrointimal thickening of the arteries with fibrinoid deposits in the wall. Auto-immune screen was negative. Serum creatinine peaked at 749 µmol/l. Adequate control of blood pressure and supportive oxygen therapy lead to a complete clinical and radiological resolution of the pulmonary hemorrhage and he did not need dialysis. Eighteen months on, his serum creatinine is stable at 279 µmol/l with good blood pressure control. Malignant hypertension is not a recognized cause of the renal-pulmonary syndrome and physicians should be aware of the possibility, if only to avoid inappropriate treatments like plasmapheresis and immunosuppression. History of cocaine use is important in the setting of an acute vascular event.Correspondence to:
S. Aithal, MD, MRCP
Morriston Hospital
Swansea, UK
Email: saithal10@hotmail.com
Letter to the Editor
Patient survival after renal transplantation in HCV and HBV infected patients needs more attention than other risk factors
S.-M. Alavian
Letter to the Editor
Concurrent occurrence of membranous desquamation in Escherichia coli O157:H7 hemolytic uremic syndrome
H. Matsukura, H. Sakaki, T. Itazawa, K. Shinozaki and T. Miyawaki
Abstract
H. Matsukura, H. Sakaki, T. Itazawa, K. Shinozaki and T. Miyawaki
