Volume 73, No. 1/2010(January)
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 Clinical Nephrology
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Lead article
Effect of statins on erythropoietin responsiveness in Type 2-diabetic versus non-diabetic hemodialysis patients
Abstract
K. Tangdhanakanond1 and R. Raja2
1Department of Internal Medicine, 2Division of Nephrology, Albert Einstein Medical Center, Philadelphia, PA, USA
Aims: This study investigated whether the antiinflammatory effect of statins improved erythropoietin responsiveness in hemodialysis patients. We also examined if Type 2 diabetes mellitus, which had been shown to increase erythropoietin resistance, affected this effect of statins. Methods: 103 patients were included in the cross-sectional study. Patients were stratified into statin and non-statin groups, and subgrouped based on the presence of Type 2 diabetes mellitus. Demographic, laboratory and other relevant data were analyzed by independent sample t-tests. The outcome of interest was erythropoietin dose. Two-way analysis of variance was used to determine the interaction between the use of statins and the presence of Type 2 diabetes mellitus. Results: Of 103 patients, 34% were on statins and 38.8% were diabetic. The mean erythropoietin dose (units/kg per week) was significantly lower in the statin group (275.6 ± 273.2, 449.5 ± 555.9, p < 0.05). 20% of patients in the statin group required erythropoietin dose in excess of an epoetin equivalent of 500 units/kg per week, compared to 30.88% in the non-statin group. The mean C-reactive protein level (mg/l) was lower in the statin group, although there was no statistical significance (1.13 ± 1.22, 1.77 ± 2.43, p = 0.08). The two-way analysis of variance showed no interaction between the use of statins and the presence of Type 2 diabetes mellitus on erythropoietin dose. Conclusions: Our study demonstrated that hemodialysis patients who were on statins had a significantly lower erythropoietin requirement. This association is possibly due to the pleiotropic effect of statins.Correspondence to:
K. Tangdhanakanond, MD
Department of Internal Medicine
Albert Einstein Medical Center
5501 Old York Road
Philadelphia, PA 19141, USA
Email: kawin4180759@hotmail.com
Original
Serum-soluble Fas and serum levels of erythropoietin in chronic kidney disease
Abstract
M.A. Góes1, M.A. Dalboni1, S.R. Manfredi1, M.S. Cendoroglo1, M.C. Batista1, M.E. Canziani1, V.S. Balakrishnan2, B.J.G. Pereira2, S.A. Draibe1 and M. Cendoroglo1,2
1Division of Nephrology, Federal University of São Paulo, UNIFESP, São Paulo, Brazil, and 2Division of Nephrology, New England Medical Center, Tufts School of Medicine, Boston, MA, USA
Background: Soluble Fas levels (sFas) are increased in the serum of uremic patients and are associated with the presence of anemia and recombinant human EPO (rHuEPO) dosage in dialysis patients. It is possible that sFas levels are associated with an increased need for serum erythropoietin levels (Epo) in chronic kidney disease and dialysis patients in order to maintain hematocrit (Hct) levels. Aims: To investigate the relationship between serum sFas levels, serum Epo levels and the ratio between Epo levels and Hct in uremic patients. Methods: We studied 52 predialysis chronic kidney disease patients (CKD; 33 M, 57 ± 12 years, hematocrit (Hct) = 37 ± 7%), 29 peritoneal dialysis patients (PD; 12 M, 54 ± 14 years, Hct = 36 ± 7%), 29 hemodialysis patients (HD; 19 M, 47 ± 14 years, Hct = 33 ± 5%) and 29 healthy volunteers (control group 17 M, 50 ± 16 years, Hct = 43 ± 3%). We examined the relationship between Hct and serum levels of Epo, sFas, C-reactive protein, IL-6 and iron status. The ratio of serum Epo divided by Hct (Epo/Hct) was used as an indicator of Epo responsiveness. Results: Compared to normal subjects, the CKD, PD and HD groups presented lower Hct levels and higher serum levels of sFas, Epo, Epo/Hct and IL-6. Serum levels of sFas correlated negatively with albumin (r = –0.24, p = 0.02), IL-6 (r = –0.18, p = 0.04) and Epo/Hct (r = –0.37, p < 0.001). In multivariate analysis, after adjusting for markers of iron store and inflammation, only sFas correlated with Epo/Hct. In the CKD group, there were negative correlations between serum levels of sFas and glomerular filtration rate (GFR) (r = –0.45, p < 0.001) and between Epo/Hct and GFR (r = –0.32; p = 0.02). There was a positive correlation between Epo/Hct and serum levels of sFas in the CKD group (r = 0.31, p = 0.03) and in the HD groups (r = 0.58, p = 0.001). Conclusion: Our findings show that serum sFas is associated with higher Epo/Hct ratio, suggesting that sFas may be a marker of Epo hyporesponsiveness in uremia. Further studies are needed to determine whether sFas is just a marker of Epo hyporesponsiveness or is also involved in its pathophysiology.Correspondence to:
M.A. Góes, MD
Division of Nephrology
Federal University of São Paulo – UNIFESp
Rua Pedro de Toledo, 781-14º andar-fundos
Vila Clementino/São Paulo, Brazil
Email: miguelangelo@nefro.epm.br
Original
The relationship between serum level of N-terminal pro-B-type natriuretic peptide and nutritional status, and inflammation in chronic hemodialysis patients
Abstract
A. Bednarek-Skublewska, W. Zaluska and A. Ksiazek
Department of Nephrology, Medical University of Lublin, Poland
Background: N-terminal pro-B-type natriuretic peptide (NT-pro BNP), a biomarker of heart failure, is involved in regulation of the body fluid homeostasis and vascular tone. The purpose of this study was to investigate the relationship between serum level of NT-pro BNP and nutritional status, inflammation and hydration in patients on maintenance hemodialysis (HD). Materials and methods: The study involved 97 HD patients (mean age: 65.3 ± 13.9 years, HD duration: 36.3 ± 43.5 months). Blood tests comprised the measurements of serum levels of NT-pro BNP, interleukin-6 (IL-6), human soluble tumor necrosis factor receptor I (s TNF RI), hemoglobin (Hb), albumin (alb) and urea. Furthermore, normalized protein catabolic rate (n PCR), body mass index (BMI), mean arterial blood pressure (MAP), adequacy of HD (Kt/V), and interdialytic body weight gain (IBWG) were calculated. In addition, NT-pro BNP was measured in a healthy control group (CG; n = 24, mean age 49.5 ± 15.0 years). Hydration status was determined by bioimpedance analysis (BIA). Results: Irrespective of gender, NT-pro BNP levels were markedly elevated in HD patients compared with CG (15879.2 ± 14033.3 pg/ml vs. 73.45 ± 23.56 pg/ml; p < 0.00001). NT-pro BNP was unrelated to any measures of body fluid compartments. Multivariate regression analysis revealed that only four parameters (nPCR, Hb, MAP, and total time on HD) influenced serum NT-pro BNP levels. Conclusion: While there was only moderate direct association of NT-pro BNP with hydration status, it was elevated in patients with intensive catabolism, severe anemia, higher MAP and longer total duration of HD.Correspondence to:
A. Bednarek-Skublewska
20-071 Lublin
ul. Wieniawska 6/48, Poland
Email: anna.bednarek@diaverum.com
Original
B-type natriuretic peptide and severe heart failure at baseline predict overall mortality in incident dialysis patients
Abstract
M. Koch1, R. Trapp1, M. Kohnle1, S. Aker1, B. Haastert2 and L.-C. Rump3
1Center of Nephrology, Mettmann, 2mediStatistica, Neuenrade and 3Clinic of Nephrology, Heinrich Heine University Düsseldorf, Germany
Aims: The B-type natriuretic peptide (BNP) has become increasingly important as a diagnostic and prognostic method for cardiovascular disease or death. To our knowledge no prospective studies exist to evaluate the value of baseline BNP and baseline heart failure as predictors of overall death in incident rather than prevalent hemodialysis patients with end-stage renal disease (ESRD). Methods: 255 ESRD patients were included in our observational study with a median observation period of 1.11 years. A Kaplan-Meier survival curve was stratified by BNP concentration (< 340 pg/ml and ≥ 340 pg/ml) to estimate the impact on the overall mortality rate. Univariate and multiple Cox regression models were fitted for a variety of covariables including severe heart failure (graded according to the New York Heart Association) to evaluate the independent predictors of death. Association between BNP and four explanatory variables was described in a multiple linear regression model. Results: Survival analysis demonstrated a significantly higher mortality rate in patients with higher BNP values at baseline. The independent predictive value of high BNP concentration at baseline could be statistically confirmed by multiple Cox regression analysis. However, when including the covariates hemoglobin and severe heart failure, significantly associated with BNP, in the same model, severe heart failure rather than BNP becomes a significant predictor of overall death. Conclusions: A higher BNP level at baseline may be confirmed as an independent predictor of death in the incident dialysis population. However, severe heart failure may affect the impact of BNP on the overall survival rate and thus be a stronger predictor of death than BNP.Correspondence to:
M. Koch, MD
Gartenstraße 8
40822 Mettmann, Germany
Email: Koch@dialyse-mettmann.de
Original
Metal ion and vitamin adsorption profiles of phosphate binder ion-exchange resins
Abstract
K. Takagi1, K. Masuda2, M. Yamazaki1, C. Kiyohara3, S. Itoh4, M. Wasaki1 and H. Inoue5
1Safety Research Laboratory, Research Division, Mitsubishi Tanabe Pharma Corporation, Chiba, 2Discovery Formulation Research Dept. of Medicinal Chemistry Laboratory, Mitsubishi Tanabe Pharma Corporation, Kanagawa, 3Tsukuba Laboratory, Analytical Services Division, Mitsubishi Chemical Group Science and Technology Research Center, Ibaraki, 4Yokohama Laboratory, Analytical Services Division, Mitsubishi Chemical Group Science and Technology Research Center, Kanagawa, and 5Department of Chemistry, Keio University School of Medicine, Kanagawa, Japan
Aims: To determine the metal ion and vitamin in vitro adsorption profile of sevelamer hydrochloride (sevelamer-HCl) and colestilan(INN)/colestimide(JAN), a novel ion-exchange resin being developed as a phosphate binder for end-stage renal disease (ESRD) patients undergoing hemodialysis, adsorption of metal ions (iron, cobalt, copper and zinc) and vitamins (B6, B12, C, K and folic acid) essential for hematopoiesis/blood coagulation was assessed. Methods: Mixtures of each resin (colestilan or sevelamer-HCl, 4 mg/ml) and metal ions (Fe(III), Fe(II), Co(II), Cu(II), and Zn(II), 1 microg/ml) were adjusted to pH 1.2 or 6.8 and incubated at 37 °C for 1 hour. Metal ions in the recovered filtrate were detected by inductively coupled plasma optical emission spectrometry. In addition, the mixtures of each resin (4 mg/ml) and vitamins (B6, B12, C, K and folic acid, 0.5 – 250 microg/ml) were adjusted to pH 6.8 and incubated at 37 °C for 0.5 hour. The vitamin concentrations in the recovered filtrate were quantified by HPLC. Results: Colestilan did not adsorb any metals tested at either pH level, whereas sevelamer-HCl adsorbed copper(II) and zinc(II) ion at pH 6.8 with adsorption ratios of 99% and 38%, respectively. Both resins showed almost complete adsorption of vitamin C, vitamin K, and folic acid, but weak adsorption of vitamin B6, and no adsorption of vitamin B12. Conclusions: The differing adsorption profiles for metal ions and vitamins between sevelamer-HCl and colestilan may be of importance for the individualized management of anemia and malnutrition in chronic hemodialysis patients receiving phosphate binding ion-exchange resins for the control of hyperphosphatemia.Correspondence to:
K. Takagi, DVM
Safety Research Laboratory
Research Division, Mitsubishi Tanabe Pharma Corporation
1-1-1 Kazusakamatari, Kisarazu-shi
Chiba 292-0818, Japan
Email: Takagi.Kan@me.mt-pharma.co.jp
Original
Emotional symptoms, quality of life and cytokine profile in hemodialysis patients
Abstract
V. Montinaro1, G.P. Iaffaldano1, S. Granata2, P. Porcelli3, O. Todarello4, F.P. Schena1,2 and G. Pertosa1,2
1Nephrology, Dialysis and Transplant Unit, Azienda Ospedaliero-Universitaria “Consorziale Policlinico”, 2Department of Emergency and Organ Transplantation (DETO), University of Bari, and 3Psychosomatic Unit, IRCCS “De Bellis” Hospital, Castellana Grotte, and 4Department of Psychiatry, University of Bari, Italy
Background: Mental disorders are frequent in hemodialysis (HD) patients. Depression and anxiety along with physical co-morbidity affect quality of life (QOL). Uremia is associated with inflammation and release of cytokines by lymphomonocytes. Inflammatory cytokines are relevant in depression. The aim of this study was to assess the psychological alterations and QOL in HD patients, and to correlate them with pattern of cytokine production. Methods: Patients: 30 HD patients and 20 subjects with CKD Stage I-II K-DOQI. Psychometric tests were administered: 1) Hospital Anxiety and Depression Scale (HADS) composed of an anxiety subscale (HADS-A) and a depression subscale (HADS-D); 2) Kidney Disease Quality of Life (KDQOL) modified, including a cognitive function subscale (KDQOL-CF). Whole blood samples collected at beginning of HD session were diluted with RPMI/heparin and incubated for 24 h in presence of lipopolysaccharide (LPS). IL-1Γ, IL-6, TNF-α and IL-10 were assayed on supernatants and results were normalized per number of lymphomonocytes (ng/106 cells). Results: A depressive mood was more frequent in HD patients (50%) than controls (20%, p < 0.0001). No difference for anxiety (HD = 43%, controls = 45%) was observed. QOL score was significantly lower in HD than controls (p = 0.006) and correlated inversely with HADS total, HADS-A and HADS-D (p < 0.0001). Albumin, Kt/V and phosphate were comparable in patients with or without anxiety or depression. Cytokine production was significantly higher in HD patients than controls (IL-1β p = 0.05; IL-6 p = 0.010; TNF-α p < 0.0001; IL-10, p = 0.0019). HD patients with the HADS-A positive for anxiety showed higher IL-6 production (p = 0.026), while IL-1β levels were not associated with symptoms of depression. KDQOL-CF correlated inversely with levels of IL-6, TNF-α and IL-10. Conclusions: HD patients have symptoms of depression and anxiety that negatively affect QOL. These symptoms are independent of the efficiency of dialysis and nutritional status. On the contrary, IL-6 is linked to the presence of psychological discomfort in these patients.Correspondence to:
Dr. V. Montinaro
Divisione di Nefrologia
Dialisi e Trapianto Azienda
Ospedaliero-Universitaria “Consorziale Policlinico” Bari
Piazza G. Cesare, 11
70124 Bari, Italy
Email: v.montinaro@nephro.uniba.it
Original
Relation between polymorphisms of receptor for advanced glycation end products (RAGE) and cardiovascular diseases in Chinese patients with diabetic nephropathy
Abstract
P.Y.-K. Poon, C.-C. Szeto, K.-M. Chow, B.C.-H. Kwan and P.K.-T. Li
Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
Background: Interaction of receptor for advanced glycation end products (RAGE) with advanced glycation end products (AGEs) is an important pathogenic mechanism of diabetic complications. Three mutations in the promoter region of the RAGE gene (T-429C, T-374A and a 63bp deletion spanning from –407 to –345 nucleotides) were known to have increased transcriptional activities. We investigated the relationship between these polymorphisms and the risk of cardiovascular diseases in Chinese subjects with overt diabetic nephropathy. Methods: A total of 219 Type 2 diabetic subjects with nephropathy were recruited. Genotyping of the three polymorphisms in the genomic DNA was done by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Patients were followed for 8 years for the development of cardiovascular events and survival. Results: The T-429C and T-374A polymorphism had no effect on the event-free survival of the subjects. For the 63bp deletion polymorphism, the event-free survival was 37.0% and 63.2% at 96 months for del-/- and del-/+ genotypes, respectively (log-rank test, p = 0.034). After adjusting for confounders, the 63bp deletion polymorphism had a marginal effect on event-free survival (adjusted hazard ratio: 3.517, 95% CI: 0.852 – 14.521, p = 0.082). Subjects without any mutation of the three polymorphisms have significantly higher risk of first ischemic heart disease than those with any of the three mutations (adjusted hazard ratio: 0.218, 95% CI: 0.062 – 0.764, p = 0.017). Conclusion: The 63bp del-/+ genotype of the RAGE gene has a marginal benefit on the cardiovascular event-free survival in subjects with diabetic nephropathy. Subjects with any of the three mutations have a lower risk of ischemic heart disease. The role of RAGE in the pathogenesis of cardiovascular disease in diabetic patients requires further study.Correspondence to:
Dr. C.C. Szeto
Department of Medicine and Therapeutics
Prince of Wales Hospital
Chinese University of Hong Kong
Shatin, N.T., Hong Kong, China
Email: ccszeto@cuhk.edu.hk
Original
Aminothiols and allantoin in chronic dialysis patients: effects of hemodialysis sessions
Abstract
E. Caussé1,5, D. Ribes3, N. Longlune3, N. Kamar2,3,5, D. Durand3,5, R. Salvayre1,2,5 and L. Rostaing3,4,5
1Biochemistry Laboratory, CHU RANGUEIL, 2INSERM U 858, 3Department of Nephrology, Dialysis, and Organ Transplantation, University Hospital, CHU RANGUEIL, 4INSERM U 563, Toulouse Cédex and 5PRES, Toulouse University, France
Background: To investigate the possible relationship between homocysteine and allantoin levels in hemodialyzed patients, serum levels of thiols and purine compounds were analyzed before and after dialysis sessions. Methods: 16 clinically stable non-diabetic patients hemodialyzed on polysulfone membranes were compared with 36 control subjects. Serum samples were collected before and after hemodialysis sessions. Total homocysteine, cysteine, glutathione, cysteinylglycine, uric acid, hypoxanthine, and allantoin were measured by capillary electrophoresis. Results: Pre-dialysis homocysteine, allantoin, and uric acid were significantly elevated in dialysis patients as compared to controls. Cysteine, glutathione, and hypoxanthine levels were similar in both groups. Homocysteine significantly decreased, but did not normalize after dialysis sessions. Glutathione and cysteinylglycine levels remained unchanged after dialysis sessions, whereas cysteine decreased. Uric acid, hypoxanthine, and allantoin levels were significantly reduced by dialysis sessions. The allantoin/uric acid ratio was higher in dialyzed patients before hemodialysis (0.049 ± 0.023 vs. 0.016 ± 0.012 in controls; p < 0.001), and became elevated after a dialysis session (0.084 ± 0.033; p = 0.002). Conclusions: Despite the use of biocompatible membranes, homeostasis of thiols and purine compounds is disturbed in hemodialysed patients. We suggest that allantoin could be used as a marker for oxidative stress in hemodialyzed patients.Correspondence to:
E. Caussé, MD
CHU Rangueil, Laboratoire de Biochimie
1 av. Jean Poulhés, TSA 50032
31059 Toulouse Cedex 9, France
Email: causse.e@chu-toulouse.fr
Original
Evolution of Fabry disease in male patients: The Greek experience
Abstract
E. Andrikos1, C. Iatrou2, J.N. Boletis3, A. Diamandopoulos4, C. Katsinas5, K. Kalaitzidis6, A. Galinas7, A. Xaidara8, M. Pappas1 and K.C. Siamopoulos9
1General Hospital “G. Hatzikosta”, Ioannina, 2General Hospital, Nikea-Piraeus, 3Genener Hospital “Laiko”, Athens, 4General Hospital “Agios Andreas”, Patras, 5General Hospital, Ptolemaida, 6General Hospital, Kavala, 7251 General Aeronautic Hospital, Athens, 8Pediatric Hospital “Aghia Sophia”, Athens and 9University Hospital, Ioannina, Greece
Fabry disease is a progressive metabolic disorder with a clinical course characterized by different phases and a variety of disease manifestations. The first symptoms generally appear in childhood or early adolescence and are followed by late life-threatening complications involving vascular, renal, cardiac, and cerebral systems. We report the clinical and biochemical characteristics of 16 male patients from 10 unrelated families who represent almost the entire cohort of known Fabry patients in Greece. Despite the presence of early symptoms in almost every patient (mean age at onset of symptoms 15.6 years), the diagnosis was delayed for a mean of about 18 years (mean age of diagnosis 36 years). Patients are currently monitored and the majority (15 out 16 patients) treated with Enzyme Replacement Therapy.Correspondence to:
K.C. Siamopoulos, MSc, MD, FRSH
Professor of Medicine/Nephrology
Division of Nephrology, Department of Internal Medicine
Medical School, University of Ioannina
451 10 Ioannina, Greece
Email: ksiamop@cc.uoi.gr
Case Report
Tetanus as a cause of rhabdomyolysis and acute renal failure
Abstract
M.F. Weiss1, J. Badalamenti2 and E. Fish2
1Renal Replacement LLC, Lyndhurst, OH, and 2Division of Nephrology, St. Mary’s Hospital and Medical Center, Grand Junction, CO, USA
Acute renal failure developed in an elderly woman with a rapidly progressive illness characterized by nuchal rigidity, limb spasm, repetitive grunting vocalizations without intelligible speech, and risus sardonicus. Eventually she developed characteristic findings of increased tone in her masseter muscles (trismus) and rigid upper and lower extremities, consistent with generalized tetanus. Increasing serum creatinine was temporally associated with rising creatine phosphokinase (CPK) and striking elevations of plasma myoglobin. The patient had marked lability of blood pressure and pulse. She improved briefly after tetanus toxoid and broad-spectrum antibiotics, but died of heart failure after 9 days of hospitalization. A necrotic pelvic tumor was believed to be the source of infection. Tetanus is a preventable disease, which has not been eradicated, even in Western populations. Full-blown tetanus has a high fatality rate, and should be considered in the differential diagnosis of acute renal failure in the setting of rising CPK and continued release of muscle myoglobin.Correspondence to:
M.F. Weiss, MD
5096 Dogwood Trail
Lyndhurst, OH 44124, USA
Email: miriam.weiss@case.edu
Case Report
Tonsillectomy and steroid pulse therapy for recurrent IgA nephropathy in renal allograft
Abstract
T. Tsuchiya1, S. Ito1, Y. Yamaguchi2, Y. Moriyama1, H. Ehara1 and T. Deguchi1
1Department of Urology, Gifu University School of Medicine, Gifu, and 2Department of Pathoology, Kashiwa Hospital, Jikei University School of Medicine, Kashiwa, Japan
We experienced two cases of steroid pulse therapy combined with tonsillectomy for recurrent IgA nephropathy (IgAN) in a renal allograft. We defined recurrent IgAN in renal allograft as IgA deposits in glomeruli with persistent proteinuria (> 0.5 g/ day) and microscopic hematuria in renal transplant recipients with biopsy-proven IgAN of their native kidneys. We performed steroid pulse therapy following tonsillectomy as therapeutic protocol for recurrent IgAN. The first patient was diagnosed with recurrent IgAN by allograft biopsy 3 years after renal transplantation, and a second patient was diagnosed after one year. The former patient’s proteinuria disappeared 4 months after treatment and the latter patient’s proteinuria disappeared after one month. Tonsillectomy combined with steroid pulse therapy can induce clinical remission in patients with recurrent IgAN after renal transplantation.Correspondence to:
T. Tsuchiya, MD
Department of Urology
Gifu University School of Medicine
1-1 Yanagido, Gifu 501-1194, Japan
Email: tuchiyat@gifu-u.ac.jp
Case Report
Successful treatment of refractory septic arthritis caused by salmonella and staphylococcus aureus with preservation of graft function in a long-term renal transplant recipient by total withdrawal of immunosuppressants
Abstract
J.-W. Chang1,3, H.-L. Tsai2,3 and L.-Y. Yang1,3
1Department of Pediatrics, Taipei Veterans General Hospital, Taiwan, 2Division of Pediatric Surgery, Department of Surgery, Taipei Veterans General Hospital, and 3Institute of Clinical Medicine, National Yang Ming University, School of Medicine, Taipei, Taiwan
An 18-year-old female had received a 2 HLA incompatible renal transplant 10 years before. She initially presented with septic arthritis and osteomyelitis caused by Salmonella enterica co-infected with Staphylococcus aureus of her left knee with development of secondary septic arthritis of the right knee and left shoulder. This was complicated by a recurrent subcutaneous abscess and intermittent high fever. The infection was successfully treated with a combination of a prolonged course of antibiotics, twice joint washout and debridement, repeat aspiration, hyperbaric oxygen therapy and a total withdrawal of immunosuppressant resulting in good joint function and preservation of normal renal graft function. In our experience, it was possible to keep stable renal graft function in spite of complete withdrawal of immunosuppressants for 12 months in a recipient with 2 HLA mismatches.Correspondence to:
L.-Y. Yang MD, PhD
Department of Pediatrics
Veterans General Hospital, No. 201, Section 2
Shih-Pai road, Taipei, 11217 Taiwan
Email: yangly@vghtpe.gov.tw
Case Report
Two cases of Weil’s disease with acute renal failure in the central Tokyo metropolitan area
Abstract
T. Inoue1, K. Yoshikawa2, M. Tada1, T. Nakamura3 and F. Hinoshita1
1Division of Nephrology, International Medical Center of Japan, Tokyo, 2Division of Nephrology, Kawashima Hospital, Tokushima and 3Division of Nephrology, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
The incidence of leptospirosis, or Weil’s disease, in developed countries, particularly in temperate regions, has been dramatically decreasing due to recent improvements in the hygienic environment. In these areas, physicians rarely face this disease and inclusion as a differential diagnosis of acute renal failure seems increasingly uncommon. However, we encountered two cases of severe leptospirosis requiring hemodialysis in central Tokyo. Both cases showed hyperbilirubinemia, thrombocytopenia and mental disturbance in addition to acute renal failure. Severe leptospirosis remains associated with high mortality rates, and early clinical suspicion and laboratory confirmation of the disease are crucial. Detailed history-taking suggested that leptospirosis was caused by transmission from rats in both cases. Rodents inhabit most land areas, implying that the disease can occur all over the world, even in huge metropoles such as Tokyo. These two cases indicate the need for awareness of leptospirosis among physicians working even in urban areas of developed countries.Correspondence to:
F. Hinoshita, MD, PhD
1-21-1 Toyama
Shinjuku, Tokyo, Japan
Email: fhinoshi@imcj.hosp.go.jp
Letter to the Editor
Placement of dual lumen non-cuffed dialysis catheter into persistent left superior vena cava
Abstract
P. Sriramnaveen, C. Krishna Kishore, V.V. Sainaresh, G. Sivaramakrishna, B. Vijayalakshmi Devi, A.Y. Lakshmi and V. Sivakuma
