Volume 76, No. 2/2011(August)
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 Clinical Nephrology
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Nephrology Education
Two cases of renal hypouricemia in which dopamine infusion produced a good recovery from exercise-induced acute kidney injury
O. Saito, T. Sugase, T. Saito, T. Akimoto, M. Inoue, Y. Ando, S. Muto and E. Kusano
Abstract
Clinical Nephrology, Vol. 76 – No. 2/2012 (83-89)
Two cases of renal hypouricemia in which dopamine infusion produced a good recovery from exercise-induced acute kidney injury
O. Saito, T. Sugase, T. Saito, T. Akimoto, M. Inoue, Y. Ando, S. Muto and E. Kusano
Division of Nephrology, Department of Medicine, Jichi Medical University, Tochigi, Japan
We report 2 cases with a good recovery from acute kidney injury (AKI) due to exercise-induced AKI associated with renal hypouricemia. Case 1 involves a 20-yearold man who had a similar episode 1 year earlier. He complained of nausea, vomiting and loin pain after playing football. On admission, his serum creatinine was 3.27 mg/dl and he was treated with intravenous fluid infusion (2 l/d). His renal function deteriorated and creatinine rose to 9.82 mg/dl. A renal hemodynamic evaluation using duplex Doppler ultrasound showed a high arterial resistance index (RI). After we changed his treatment to intravenous continuous infusion of 2 µg/kg/min dopamine, RI decreased sequentially and creatinine decreased without hemodialysis. A renal biopsy performed 7 days after dopamine infusion showed no changes in glomeruli and tubules, suggesting the absence of acute tubular necrosis, and no uric acid crystals or myoglobin casts in tubules. Case 2 involves a 42-year-old man who complained of loin pain after riding a motorcycle. On admission, his creatinine and creatine phosphokinase (CPK) were 3.93 mg/dl and 59 mU/ml, respectively. His RI was also high and he was treated immediately with an intravenous continuous infusion of 2 µg/kg/min dopamine. RI and creatinine decreased sequentially. Both cases suggest the effectiveness of dopamine infusion for AKI due to renal hypouricemia in which the RI of the renal arteries is high.Correspondence to:
O. Saito, MD
Department of Nephrology
Jichi Medical University
3311-1 Yakushiji Simotsuke
Tochigi, 329-0498, Japan
Email: nephsait@jichi.ac.jp
Original
Hepcidin and disordered mineral metabolism in chronic kidney disease
C. Carvalho, T. Isakova, G. Collerone, G. Olbina, M. Wolf, M. Westerman and O.M. Gutiérrez
Abstract
Clinical Nephrology, Vol. 76 – No. 2/2011 (90-98)
Hepcidin and disordered mineral metabolism in chronic kidney disease
C. Carvalho1, T. Isakova2, G. Collerone2, G. Olbina3, M. Wolf1, M. Westerman3 and O.M. Gutiérrez1
1Division of Nephrology and Hypertension, Department of Medicine, University of Miami, Miller School of Medicine, Miami, FL, 2Nephrology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, and 3Intrinsic LifeSciences, La Jolla, CA, USA
Background: Hepcidin regulates iron homeostasis by blocking iron absorption from the gut and iron release from macrophage and hepatocyte stores. Hepcidin levels are elevated in kidney failure and thus, are thought to contribute to dysregulation of iron homeostasis in chronic kidney disease (CKD). However, the primary factors associated with increased hepcidin levels in CKD patients have not been well-defined. In particular, few studies examined the relationships between hepcidin and disorders of mineral metabolism, which are among the earliest and most common complications of CKD. Methods: We examined the associations between hepcidin, iron indexes, and markers of mineral metabolism in 125 patients from across the spectrum of pre-dialysis CKD. Bioactive hepcidin levels were measured in serum samples by competitive ELISA. Results: Hepcidin was inversely associated with eGFR and linearly associated with ferritin (p < 0.001 for both). In unadjusted analyses, increased serum phosphate and parathyroid hormone (PTH) and decreased 1,25-dihydroxyvitamin D (1,25(OH)2D) levels were associated with increased hepcidin. When examined in forward stepwise regression analysis, higher phosphate and PTH levels and lower 1,25(OH)2D and FGF23 levels were selected as independent predictors of higher hepcidin levels, whereas there was no association between eGFR and hepcidin. Conclusions: Abnormalities in phosphate and vitamin D metabolism were associated with increased hepcidin levels independently of eGFR in CKD patients. These findings suggest that disorders of mineral metabolism may promote increased hepcidin secretion in CKD. Whether inflammation mediates these associations requires further study.Correspondence to:
O.M. Gutiérrez, MD, MMSc
University of Alabama at Birmingham
ZRB 614, 1530 3rd AVE S
Birmingham, AL 35294-0006, USA
Email: ogutierr@uab.edu
Original
Improved parathyroid hormone control by cinacalcet is associated with reduction in darbepoetin requirement in patients with end-stage renal disease
M. Battistella, R.M.A. Richardson, J.M. Bargman and C.T. Chan
Abstract
Clinical Nephrology, Vol. 76 – No. 2/2011 (99-103)
Improved parathyroid hormone control by cinacalcet is associated with reduction in darbepoetin requirement in patients with end-stage renal disease
M. Battistella, R.M.A. Richardson, J.M. Bargman and C.T. Chan
Division of Nephrology, Department of Medicine, University Health Network, Toronto, ON, Canada
Background: Uncontrolled hyperparathyroidism causes bone marrow fibrosis, leading to erythropoietin (EPO) resistance. Medical treatment with cinacalcet is effective in reducing plasma parathyroid hormone (PTH) levels, but its effect on darbepoetin dosing is unknown. Methods and aims: We conducted a retrospective cohort study of 40 end-stage renal disease (ESRD) patients (age: 55 ± 14; mean ± SD; 21:male) who had at least 12 months of cinacalcet therapy. The distribution of renal replacement therapies were: 14 peritoneal dialysis, 18 conventional hemodialysis and 8 nocturnal hemodialysis. Standard dialysis related biochemical indices and medications used were recorded. The primary objective of the study was to ascertain the difference in darbepoetin responsiveness before and after 12 months of cinacalcet therapy. Our secondary objective was to determine if there was a relationship between the changes in PTH and darbepoetin requirement. Results: Overall, PTH levels decreased from 197.5 (151.8; 249.2) to 66.1 (41.2; 136.5) (median (25th;75th percentile)) pmol/l; p < 0.001. Cinacalcet dose increased from 30.0 ± 6 to 63 ± 25 mg/day, p < 0.05. Hemoglobin remained unchanged (116 ± 13 to 116 ± 13 g/l), while darbepoetin requirement decreased from 40 (20; 60) to 24 (19; 59) μg/week, p = 0.02. The remainder of the dialysis-related biochemistry (electrolytes, calcium, phosphate, iron status) and vitamin D use remained unchanged. A reduction in PTH level of greater than 30% was experienced by 82.5% (33/40) of our cohort. Among the responders, the fall in PTH and reduction darbepoetin requirement were related (R = –0.48, p = 0.004). Conclusions: Reduction of PTH by cinacalcet is associated with a decrease in darbepoetin requirement. The interface between bone and bone marrow in uremia represents a critical step in red blood cell production which merits further investigation.Correspondence to:
Dr. C.T. Chan
200 Elizabeth Street, 8 N room 842
Toronto, Ontario M5G 2C4, Cananda
Email: christopher.chan@uhn.on.ca
Original
The utility of intraoperative PTH measurement in surgical parathyroidectomy after renal transplantation
C.K. Cheung, R.J.A. England and S. Bhandari
Abstract
Clinical Nephrology, Vol. 76 – No. 2/2011 (104-109)
The utility of intraoperative PTH measurement in surgical parathyroidectomy after renal transplantation
C.K. Cheung1, R.J.A. England2 and S. Bhandari1
1Departments of Renal Medicine, and 2Otolaryngology/Head and Neck Surgery, Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Hull, UK
Aims: Intraoperative PTH (ioPTH) monitoring is used widely to guide surgery in primary hyperparathyroidism, but its reliability in renal transplant recipients is largely unknown. The aim of this study was to examine the utility of ioPTH monitoring in predicting long-term effectiveness of parathyroid tissue excision in renal transplant recipients, and to investigate the effect of parathyroidectomy on transplant function. Methods: Renal transplant recipients undergoing primary parathyroidectomy for persistent hyperparathyroidism were included. Intact PTH levels were measured at induction of anesthesia (PTH0), intra-operatively following removal of parathyroid tissue (PTH1) and 15 minutes after resection (PTH2). Serum PTH, calcium, phosphate and creatinine levels were measured up to 12 months postoperatively. Results: 14 patients (9 male, mean age 55 ± 3 y) were included. PTH levels fell significantly from baseline (PTH0 237.4 ± 43.5 pg/ml) at both time points (PTH1 108.4 ± 38.3 pg/ml; PTH2 62.4 ± 31.3 pg/ml; p = 0.001). Three patients had a raised PTH level at 12 months post procedure. Analysis of these cases showed no difference in the fall of ioPTH, compared to patients in which the PTH level remained controlled. There was no significant change in renal function from baseline to 1 year post parathyroidectomy. Conclusion: Intra-operative and early postoperative measures of PTH may not be a reliable indicator of satisfactory parathyroid tissue excision in renal transplant recipients. Parathyroidectomy does not appear to be detrimental to long-term transplant function.Correspondence to:
C.K. Cheung
Department of Renal Medicine
Alderson House, Hull Royal Infirmary
Anlaby Road, Hull, HU3 2JZ, UK
Email: cheekaycheung@gmail.com
Original
Vitamin D and muscle strength, functional ability and balance in peritoneal dialysis patients with vitamin D deficiency
H. Taskapan, O. Baysal, D. Karahan, B. Durmus, Z. Altay and O. Ulutas
Abstract
Clinical Nephrology, Vol. 76 – No. 2/2011 (110-116)
Vitamin D and muscle strength, functional ability and balance in peritoneal dialysis patients with vitamin D deficiency
H. Taskapan1, O. Baysal2, D. Karahan1, B. Durmus2, Z. Altay2 and O. Ulutas1
1Nephrology Department, and 2Physical Medicine and Rehabilitation Department, Turgut Ozal Medical Center of Inonu University, Medical Faculty, Malatya, Turkey
25(OH)D deficiency has been associated with significantly worse physical performance in individuals with normal renal function. We examined the physical function, muscle strength and balance in age- and gender-matched 25 Stage 3 – 4 CKD patients and 47 Stage 5 CKD patients on peritoneal dialysis (PD) with vitamin D deficiency by objective methods and evaluated the effect of vitamin D replacement on physical performance tests: the “timed up and go” (TUG) test, gait velocity test, timed chair stand test, stair climb test, dynamic balance tests (TUG test, dynamic postural stability test), static balance test (functional reach test) and muscle strength in these two groups. At baseline 25(OH)D in the Stage 3 – 4 CKD patients and patients on PD were 6.9 ± 3.5 ng/ ml (17.2 ± 8.7 nmol/l) and 5.7 ± 3.3 ng/ml (14.2 ± 8.2 nmol/l), respectively (p > 0.05). Mean (± SD) 25(OH)D in Stage 3 – 4 CKD patients and those on PD were 52.0 ± 40.9 ng/ml (129.7 ± 102.2 nmol/l) and 41.9 ± 21, ng/ml (104,5 ± 52,6 nmol/l) respectively after vitamin D replacement (p > 0.05). When both Stage 3 – 4 CKD and dialysis patients became vitamin D-sufficient after vitamin D replacement, they took a significantly shorter time to complete the TUG test, gait velocity test, the timed chair stand test and stair climb test. Results of physical performance tests, static and dynamic balance tests and isometric strength tests improved in both groups after the treatment (p < 0.05). In conclusion, our results show that vitamin D supplementation improves muscle strength, functional ability and balance in both CKD and dialysis patients.Correspondence to:
H. Taskapan, MD
Professor of Medicine and Nephrology
Inonu University Medical School
Department of Nephrology
Malatya, Turkey
Email: hulyataskapan@yahoo.com
Original
Urinary angiotensinogen levels reflect the severity of renal histopathology in patients with chronic kidney disease
S.M. Kim, H.R. Jang, Y.-J. Lee, J.E. Lee, W. Huh, D.J. Kim, H.Y. Oh and Y.-G. Kim
Abstract
Clinical Nephrology, Vol. 76 – No. 2/2011 (117-123)
Urinary angiotensinogen levels reflect the severity of renal histopathology in patients with chronic kidney disease
S.M. Kim1, H.R. Jang1, Y.-J. Lee2, J.E. Lee1, W.S. Huh1, D.J. Kim1, H.Y. Oh1 and Y.-G. Kim1
1Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, and 2Nephrology Division, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
Background/Aims: Recent studies have suggested that urinary angiotensinogen (AGT) reflects the activity of the intrarenal renin angiotensin system (RAS), which is involved in tissue injury in patients with chronic kidney disease. In this study, we investigated whether urinary AGT directly reflected the severity of histopathology in such patients. Methods: AGT was measured using a sandwich enzyme-linked immunosorbent assay (ELISA) on urine and plasma samples obtained from 58 patients on the day of renal biopsy. We measured the urinary transforming growth factor (TGF)-beta1, a representative cytokine of fibrogenic property, and analyzed the correlation among urinary TGF-beta1, urinary AGT, and the severity of renal injury. Mesangial proliferation, glomerulosclerosis, tubular atrophy and interstitial fibrosis were scored for the biopsied tissues. Results: Urinary AGT levels correlated positively with proteinuria, urinary TGF-beta1 levels and diastolic blood pressure, but negatively with the estimated glomerular filtration rate (GFR). Urinary AGT concentrations were increased in patients with severe glomerulosclerosis, tubular atrophy and interstitial fibrosis. Conclusion: Urinary AGT levels correlated with the deterioration of renal function in patients with chronic kidney disease and reflected the histological severity of renal injury.Correspondence to:
Y.-G. Kim, MD
Division of Nephrology
Department of Medicine
Samsung Medical Center
Sungkyunkwan University School of Medicine
50 Irwondong, Gangnam-gu
135-710, Seoul, Korea
Email: ygkim26@skku.edu
Original
Peritoneal dialysis for patients suffering from severe heart failure
N.G. Sotirakopoulos, I.M. Kalogiannidou, M.E. Tersi and K.S. Mavromatidis
Abstract
Clinical Nephrology, Vol. 76 – No. 2/2011 (124-129)
Peritoneal dialysis for patients suffering from severe heart failure
N.G. Sotirakopoulos, I.M. Kalogiannidou, M.E. Tersi and K.S. Mavromatidis
Renal Department of General Hospital of Komotini, Komotini, Greece
Over a period of 6.5 years, we treated 19 patients, all of whom suffered from severe heart failure and various stages of chronic kidney disease, excluding those with end-stage kidney failure. Before peritoneal catheter implantation, all patients had ascites, dyspnea, orthopnea, and an ejection fraction ranging from 20 to 45%. Seven of them (7/19) were able to take care of themselves, 9/19 needed assistance for their daily activities, and the remaining 3 were bedridden. All of them needed hospitalization 1 – 3 times/month during the year before the initiation of continuous ambulatory peritoneal dialysis (CAPD). With peritoneal dialysis, daily ultrafiltrate volume ranged from 500 to 3,000 ml and, after an average of 2 months of peritoneal dialysis, body weight decreased significantly (74.7 ± 13 vs. 69.7 ± 10.2, p = 0.02). At the same time, diuresis improved significantly, and this allowed a reduction in the dose of diuretics. Dyspnea and orthopnea improved significantly in all patients. The patients’ degree of self-care and ability to sleep lying flat improved significantly as the need for hospitalization declined. Before peritoneal dialysis, patients were hospitalized for 5 – 20 days/month for pulmonary edema or overhydration, whereas with peritoneal dialysis, nobody was hospitalized for these causes (chi2, p = 0.0001). Ejection fraction also improved in all of them (28.6 ± 8.6 vs. 36.8 ± 12.5%, p = 0.0001). Actual survival of our patients ranged from 6 to 86 months (mean ± SD = 24.6 ± 20.8). Actuarial survival was 68% at 1 year and 42% at 2 years. During peritoneal dialysis we observed only two episodes of peritonitis. Four patients developed a severe episode of hypotension during implantation of the catheters from the sudden removal of 4 – 6 l of ascitic fluid. We conclude that peritoneal dialysis is a good method for the treatment of congestive heart failure because it increases the quality of life and life expectancy in patients with poor prognosis.Correspondence to:
K. Mavromatidis
Antoni Rossidi 11 – 69100
N. Mosinoupoli, Komotini, Greece
Email: mavromatidis_k@yahoo.com
Original
Hypernatremia without water depletion
T. Kahn
Abstract
Clinical Nephrology, Vol. 76 – No. 2/2011 (130-135)
Hypernatremia without water depletion
T. Kahn
J P Peters Bronx Veterans Administration Medical Center, New York, NY, USA
Hypernatremia is generally thought to be a condition in which water depletion raises the serum sodium concentration despite some salt loss. However, many patients with hypernatremia have been shown to have normal or increased total body water, indicating that these patients are salt- and frequently water-overloaded. Possible pathophysiological reasons for these abnormalities are discussed. Recognition of this clinical condition is important because therapy should avoid further worsening the salt and water overload.Correspondence to:
Prof. T. Kahn, MD
J P Peters Bronx Veterans Administration Medical Center
130, West Kingsbridge Road
New York, NY 10468, USA
Email: thomas.kahn@va.gov
Original
Treatment with cyclosporine A improves SLE disease activity of Japanese patients with diffuse proliferative lupus nephritis
Y. Kamijo, K. Hashimoto, K. Takahashi, T. Ehara, H. Shigematsu and M. Higuchi
Abstract
Clinical Nephrology, Vol. 76 – No. 2/2011 (136-143)
Treatment with cyclosporine A improves SLE disease activity of Japanese patients with diffuse proliferative lupus nephritis
Y. Kamijo1, K. Hashimoto1, K. Takahashi1, T. Ehara2, H. Shigematsu2 and M. Higuchi1
1Department of Nephrology Internal Medicine and 2Department of Pathology, Shinshu University School of Medicine, Nagano, Japan
Aims: Cyclosporine A (CyA), a representative calcineurin inhibitor, may be useful for the treatment of lupus nephritis. In contrast to knowledge about its strong effects against proteinuria, however, there is little information about the beneficial effects of CyA against clinical disease activity of diffuse proliferative lupus nephritis. Methods: To elucidate this issue, we investigated the effects of low-dose CyA treatment (< 2.5 mg/kg/d) in 11 Japanese adult patients (1 male, 10 female) with uncontrolled diffuse proliferative lupus nephritis with severe clinical SLE disease activity. Results: In addition to amelioration of the proteinuric state, the clinical SLE disease activities, estimated by serological markers and the SLE disease activity index (SLEDAI), were significantly improved in all patients within 1 month. The required amounts of corticosteroid were decreased in these patients. These favorable effects continued for 2 y without serious adverse effects. Kidney function was not changed in the patients with satisfactory kidney function prior to CyA therapy (serum creatinine < 1.1 mg/dl, and eGFR > 45 ml/ min/1.73 m2). Conclusion: The current study results suggest that low-dose CyA treatment could ameliorate the severe clinical SLE disease activity as well as improve proteinuria in Japanese patients with diffuse proliferative lupus nephritis. This treatment would be safe and useful for SLE patients with satisfactory kidney function.Correspondence to:
Y. Kamijo, MD, PhD
Department of Nephrology
Internal Medicine, Shinshu University
School of Medicine
3-1-1 Asahi
Matsumoto, 390-8621, Japan
Email: yujibeat@shinshu-u.ac.jp
Original
Urinary interleukin-6 (IL-6) and transforming growth factor (TGF-β) levels in corticosteroidtreated patients with IgA nephropathy
P. Kalliakmani, L. Nakopoulou, S. Tsakas, M. Gerolymos, M. Papasotiriou and D.S. Goumenos
Abstract
Clinical Nephrology, Vol. 76 – No. 2/2011 (144-150)
Urinary interleukin-6 (IL-6) and transforming growth factor (TGF-β) levels in corticosteroidtreated patients with IgA nephropathy
P. Kalliakmani1, L. Nakopoulou2, S. Tsakas3, M. Gerolymos1, M. Papasotiriou1 and D.S. Goumenos1
1Department of Internal Medicine-Nephrology, University Hospital, Patras, 2Department of Pathology, Medical School, University of Athens, Athens, and 3Laboratory of Biology, Department of Biology, University of Patras, Patras, Greece
Background: Interleukin–6 (IL-6) and transforming growth factor-β (TGF-β) are implicated in the progression of IgA nephropathy, which is usually treated with corticosteroids. Patients and methods: Urinary IL-6 and TGF-β were measured in 21 proteinuric patients with IgA nephropathy, before and after treatment with corticosteroids, to estimate the activity of the disease after remission of proteinuria. Results: Urinary IL-6 and TGF-β levels at diagnosis were significantly higher in patients with IgA nephropathy compared to healthy subjects. TGF-β levels, were significantly higher in patients with proteinuria > 1 g/24 h and/or severe mesangial proliferation. Although a significant reduction of proteinuria was observed with corticosteroid treatment, urinary IL-6 and TGF-β levels remained elevated. Deterioration of renal function over a period of 5 years was observed in 3 patients. High urinary IL-6 levels at diagnosis represent a significant parameter distinguishing patients with progressive course in comparison to those with favorable clinical outcome (p = 0.01). Conclusion: Treatment of patients with IgA nephropathy with corticosteroids is followed by remission of proteinuria but still increased urinary IL-6 and TGF-β excretion. This may be related to an ongoing inflammatory process within the kidney, and further research is required to estimate the value of urinary IL-6 and TGF-β as markers of activity of the disease.Correspondence to:
Prof. D.S. Goumenos
Internal Medicine Nephrology
University Hospital of Patras
26500 Patras, Greece
Email: dgoumenos@med.upatras.gr
Original
Rituximab in adult patients with immunosuppressive-dependent minimal change disease
E. Hoxha, R.A.K. Stahl and S. Harendza
Abstract
Clinical Nephrology, Vol. 76 – No. 2/2011 (151-158)
Rituximab in adult patients with immunosuppressive-dependent minimal change disease
E. Hoxha, R.A.K. Stahl and S. Harendza
University Medical Center Hamburg-Eppendorf, III. Medizinische Klinik, Hamburg, Germany
Background: Minimal change disease (MCD) is one of the leading causes of nephrotic syndrome. Steroid therapy is effective in achieving remission, but relapses, steroid dependence, and steroid resistance are therapeutic challenges. The use of second-line agents such as cyclophosphamide is associated with toxicity and adverse effects. Therefore, we studied the effect of rituximab (RTX) on proteinuria in adult patients with immunosuppressive (IS)-dependent MCD. Methods: In this single-center, prospective, open series study, 6 consecutive patients with IS-dependent MCD and frequent relapses on different IS regimens – one of them after previous RTX treatment – were included. Patients were treated with a single dose of RTX (375 mg/m²). An additional dose of RTX was administered depending on B-cell count and proteinuria. Results: 5 out of 6 patients achieved complete remission at the end of the follow-up; the other patient had a partial remission. All patients are free of additional IS agents and other medications were remarkably reduced. Three patients had a relapse, which was successfully treated with a further RTX treatment. Conclusions: RTX could be an alternative in the therapy of patients with IS-dependent MCD, leading to successful cessation of other IS treatment.Correspondence to:
Prof. Dr. S. Harendza, MME
University Medical Center Hamburg-Eppendorf
Martinistraße 52
20246 Hamburg, Germany
Email: harendza@uke.de
Nephrology Education
Acute kidney injury with cryoglobulinemic peritubular neutrophilic capillaritis
M.L. Troxell, D.V. Shackleton, P. Raguram and D.C. Houghton
Abstract
Clinical Nephrology, Vol. 76 – No. 2/2011 (159-164)
Acute kidney injury with cryoglobulinemic peritubular neutrophilic capillaritis
M.L. Troxell1, D.V. Shackleton1, P. Raguram2 and D.C. Houghton1
1Department of Pathology, Oregon Health Science University, and 2Portland Hypertension Nephrology LLP, Portland, OR, USA
Background: Neutrophil predominant capillaritis and interstitial inflammation is an uncommon renal biopsy finding, with a broad differential diagnosis. Case: A 77-year-old woman presented with a complicated history including vasculitis, cryoglobulinemia, malaise, and systemic symptoms, which progressed to acute kidney injury. Renal biopsy demonstrated prominent neutrophilic capillaritis with interstitial inflammation, and fibrinoid deposits in medullary capillaries and interstitium. Glomeruli showed membranoproliferative glomerulonephritis, but no crescents or necrosis. Discussion: We interpret the capillary and interstitial changes as evidence of cryoglobulin-associated vasculitis, and discuss the differential diagnosis of this uncommon histologic pattern of renal pathology, including other vasculitides, infection, ischemia-infarction, collagen vascular disease, and antibody-mediated allograft rejection, among others.Correspondence to:
M.L. Troxell, MD, PhD
Department of Pathology, L471
3181 SW Sam Jackson Park Rd
Portland, OR 97239, USA
Email: troxellm@ohsu.edu
