Volume 73 (2010), No. 4/2010(April)
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Lead article
Laboratory and imaging features of kidney involvement in autoimmune pancreatitis: incidence, correlation, and steroid therapy response
H. Nishi, Y. Shibagaki, K. Hirano, M. Akahane, R. Kido, M. Nangaku, S. Kaname, N. Sasahira, H. Isayama, M. Tada, R. Tsukamoto, K. Ohtomo, M. Omata and T. Fujita
Page No. 253
Abstract
Clinical Nephrology, Vol. 73 – No. 4/2010 (253-259)
Laboratory and imaging features of kidney involvement in autoimmune pancreatitis: incidence, correlation, and steroid therapy response
H. Nishi1, Y. Shibagaki1,4, K. Hirano2, M. Akahane3, R. Kido1, M. Nangaku1, S. Kaname5, N. Sasahira2, H. Isayama2, M. Tada2, R. Tsukamoto3, K. Ohtomo3, M. Omata2 and T. Fujita1
1Division of Nephrology and Endocrinology, 2Gastroenterology, 3Radiology, University of Tokyo School of Medicine, Tokyo, 4Department of Nephrology and Hypertension, St. Marianna University Hospital, Kanagawa, and 5First Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan
Aim: Autoimmune pancreatitis (AIP) is a rare subtype of chronic pancreatitis. AIP has been suggested to be complicated by tubulointerstitial nephritis or glomerulonephritis, implying that the kidney is involved as a phenotype of IgG4-positive multi-organ lymphoproliferative syndrome; however, the clinical significance of this novel entity is not well-defined. Methods: We conducted a retrospective cohort analysis of 47 (male, 39; female, 8) AIP patients. Results: The patients (mean age, 70.3 ± 9.5 years) had a mean observation period of 4.1 years. Before treatment, renal dysfunction with an eGFR of 30 and 15 ml/min/1.73 m2 developed only in 10.6% (5/47) and 2.1% (1/47) of the patients, respectively. Nevertheless, urinary N-acetyl-β-D-glucosaminidase and α1-microglobulin levels were elevated in 78.6% (11/14) and 30.8% (4/13) of the patients, respectively. Renal involvement in contrast-enhanced CT imaging was present in 18.2% (8/44) of the patients and was associated with proteinuria (p = 0.04) and a decrease in eGFR (p < 0.01). Furthermore, a follow-up CT study (mean, 545 days) revealed improved kidney lesions in 80.0% (4/5) of the patients after oral corticosteroid administration. In contrast, first-time kidney involvements appeared newly in 3.6% (1/28) of the patients after steroid therapy for nonrenal AIP symptoms, and in 14.3% (1/7) of the patients under no specific therapy (p = 0.02). Conclusion: Although severe renal failure develops rarely in AIP patients, renal abnormalities have been significantly detected by biochemical and radiological tests. Oral corticosteroid administration, even when not targeting symptomatic nephropathy, can treat and prevent kidney involvements in AIP.Correspondence to:
Y. Shibagaki, MD, FACP
Department of Nephrology and Hypertension
St. Marianna University Hospital
2-16-1 Sugao Miyamae-ku
Kawasaki, Kanagawa 216-8511, Japan
Email: [email protected]
Original
Referral patterns of primary care physicians for chronic kidney disease in general population and geriatric patients
S.D. Navaneethan, P. Kandula, V. Jeevanantham, J.V. Nally Jr. and S.E. Liebman
Page No. 260
Abstract
Clinical Nephrology, Vol. 73 – No. 4/2010 (260-267)
Referral patterns of primary care physicians for chronic kidney disease in general population and geriatric patients
S.D. Navaneethan1, P. Kandula2, V. Jeevanantham3, J.V. Nally Jr.1 and S.E. Liebman4
1Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, 2Division of General Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, 3Department of Medicine, Wake Forest University, Winston-Salem, NC, and 4Division of Nephrology, University of Rochester, Rochester, NY, USA
Background: Late referral of patients with chronic kidney disease (CKD) by primary care physicians (PCPs) is associated with poor outcomes. We sought to assess factors influencing PCPs referral patterns in the general population and in geriatric patients, and compared their perceptions to the referral patterns. Methods: We retrospectively reviewed 268 patients with Stage 3 CKD (early referral) and 280 with Stage 4 CKD (appropriate referral) seen in renal clinic and compared them to 268 randomly selected non-referred Stage 4 CKD patients from primary care physicians office records. We also surveyed 400 regional PCPs on factors influencing their referral for CKD. Results: Non-referred patients were significantly (p < 0.05) more likely to be over 65 years (OR: 3.5; 95% CI: 2.3 – 5.2), females (OR: 1.4; 95% CI: 1.0 – 2.0) and of non-white race (OR: 2.6; 95% CI: 1.5 – 4.5) after adjusting for relevant confounding variables. Charlson comorbidity index greater than 4 was associated with non-referral when the non-referral group was compared to the early referral group. Among geriatric patients, women and a higher comorbidity index were associated with non-referral. 25% of PCPs completed the survey and 62% PCPs were unfamiliar with K/DOQI referral guidelines. Age > 75 years, limited life expectancy, patient noncompliance or refusal to consider dialysis influenced PCPs decision to refer. Conclusions: Our study shows that elderly women, minorities and patients with multiple comorbidities are at risk for non-referral for CKD care. Educating PCPs on the appropriate referral of CKD patients, especially those at risk for late or non-referral to a nephrologist is warranted, as are trials assessing different educational strategies.Correspondence to:
S.D. Navaneethan, MD, MPH
Department of Nephrology and Hypertension
Cleveland Clinic Foundation
9500 Euclid Avenue, Q7
Cleveland, OH 44122, USA
Email: [email protected]
Original
Outcomes associated with serum phosphorus level in males with non-dialysis dependent chronic kidney disease
C.P. Kovesdy, J.E. Anderson and K. Kalantar-Zadeh
Page No. 268
Abstract
C.P. Kovesdy1,2, J.E. Anderson3 and K. Kalantar-Zadeh4,5
1Division of Nephrology, Salem Veterans Affairs Medical Center, Salem, 2Department of Medicine, University of Virginia, Charlottesville, VA, 3Department of Nephrology, Johns Hopkins Bayview Medical Center, Baltimore, MD, 4Harold Simmons Center for Chronic Disease Research and Epidemiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance and 5David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Background/Aims: Hyperphosphatemia is associated with higher mortality and increased incidence of end-stage renal disease in patients with non-dialysis dependent CKD (NDD-CKD), but there has not been a concomitant assessment of mortality and progressive kidney disease that would also account for cumulative effects of hyperphosphatemia. Methods: In order to account for the cumulative effects of abnormal serum phosphorus we examined associations of not only baseline, but also time-averaged serum phosphorus levels with all-cause mortality, the composite of mortality or ESRD and the slopes of estimated glomerular filtration rate (eGFR), by using Cox models and mixed effects models in a contemporary cohort of 713 males with moderate and advanced NDD-CKD. Results: Higher baseline and time-averaged serum phosphorus were both associated with mortality and with the composite outcome. A 1 mg/dl higher time-averaged serum phosphorus was associated with a multivariable adjusted hazard ratio of all-cause mortality (95% CI) of 1.56 (1.19 – 2.05), p = 0.001. Higher serum phosphorus was associated with a steeper slope of eGFR in unadjusted analyses, but this association became non-significant after multivariable adjustments. Conclusion: The cumulative burden of hyperphosphatemia is associated with increased mortality in patients with moderate and advanced NDD-CKD. Clinical trials are needed to determine if lowering serum phosphorus can result in improved mortality in this population.Correspondence to:
C. P. Kovesdy, MD FASN
Division of Nephrology
Salem VA Medical Center
1970 Roanoke Blvd.
Salem, VA 24153, USA
Email: [email protected]
Original
Treatment of vitamin D deficiency in CKD patients with ergocalciferol: are current K/DOQI treatment guidelines adequate?
W.Y. Qunibi, A. Abdellatif, S. Sankar, Z. Hamdan, F.-Y. Lin, J. Ingle, A. Cadena, J. Gelfond and B. Kasinath
Page No. 276
Abstract
Clinical Nephrology, Vol. 73 – No. 4/2010 (276-285)
Treatment of vitamin D deficiency in CKD patients with ergocalciferol: are current K/DOQI treatment guidelines adequate?
W.Y. Qunibi1, A. Abdellatif1, S. Sankar1, Z. Hamdan1, F.-Y. Lin1, J. Ingle1, A. Cadena1, J. Gelfond2 and B. Kasinath1
Nephrology Division, 1Department of Medicine and 2Epidemiology and Biostatistics, University of Texas Health Science Center, San Antonio, TX, USA
Background: Vitamin D deficiency/insufficiency (VDDI) is common in CKD patients and may be associated with abnormal mineral metabolism. It is not clear whether the K/DOQI recommended doses of ergocalciferol are adequate for correction of VDDI and hyperparathyroidism. Methods: Retrospective study of 88 patients with CKD Stages 1 – 5 and baseline 25-hydroxyvitamin D level < 30 ng/ml (< 75 nmol/l). Patients treated with ergocalciferol as recommended by K/DOQI guidelines. Only 53 patients had elevated baseline PTH level for the CKD stage. Patients were excluded if they received vitamin D preparations other than ergocalciferol or phosphate binders. 25-hydroxyvitamin D level, intact PTH level (iPTH), and other parameters of mineral metabolism were measured at baseline and after completion of ergocalciferol course. Results: 88 patients with CKD were treated with ergocalciferol. Mean age 56.8 ± 9.5 years and 41% were males. The mean (± SD) GFR was 28.3 ± 16.6 ml/min. At the end of the 6-month period of ergocalciferol treatment, the mean 25-hydroxyvitamin D level increased from 15.1 ± 5.8 to 23.3 ± 11.8 ng/ml (37.75 ± 14.5 to 58.25 ± 29.5 nmol/l) (p < 0.001). Treatment lead to ≥ 5 ng/ml (12.5 nmol/l) increases in 25-hydroxyvitamin D level in 54% of treated patients, and only 25% achieved levels ≥ 30 ng/ml (75 nmol/l). Mean iPTH level decreased from 157.9 ± 125.9 to 150.7 ± 127.5 pg/ml (p = 0.5). Only 26% of patients had ≥ 30% decrease in their iPTH level after treatment with ergocalciferol. Conclusions: Current K/DOQI guidelines are inadequate for correcting VDDI or secondary hyperparathyroidism in CKD patients. Future studies should examine the effects of higher or more frequent dosing of ergocalciferol on these clinical endpoints.Correspondence to:
Prof. W.Y. Qunibi, MD
Medical Director of Dialysis Services
University of Texas Health Science Center
at San Antonio,
7703 Floyd Curl Drive
San Antonio, TX 78229-3900, USA
Email: [email protected]
Original
The higher risk of death on peritoneal dialysis in the United States is not explained by background general population mortality: the CANUSA study revisited
R.R. Quinn, K.E. Thorpe, and J.M. Bargman
Page No. 286
Abstract
Clinical Nephrology, Vol. 73 – No. 4/2010 (286-293)
The higher risk of death on peritoneal dialysis in the United States is not explained by background general population mortality: the CANUSA study revisited
R.R. Quinn1, K.E. Thorpe2,3 and J.M. Bargman4
1Sunnybrook Health Sciences Center, 2Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 3Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto and 4University Health Network, Toronto, ON, Canada
The CANUSA investigators reported a near doubling of the risk of death in peritoneal dialysis patients treated at U.S. sites compared to Canadian centers. Recently, evidence has suggested that background mortality rates in the general population might be responsible for differences in death rates on dialysis. The objective of this study was to determine if differences in background mortality in the general population were responsible for the increased risk of death observed in American patients in the CANUSA study. The CANUSA study was a prospective cohort study of 680 consecutive peritoneal dialysis patients at 14 centers in the U.S. and Canada. Extensive baseline data were available for all patients. The expected mortality rate of an individual of the same age, sex, and country of residence was determined at the time of enrollment in the CANUSA study. Cox proportional hazards models were used to determine if background mortality rates were responsible for the observed differences in survival between the two countries. Background mortality rate in the general population was associated with an increased risk of death on peritoneal dialysis, but after adjustment for other baseline factors, it was no longer significant. The adjusted, relative hazard of dying in the U.S. compared to Canada was unchanged after further adjusting for background mortality rate in statistical models (HR = 1.93; 95% confidence interval: 1.13 – 3.28). In conclusion, the increased risk of mortality in U.S. patients enrolled in the CANUSA study was not explained by differences in the background mortality rate in the general population.Correspondence to:
R.R. Quinn, MD, PhD, FRCPC
Foothills Medical Centre, Room C202C
1403 29 St NW, Calgary, AB, T2N 2T9, Canada
Email: [email protected]
Original
Pain prevalence in patients with chronic kidney disease
P.C.T. Pham, K. Dewar, S. Hashmi, E. Toscano, P.M.T. Pham, P.A.T. Pham and P.T.T. Pham
Page No. 294
Abstract
Clinical Nephrology, Vol. 73 – No. 4/2010 (294-299)
Pain prevalence in patients with chronic kidney disease
P.C.T. Pham1, K. Dewar1, S. Hashmi1, E. Toscano1, P.M.T. Pham2, P.A.T. Pham3 and P.T.T. Pham4
1Olive View-UCLA Medical Center, Department of Medicine, Nephrology Division, Sylmar, 2Greater Los Angeles VA Medical Center, Department of Medicine, Los Angeles, 3Mercy General Hospital, Sacramento, and 4David Geffen School of Medicine at UCLA, Kidney and Pancreas Transplant Program, Los Angeles, CA, USA
Background: The prevalence of pain in patients with chronic kidney diseases (CKD) is not known. In the current study, we aim to determine the prevalence of pain in CKD patients and its associations with various medical and psychosocial factors. Methods: Consecutive CKD patients who were presented to the renal clinic at Olive View-UCLA Medical Center, a Los Angeles County tertiary referral center, over a 3-month period were interviewed on their medical and psychosocial histories and a history of pain including duration, severity and source. χ2-testing for independence and binary logistic regression performed for the presence of pain and CKD stages as well as other medical and psychosocial factors were determined. A separate survey for pain was also done for 100 consecutive non-CKD patients who were presented to our ambulatory medicine clinic for routine care. Results: 54.6% of 130 patients with known CKD interviewed were women. Any type of pain of at least a 2 week duration was reported in 72.9%. The most common source of pain was musculoskeletal. The presence of pain of less than a 2 week duration was associated with worse CKD stages (3 – 5 versus 1 – 2) and non-exercisers. Higher body mass index was associated with having pain lasting longer than a 2 week duration. Among patients who had pain, 33.8% used acetaminophen, 15.4% nonsteroidal anti-inflammatory drugs and 7.8% combination analgesics. In contrast to CKD patients, only 9% of non-CKD patients reported to have any type or duration of pain. Conclusions: Pain was much more prevalent among our CKD compared with non-CKD patients.Correspondence to:
P.-C.T. Pham, MD
Olive View-UCLA Medical Center
Department of Medicine, Nephrology Division
14445 Olive View Drive, 2B-182
Sylmar, CA 91342, USA
Email: [email protected]
Original
Body fluid volume and nutritional status in hemodialysis: vector bioelectric impedance analysis
M.A. Espinosa Cuevas, , G. Navarrete Rodriguez, M.E. Villeda Martinez, X. Atilano Carsi, P. Miranda Alatriste, T. Tostado Gutiérrez and R. Correa-Rotter
Page No. 300
Abstract
Clinical Nephrology, Vol. 73 – No. 4/2010 (300-308)
Body fluid volume and nutritional status in hemodialysis: vector bioelectric impedance analysis
M.A. Espinosa Cuevas1, 2, G. Navarrete Rodriguez1, M.E. Villeda Martinez1, X. Atilano Carsi1, P. Miranda Alatriste1,2, T. Tostado Gutiérrez3 and R. Correa-Rotter1,3
1Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, 2Departamento de Atención a la Salud, Universidad Autónoma Metropolitana-Xochimilco and 3Unidad de Diálisis Fresenius MC Médica Sur, México D.F.
Background: Protein-energy malnutrition and hypervolemia are major causes of morbidity and mortality in patients on chronic hemodialysis (CHD). The methods used to evaluate nutritional status and volume status remain controversial. Vector bioelectric impedance analysis (vector- BIA) has recently been developed to assess both nutritional status and tissue hydration. The purpose of the study was to assess the nutritional status and volume status of patients on CHD with conventional nutritional assessment methods and with vector-BIA and then to compare the resulting findings. Methods: 76 Mexican patients on CHD were studied. Nutritional status and body composition were assessed with anthropometry, biochemical variables, and the modified Bilbrey nutritional index (mBNI), the results were compared with both conventional BIA and vector-BIA. Results: The BNI was used to determine the number of patients with normal nutritional status (n = 27, 35.5%), and mild (n = 31, 40.8%), moderate (n = 10, 13.2%) and severe malnutrition (n = 8, 10.5%). Patients displayed shorter vectors with smaller phase angles or with an overhydration vectorial pattern before the initiation of their hemodialysis session. There was general improvement to normal hydration status post-dialysis (p < 0.05); however, 28% remained overhydrated as assessed by vector-BIA. The vector-BIA results showed that worse malnutrition status was associated with greater volume overload (p < 0.05). Diabetes mellitus (DM) was associated with shorter vectors with smaller phase angles (a vectorial pattern of overhydration and cachexia) (p < 0.05). Patients with lower serum creatinine presented with shorter vectors and smaller phase angles (vectorial patterns of malnutrition and/or overhydration) (p < 0.05). In women, lower serum albumin (< 3.4 g/dl) correlated with greater overhydration and malnutrition (p < 0.05). Conclusions: In this population, the vector-BIA showed that 28% of the population remained overhydrated after their hemodialysis session. Diabetics and those with moderate or severe malnutrition were more overhydrated, which is a condition that may be associated with increased cardiovascular morbidity. Because nutritional and volume status are important factors associated with morbidity and mortality in CHD patients, we focused on optimizing the use of existing methods. Our studies suggest that vector-BIA offers a comprehensive and reliable reproducible means of assessing both volume and masses at the bedside and can complement the traditional methods.Correspondence to:
M.A. Espinosa Cuevas, PhD
Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán
Departamento de Nefrología y Metabolismo Mineral
Vasco de Quiroga # 15
sección XVI Tlalpan C.P.14000 México D.F
Email: [email protected]
Original
Brucellosis in dialysis patients. Does it exist?
K. Kantartzi, S. Panagoutsos, V. Kokkinou, E. Alepopoulou, E. Mourvati, P. Passadakis and V. Vargemezis
Page No. 309
Abstract
Clinical Nephrology, Vol. 73 – No. 4/2010 (309-313)
Brucellosis in dialysis patients. Does it exist?
K. Kantartzi, S. Panagoutsos, V. Kokkinou, E. Alepopoulou, E. Mourvati, P. Passadakis and V. Vargemezis
Division of Nephrology, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece
Background: Brucellosis is a zoonotic disease transmittable to humans. It is diagnosed either by isolation of Brucella organism in culture of blood or other sample types (e.g., bone marrow or liver biopsy specimens), or by a combination of serological tests and clinical findings. Dialysis patients constitute a special population group with an impaired autoimmune system and a propensity to develop infections, such as brucellosis. This paper presents the high incidence of brucellosis in our dialysis patients during last year, while there was not any zoonotic infection recorded in the previous at least 5 year period. Methods – Results: This is a retrospective study including 8 dialysis patients, undergoing renal replacement therapies (5 patients were on hemodialysis (HD) and 3 on peritoneal dialysis (PD)), who out of a total of 124 patients developed brucellosis, during the last year. Four patients were male and four female and their mean age was 67 ± 9 years. Clinical presentation of Brucellosis infection was mild with low-grade fever and symptoms of influenza. All patients were living in places where animal brucellosis was prevalent. Infection was diagnosed on the basis of clinical symptoms and signs and with polymerase chain reaction (PCR) analysis of peripheral blood. The affected patients had consumed fresh unpasteurized milk and cheese and were treated with oral doxycycline and oral rifampicin for 6 weeks. All patients are in follow up for at least 1 year, during which there were no relapses. Conclusions: Brucellosis is a zoonotic disease that can occur in dialysis patients who are susceptible to infection under certain conditions. Our brucellosis patients lived in agricultural and veterinary areas and had consumed unpasteurized milk and cheese and insufficiently cooked meat derived from infected animals.Correspondence to:
K. Kantartzi, MD
Kolokotroni 15
68100 Alexandroupolis, Greece
Email: [email protected]
Case Report
Uterine leiomyoma causing urinary obstruction of the transplanted kidney
M. Abate, N.K. Wadhwa and E.P. Nord
Page No. 314
Abstract
Clinical Nephrology, Vol. 73 – No. 4/2010 (314-317)
Uterine leiomyoma causing urinary obstruction of the transplanted kidney
M. Abate, N.K. Wadhwa and E.P. Nord
Division of Nephrology, Department of Medicine, School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
Obstruction of the ureter as a cause of acute or chronic kidney injury in the transplanted kidney is unusual beyond the perioperative period. We present a case of ureteric obstruction, infection and septicemia caused by a large uterine leiomyoma in a patient 8 years post transplantation. Initial treatment comprised of intravenous fluid and antibiotics followed by urgent drainage of the collecting system. Subsequent hysterectomy resolved the obstruction with resolution of renal failure. In young female kidney transplant recipients, gynecologic causes, although rare, need to be considered as possible etiologies of urinary obstruction and renal dysfunction.Correspondence to:
E.P. Nord, MD
Division of Nephrology, Department of Medicine
School of Medicine, HSC T-16 Rm-080
State University of NY at Stony Brook
Stony Brook, NY 11794, USA
Email: [email protected]
Case Report
Polyarthritis and anemia in a hemodialysis patient: systemic lupus erythematosus following treatment with Interferon alpha
M. Touzot, F. Touzot, L. Galicier, M-P. Ripault, M-N.Peraldi, D. Glotz and E. Pillebout
Page No. 318
Abstract
Clinical Nephrology, Vol. 73 – No. 4/2010 (318-320)
Polyarthritis and anemia in a hemodialysis patient: systemic lupus erythematosus following treatment with Interferon alpha
M. Touzot1,3, F. Touzot2, L. Galicier2, M-P. Ripault4, M-N.Peraldi1, D. Glotz1 and E. Pillebout1
1Nephrology and kidney Transplantation, Unit Saint Louis Hospital, 2Clinical Immunology, Saint Louis Hospital, 3Inserm U932 immunité anti tumoral, Institut Curie and 4Hepatology Saint Louis Hospital, Paris, France
Autoimmune manifestations may occur with interferon α (IFNα) therapy. However IFNα induced Systemic lupus erythematosus is a rare event. We report a 33-year-old hemodialysis patient who presented polyarthritis and anemia 4 months after initiation of IFNα for chronic hepatitis C. Systemic lupus erythematosus was diagnosed. Clinical symptoms improved rapidly with interruption of the treatment and a low-dose steroid therapy. This is the first case of IFN-induced SLE in a hemodialysis patient to confirm the major role of IFNα in the lupus physiopathology. Treatment with steroid therapy does not seem to worsen the HCV infection.Correspondence to:
M. Touzot, MD
Immunologie Clinique, U932
Institut Curie, 26 rue d’Ulm
75284 Paris, France
Email: [email protected]
Case Report
Acute lymphoblastic leukemia complicated by acute renal failure: a case report and review of the literature
Y. Zhou, Z. Tang, Z.-H. Liu and L.-S. Li
Page No. 321
Abstract
Clinical Nephrology, Vol. 73 – No. 4/2010 (321-325)
Acute lymphoblastic leukemia complicated by acute renal failure: a case report and review of the literature
Y. Zhou, Z. Tang, Z.-H. Liu and L.-S. Li
Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
The patient, a previously healthy woman, presenting with acute renal failure and anemia, was admitted to our hospital. Her serum creatinine (Scr) had increased from 0.79 – 2.69 mg/dl over three days and hemoglobin had decreased from 12.1 – 7.8 g/dl over 4 weeks. Mild compression fracture and degeneration of the lumbar vertebra and skull were observed in X-ray. The renal biopsy showed acute proximal tubular lesions induced by multiple calcium deposition. A bone marrow biopsy showed that primitive lymphocyte was up to 92.5%. After making a diagnosis of acute lymphoblastic leukemia complicated with acute kidney injury induced by hypercalcemia, CRRT (continued renal replacement therapy) and chemotherapy were used immediately. Ten days later, the blood calcium had gradually decreased from 3.88 to normal range (1.8 mmol/l) and the renal function was back to normal (Scr 0.93 mg/dl). This unusual case shows that a patient who has a syndrome of acute renal failure, electrolyte disturbances, anemia, and elevated LDH needs bone marrow puncture to eliminate renal injury caused by hematologic diseases.Correspondence to:
T. Zheng, MD
Research Insitute of Nephrology
Jinling Hospital
Nanjing University School of Medicine
305 East Zhongshan Road
Nanjing, 210002, China
Email: [email protected]
Case Report
Therapeutic implications of heparin-induced thrombocytopenia complicating acute hemodialysis
R. Roncon-Albuquerque Jr., A. Beco, A.L. Ferreira, C. Gomes-Carvalho, A. Costa, J. Frazão, M. Pestana and P. von Hafe
Page No. 326
Abstract
Clinical Nephrology, Vol. 73 – No. 4/2010 (326-330)
Therapeutic implications of heparin-induced thrombocytopenia complicating acute hemodialysis
R. Roncon-Albuquerque Jr.1, A. Beco2, A.L. Ferreira1, C. Gomes-Carvalho2, A. Costa3, J. Frazão2, M. Pestana2 and P. von Hafe1
1Department of Internal Medicine, 2Department of Nephrology, Faculty of Medicine of Porto and 3Department of Hematology, Hospital S. João, Porto, Portugal
Although patients undergoing acute hemodialysis (HD) constitute a group at risk for heparin-induced thrombocytopenia (HIT), the optimal therapeutic strategy remains undefined. We describe a case of HIT complicated with right subclavian vein thrombosis in a patient with chronic renal insufficiency undergoing acute HD for oligoanuria and pulmonary edema. Circulating anti-heparin-PF4 complex antibodies were detected. Past medical history was relevant for an otherwise unexplained self-limited episode of thrombocytopenia following acute HD one year earlier after an anterior STEMI. All sources of heparin were discontinued and alternative anticoagulation was initiated with argatroban, a direct-thrombin inhibitor with hepatic clearance, followed by transition to warfarin. Prevention of tunneled HD catheter obstruction was accomplished with low-dose alteplase catheter locking solution. No bleeding occurred with argatroban anticoagulation. Platelet count recovered and no further thrombotic complications were observed. The present report illustrates the diagnostic and therapeutic challenges of HIT complicating acute HD.Correspondence to:
R. Roncon-Albuquerque Jr., MD
Department of Internal Medicine
Faculty of Medicine of Porto
Hospital S. João
Al. Prof. Hernâni Monteiro
4200-319, Porto, Portugal
Email: [email protected]
Letter to the Editor
Impairment of renal function in a patient with IgA deficiency-associated mesangioproliferative glomerulonephritis
W. Xia, M. Li, B. Gao and F. Zheng
Page No. 331
