Volume 76 (2011), No. 6/2011(December)
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Original
C-reactive protein levels are associated with arterial media calcification in nondiabetic patients with end-stage renal disease on long-term hemodialysis
A. Marinelli, L. Orlandi and G. Stivali
Page No. 425
Abstract
Clinical Nephrology, Vol. 76 – No. 6/2011 (425-434)
C-reactive protein levels are associated with arterial media calcification in nondiabetic patients with end-stage renal disease on long-term hemodialysis
A. Marinelli1, L. Orlandi2 and G. Stivali2
1Division of Nephrology and Dialysis, Riuniti Hospital Anzio, and 2Renal Division, Baxter SPA, Rome, Italy
Background: Vascular calcifications (VC) are associated with cardiovascular (CV) morbidity and are independent predictors of CV mortality in end-stage renal disease (ESRD). This study aimed to investigate the presence of arterial intima calcification (AIC) and arterial media calcification (AMC) in nondiabetic patients on long-term hemodialysis, and to assess the association with CV risk factors. Methods: 34 ESRD patients (17 males) on hemodialysis for at least 5 years were evaluated for VC using B-mode ultrasonography. Results: AMC and AIC patterns were detected respectively in 62% and 59% of patients, and 21% had no VC. Patients with AIC were significantly older than those without AIC (p < 0.001). CRP levels (p < 0.001) were higher in patients with AMC. Using multivariate logistic analysis of regression, older age (> 50 years) and higher CRP levels (> 5 mg/l) were associated with AIC and AMC, respectively (p = 0.007 and p = 0.003). Logistic regression analysis showed that patients with CRP > 5 mg/l had a greater relative risk of having AMC (odds ratio 30, 95% confidence interval 27.041 – 32.959; p = 0.003). Conclusions: Ultrasonography can be used to detect AIC and AMC, and could be useful for the early detection of VC. In nondiabetic patients who had been on hemodialysis for at least 5 years, older age was associated with AIC, and elevated CRP levels with AMC. Correspondence to:
Dr. A. Marinelli
Piazza San Domenico Savio 1
00179 Roma, Italy
Email: [email protected]
Original
Vascular access thrombosis and interventions in patients missing hemodialysis sessions
R. Shah, U.Y. Bhatt, S. Van Cleef, M. Farley, A. Davis, M. Swope and A.K. Agarwal
Page No. 435
Abstract
Clinical Nephrology, Vol. 76 – No. 6/2011 (435-439)
Vascular access thrombosis and interventions in patients missing hemodialysis sessions
R. Shah1, U.Y. Bhatt1, S. Van Cleef1, M. Farley2, A. Davis2, M. Swope2 and A.K. Agarwal1
1Division of Nephrology, The Ohio State University, 2Fresenius Medical Care, Columbus, OH, USA
Background: Vascular access (VA) failure is a major complication in patients with end-stage renal disease (ESRD) receiving hemodialysis (HD). Thrombosis is the most common cause of VA dysfunction, but the risk factors for VA thrombosis are not well established. While the practice of missing HD sessions (HDs) is associated with increased morbidity and mortality, its impact on VA outcomes is unknown. We evaluated the impact of missing HDs on thrombosis and intervention rates in arteriovenous (AV) accesses. Methods: Retrospective review of prevalent HD patients using AV access was done in 2 outpatient HD centers at The Ohio State University over a one-year period. Results: A total of 142 patients underwent a total of 15,692 HDs, missing 1,602 HDs. Of the 78 patients who met the inclusion criteria, 50 patients missed at least 1 HD. Those with AVF demonstrated no significant association between missing HDs and VA thrombosis. Also, the incidence rate (IR) of intervention was not significantly different for those missing and not missing HDs. However, in the AVG group, those missing HDs were more likely to experience VA thrombosis (OR 9.48, p ≈ 0.041) and had a higher IR of intervention. Conclusion: The practice of missing HDs was prevalent. Those missing dialysis sessions with AVG were more likely to experience VA thrombosis and needed more interventions to maintain VA patency. Our study reveals a differential impact of missing HDs on thrombosis in AVG and AVF, depicting a need to explore mechanistic explanations that may eventually help develop specific preventive strategies. Correspondence to:
Prof. A.K. Agarwal, MD, Director
Interventional Nephrology
The Ohio State University
395 W. 12th Avenue, Ground Floor
Columbus, OH 43210, USA
Email: anil.agarwal@ osumc.edu
Original
Comparative clinical manifestations of IgG4- related and IgG4-negative primary tubulointerstitial nephritis
T.Y. Kim, K.S. Park, J.S. Choi, S.H. Kang, Y.M. Cho and S.B. Kim
Page No. 440
Abstract
Clinical Nephrology, Vol. 76 – No. 6/2011 (440-446)
Comparative clinical manifestations of IgG4- related and IgG4-negative primary tubulointerstitial nephritis
T.Y. Kim1, K.S. Park1, J.S. Choi1, S.H. Kang2, Y.M. Cho2 and S.B. Kim1
1Department of Nephrology, and 2Department of Pathology, Asan Medical Center, Seoul, South Korea
Aims: To evaluate the prevalence of IgG4-related tubulointerstitial nephritis (TIN) and compare the clinical manifestations of IgG4-related and IgG4-negative primary TIN. Methods: Of 5,174 renal biopsies obtained between January 1996 and February 2010, 46 were positive for primary TIN without other kidney disease. Biopsy tissues were lost for 2 patients. The remaining 44 samples were assayed by immunoperoxidase staining with monoclonal mouse antibody to human IgG4. Results: Of the 44 patients with primary TIN, 12 (27%) were identified as IgG4+ plasma cells/HPF ≥ 10 and 32 (73%) as < 10. Estimated glomerular filtration rate (eGFR) was lower and proteinuria was higher in patients with IgG4+ plasma cells/ HPF ≥ 10 (p < 0.05). No other parameter such as age; gender distribution; incidence of hypertension, diabetes mellitus, drug history, pyuria; concentrations of hemoglobin and alkaline phosphatase; or kidney size differed significantly. Of the 44 patients with primary TIN, 25 (57%) were identified as IgG4-positive (IgG4+ plasma cells/HPF ≥ 1) and 19 (43%) as IgG4-negative. The two groups did not differ in age; gender distribution; incidence of hypertension, diabetes mellitus, drug history, pyuria, or proteinuria; concentrations of hemoglobin and alkaline phosphatase; eGFR; or kidney size. The improvement rate, however, was significantly higher in IgG4-positive than in IgG4-negative patients (p = 0.045). Of the 25 IgG4- positive and 19 IgG4-negative patients, 18 and 13, respectively, were treated, and 18 and 7, respectively, improved (p = 0.002). The median number of IgG4-positive plasma cells/HPF in the former group was 8 (range 1 – 90). The number of IgG4-positive plasma cells was significantly associated with the degree of proteinuria (r = 0.471, p = 0.018) and age (r = 0.529, p = 0.007). Conclusion: Routine IgG4 staining is necessary in patients with primary TIN. Early treatment is also important in patients with IgG4-related primary TIN.Correspondence to:
S.B. Kim, MD
Division of Nephrology
Department of Internal Medicine
Asan Medical Center
Seoul, South Korea
Email: [email protected]
Original
Reduced pre-pregnancy proteinuria is associated with improving postnatal maternal renal outcomes in IgA nephropathy women
H.J. Oh, S.H. Han, D.E. Yoo, S.J. Kim, J.T. Park, J.-K. Kim, T.-H. Yoo, S.-W. Kang and K.H. Choi
Page No. 447
Abstract
Clinical Nephrology, Vol. 76 – No. 6/2011 (447-454)
Reduced pre-pregnancy proteinuria is associated with improving postnatal maternal renal outcomes in IgA nephropathy women
H.J. Oh1, S.H. Han1, D.E. Yoo1, S.J. Kim1, J.T. Park1, J.-K. Kim1, T.-H. Yoo1, S.-W. Kang1,2 and K.H. Choi1
1Department of Internal Medicine, Division of Nephrology, College of Medicine, and 2Severance Biomedical Science Institute, Brain Korea 21 for Medical Science, Yonsei University, Seoul, Korea
Aims: In patients with immunoglobulin A (IgA) nephropathy, postnatal renal outcomes vary depending on kidney function and proteinuria. However, whether a decrease in proteinuria prior to conception improves postnatal maternal renal outcomes is unknown. Methods: This was a single-center retrospective study. A total of 52 pregnant women with biopsy-proven IgA nephropathy were enrolled in the study between January 2004 and December 2009. We collected data on proteinuria, which had been measured 1 year prior to conception, at conception, during pregnancy, and postnatally. The study outcomes included changes in estimated glomerular filtration rate (eGFR) and proteinuria. Results: The median serum creatinine, eGFR, and proteinuria levels at conception were 0.8 (0.5 – 2.6) mg/dl, 91.2 (24.1 – 157.0) ml/min, 0.7 (0.0 – 3.5) g/g, respectively. Compared with values measured at conception, serum creatinine (0.8 – 1.0 mg/dl, p < 0.01) and proteinuria (0.7 – 1.5 g/g, p < 0.01) increased significantly postnatally, while eGFR decreased (91.2 – 77.8 ml/min, p < 0.01). In a multiple linear regression analysis, proteinuria at conception were independently associated with a faster decline in postnatal maternal eGFR (β = 4.50, p < 0.05). In addition, a less decline in maternal eGFR was observed in patients with a reduction in proteinuria (> 30%) prior to pregnancy, compared with those with a less reduction (≤ 30%). As for newborn outcomes, preterm delivery, caesarean section, low birth weight < 2,500 g, and need for neonatal intensive care were 15.4%, 46.2%, 25.0% and 7.7%, respectively. Conclusions: This study showed that in women with IgA nephropathy, proteinuria was significantly associated with the deterioration of postnatal maternal renal outcomes. Our study also suggests that a strategy for reducing proteinuria prior to pregnancy is required to preserve kidney function after delivery.Correspondence to:
K.H. Choi, MD, PhD
Yonsei University College of Medicine
Department of Internal Medicine
134 Shinchondong Seodaemoon-gu
Seoul, Korea, 120-752
Email: [email protected]
Original
Psychosocial characteristics and self-reported functional status in patients on maintenance dialysis in Hungary
K. Polner, L. Szeifert, E.P. Vámos, C. Ambrus, M.Z. Molnár,, E. Ladányi, I. Kiss, É. Kiss, M. Török, M.S. Kopp, M. Novák,, L. Rosivall, I. Mucsi and S. Túri
Page No. 455
Abstract
Clinical Nephrology, Vol. 76 – No. 6/2011 (455-463)
Psychosocial characteristics and self-reported functional status in patients on maintenance dialysis in Hungary
K. Polner1*, L. Szeifert2*, E.P. Vámos3, C. Ambrus4, M.Z. Molnár2,5, E. Ladányi6, I. Kiss7, É. Kiss8, M. Török8, M.S. Kopp2, M. Novák2,9, L. Rosivall10, I. Mucsi2,11 and S. Túri12
1Department of Nephrology, St. Margaret Hospital, 2Institute of Behavioral Sciences, Semmelweis University, Budapest, Hungary, 3Department of Primary Care & Public Health, Imperial College London, London, UK, 4Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada, 5Los Angeles Biomedical Research, Torrance, CA, USA, 6Fresenius Medical Care, Miskolc, 7Division of Nephrology-Hypertension, Department of Internal Medicine, St Imre Teaching Hospital, 8Diaverum Dialysis Centre, Budapest, Hungary, 9Department of Psychiatry, University Health Network, University of Toronto, Toronto, Ontario, Canada, 10Department of Pathophysiology, Semmelweis University, Budapest, Hungary, 11Department of Medicine, Division of Nephrology, McGill University Health Centre, Royal Victoria Hospital, Montreal, Quebec, Canada, and 12Szegedi Tudományegyetem Gyermekgyógyászati Klinika és Gyermekegészségügyi Központ, Szeged, Hungary
Aims: This survey was conducted to assess psychosocial problems and functional status among patients on maintenance dialysis in Hungary. Methods: All adult patients (n = 4,321) receiving maintenance dialysis in the 56 dialysis centers in Hungary in 2006 were approached to participate in a national, cross-sectional survey. Patients completed a brief self-reported questionnaire. Socio-demographic parameters, disease-related information and data about functional status were collected. Self-rated health and depressive symptoms were also assessed. Results: Mean age was 62 ± 14 y; 52% were males. The prevalence of diabetes was 30%. 46% of participants reported having depressive symptoms. Significant functional limitation was frequent. In multivariable regression models, female gender, poor self-reported finances, less education, history of acute myocardial infarction (AMI) or cerebrovascular disease, the presence of visual or hearing impairment and difficulties with basic activities of daily living were independently associated with the presence of depressive symptoms. In a separate model, age, dialysis vintage, history of AMI or cerebrovascular disease, the presence of visual or hearing impairments, difficulties with basic activities of daily living and also having depressive symptoms were independently associated with self-rated health score. Conclusions: Chronic dialysis patients in Hungary have disadvantaged socioeconomic status, frequent depressive symptoms and many functional limitations. Professional psychosocial help would be particularly important for this underprivileged patient population in addition to high quality dialysis to optimize outcomes.Correspondence to:
I. Mucsi, MD, PhD, Associate professor
Department of Medicine
Division of Nephrology
McGill University Health Centre
Royal Victoria Hospital
687 Pine Avenue West, Room R2.37
Montreal, Quebec H3A 1A1, Canada
Email: [email protected]
Original
Safety and predictors of complications of renal biopsy in the outpatient setting
S.H.-T. Jiang, K.M. Karpe and G.S. Talaulikar
Page No. 464
Abstract
Clinical Nephrology, Vol. 76 – No. 6/2011 (464-469)
Safety and predictors of complications of renal biopsy in the outpatient setting
S.H.-T. Jiang, K.M. Karpe and G.S. Talaulikar
Department of Renal Medicine, The Canberra Hospital, Australia
Aim: It has been recommended that patients should be admitted for 24 h of observation after percutaneous renal biopsy. This may be performed in the ambulatory outpatient setting, though its safety in this setting is an area of debate. We aim to demonstrate the safety of biopsy in the ambulatory outpatient setting. Methods: We performed a retrospective cohort study of 475 biopsies performed in the ambulatory outpatient setting to examine safety and risk factors for complications. Transplant and native kidney biopsies performed at the Canberra Hospital, a tertiary referral university hospital, from 2006 until 2010 were included. Patients were observed for 6 h before discharge. Study outcomes were minor complications, defined as pain, hemorrhage or postural hypotension; or major complications, defined as complications requiring therapeutic intervention including blood product transfusion. Results: The overall complication rate was 8.2%. There were 33 minor complications (6.9%) and 6 major complications (1.3%). All complications occurring outside the period of observation were safely managed. Significant predictors of any complication was hemoglobin (OR 1.03, 95% CI 1.01 – 1.06), kidney size (OR 0.93, 95% CI 0.89 – 0.98), and proceduralist. Conclusions: Percutaneous renal biopsy is safe in the ambulatory outpatient setting. Establishing ongoing quality assurance programs may be helpful in early identification of operator-dependent factors.Correspondence to:
Dr. S.H.-T. Jiang
The Department of Renal Medicine
The Canberra Hospital
Yamba Drive
Garran, ACT 2605, Australia
Email: [email protected]
Original
Periodic limb movements in sleep revealed by treatment of sleep apnea with continuous positive airway pressure in the advanced chronic kidney disease population
R.L. Benz, M.R. Pressman and X. Wu
Page No. 470
Abstract
Clinical Nephrology, Vol. 76 – No. 6/2011 (470-474)
Periodic limb movements in sleep revealed by treatment of sleep apnea with continuous positive airway pressure in the advanced chronic kidney disease population
R.L. Benz1,3, M.R. Pressman2,3 and X. Wu4
1Division of Nephrology, 2Division of Pulmonary and Sleep Medicine Services, Lankenau Medical Center, 3Lankenau Institute for Medical Research, Wynnewood, PA, and 4Montgomery Nephrology and Hypertension Associates, Hillsborough, NJ, USA
The chronic kidney disease (CKD) population has a high incidence of sleep disorders, including sleep apnea (SA) and periodic limb movements in sleep (PLMS). SA and PLMS often occur concurrently and may predict mortality in the end stage renal disease (ESRD) population. In this study, we investigated whether sleep fragmentation secondary to SA masks the underlying frequency or severity of PLMS in 16 patients with CKD, dialysis and not-on-dialysis patients (CKD-ND), and if successful treatment of SA with continuous positive airway pressure (CPAP) results in the increased appearance of PLMS. All subjects had polysomnography (PSG) diagnosed SA. The mean apnea-hypopnea index (AHI) at baseline and with CPAP treatment was 49.8 ± 25.6/h and 5.2 ± 9.1/h, respectively. With successful treatment of SA with CPAP, PLMS index (PLMSI) increased 237.7% from baseline of 13.8 ± 23.8/h to 32.8 ± 33.7/h with CPAP treatment (p = 0.019). Arousing PLMS index (APLMSI) also increased 191.5% from mean baseline of 8.2 ± 18.2/h to 15.7 ± 18.5/h with CPAP treatment (p = 0.026). PLMS occur during uninterrupted NREM sleep. SA may mask the underlying incidence and severity of PLMS in CKD patients by disrupting NREM sleep. PLMS more than doubled during successful treatment of SA. Therefore, despite successful treatment of SA with CPAP, sleep deprivation may persist due to clinical manifestation of underlying PLMS in patients with CKD. The actual underlying prevalence and severity of CKD-associated PLMS are likely higher than appreciated and are suppressed by SA in the CKD population. Correspondence to:
R.L. Benz, MD
Lankenau Medical Center
Ste. 130 MOB, Division of Nephrology
100 Lancaster Avenue
Wynnewood, PA 19096, USA
Email: [email protected]
Nephrology Education
Short-term, high-dose statins in the prevention of contrast-induced nephropathy: a systematic review and meta-analysis
Y. Zhou, W.J. Yuan, N. Zhu and L. Wang
Page No. 475
Abstract
Clinical Nephrology, Vol. 76 – No. 6/2011 (475-483)
Short-term, high-dose statins in the prevention of contrast-induced nephropathy: a systematic review and meta-analysis
Y. Zhou, W.J. Yuan, N. Zhu and L. Wang
Department of Nephrology, Shanghai First People’s Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
Background: There have been conflicting reports on the use of statins for prevention of contrast-induced nephropathy (CIN). The aim of this study was to assess the effectiveness of short-term (2 – 7 days), high-dose (80 mg/d) statins in the prevention of CIN. Study design, setting and participants: Randomized controlled trials assessing the preventive effect of short-term, highdose statins on CIN (published from 1966 to 2010) were searched. Quality improvement plan: Quality of the trials was evaluated with the assessing risk of bias in studies included in the Cochrane reviews. Outcomes: CIN is the primary endpoint of the study. Measurements: Meta-regression and a fixed-effects model were used for analyses. Results: Five trials with a total of 1,009 patients were identified, with the overall effect of statins showing benefit for preventing CIN (relative risk (RR) = 0.53, 0.32 – 0.87). Meta-regression showed the existence of minor heterogeneity (I2 = 19%) could be largely accounted for by baseline serum creatinine. Two studies conducted in patients with CKD Stage ≥ 3 did not reveal a statistically significant difference in CIN incidence between the statin and placebo groups (6.5% vs. 7.2%) (RR = 0.89, 0.46 – 1.73), without evidence of heterogeneity (I2 = 0%, p = 0.79). The remaining three studies conducted in patients with CKD Stage > 3 revealed a significantly lower CIN incidence in the statin groups (3.6% vs. 11.9%) (RR = 0.28, 0.13 – 0.62), without evidence of heterogeneity (I2 = 0%, p = 0.87). Conclusions: The overall effect of shortterm, high-dose statin treatment seems to be helpful for prevention of CIN. However, the subgroup analysis shows statin benefit only in patients with CKD Stage > 3, but not in patients with CKD Stage ≤ 3. Limitations: The relative low quality of the individual studies and limited studies means that only a limited conclusion on the use of statin for prevention of CIN was possible.Correspondence to:
Dr. W.J. Yuan
Department of Nephrology
Shanghai First People’s Hospital
Shanghai Jiaotong University
100 HaiNing Road
Shanghai 200080, China
Email: [email protected]
Nephrology Education
FDG PET/CT and MRI findings in a patient with focal xanthogranulomatous pyelonephritis mimicking cystic renal malignancy
G. Cheng, D.A. Torigian and A. Alavi
Page No. 484
Abstract
Clin i cal Nephrology, Vol. 76 – No. 6/2011 (484-486)
FDG PET/CT and MRI findings in a patient with focal xanthogranulomatous pyelonephritis mimicking cystic renal malignancy
G. Cheng, D.A. Torigian and A. Alavi
Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
Focal xanthogranulomatous pyelonephritis (XGP) is a chronic inflammatory condition that can mimic other disease conditions such as pyelonephritis, tuberculosis, renal abscess, renal cell carcinoma, and renal metastasis. Urinary tract infection and obstruction are considered to be predisposing factors. The clinical symptoms and imaging findings are often nonspecific so that an incorrect initial diagnosis is common. Here, we report a case of a patient with focal XGP with FDG PET/CT findings that mimic renal malignancy.Correspondence to:
G. Cheng, MD, PhD
Division of Nuclear Medicine
Department of Radiology
Hospital of the University of Pennsylvania
3400 Spruce Street
Philadelphia, PA 19104, USA
Email: [email protected]
Nephrology Education
Membranous nephropathy and granulomatous interstitial nephritis due to tuberculosis
R. Ram, G. Swarnalatha, M. Desai, Y. Rakesh, M. Uppin, A. Prayaga and K.V. Dakshinamurty
Page No. 487
Abstract
Clinical Nephrology, Vol. 76 – No. 6/2011 (487-491)
Membranous nephropathy and granulomatous interstitial nephritis due to tuberculosis
R. Ram, G. Swarnalatha, M. Desai, Y. Rakesh, M. Uppin, A. Prayaga and K.V. Dakshinamurty
Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad, India
Tuberculous involvement of the genitourinary tract is well reported in the literature. However, reports of glomerular lesions of the kidney due to tuberculosis are rare. Tuberculosis has been identified as the most common infectious cause of granulomatous interstitial nephritis (GIN). We report a 23-year-old female patient with a membranous nephropathy and GIN due to tuberculosis. She presented with renal failure and nephrotic-range proteinuria, both of which resolved with the treatment of tuberculosis. There is only one report, from Japan, of a patient with membranous nephropathy and tuberculous granulomatous nephritis. Our patient is the second with tuberculous GIN and membranous nephropathy. In our patient, the close temporal relationship between the infection and glomerulonephritis, an ulcerated tuberculin skin test, the response to the treatment and the absence of any other systemic disease that might cause the glomerulonephritis suggested an association between tuberculosis and membranous nephropathy. However, a causal association can only be speculation, because membranous nephropathy could remit spontaneously. It is also possible that it might relapse at a later date when the tuberculosis is inactive. Therefore, the association might be either coincidental or causal, and could become clearer as similar patients are reported.Correspondence to:
Dr. R. Ram
Nizam’s Institute of Medical Sciences
Punjagutta, Hyderabad, 5090082 India
Email: [email protected]
Nephrology Education
A case of familial lecithin-cholesterol acyltransferase deficiency on hemodialysis for over 20 years
Y. Tsuchiya, Y. Ubara, R. Hiramatsu, T. Suwabe, J. Hoshino, K. Sumida, E. Hasegawa, M. Yamanouchi, N. Hayami, Y. Marui, N. Sawa, S. Hara, K. Takaichi and K. Oohashi
Page No. 492
Abstract
Clinical Nephrology, Vol. 76 – No. 6/2011 (492-498)
A case of familial lecithin-cholesterol acyltransferase deficiency on hemodialysis for over 20 years
Y. Tsuchiya1, Y. Ubara1, R. Hiramatsu1, T. Suwabe1, J. Hoshino1, K. Sumida1, E. Hasegawa1, M. Yamanouchi1, N. Hayami1, Y. Marui1, N. Sawa1, S. Hara1, K. Takaichi1 and K. Oohashi2
1Nephrology Center and 2Department of Pathology, Toranomon Hospital Kajigaya, Takatsu, Kanagawa, Japan
We trace the 34-year history of a member of the first Japanese family in which lecithin-cholesterol acyltransferase (LCAT) deficiency was diagnosed. Marriage between cousins with low LCAT activity was responsible for familial LCAT deficiency (FLD). In 1976, a 27-year-old Japanese man was noted to have FLD based on proteinuria, hematuria, grayish corneal opacity and low LCAT activity (9.83%). Genetic analysis showed insertion of G-G-C coding glycine at codon 141. Total cholesterol (C) was low at 108 mg/dl and the ratio of C-ester to total C was very low (12%), while the lecithin (phosphatidylcholine) level was very high (97.3%). When his serum creatinine reached 2.6 mg/dl at the age of 41 years (in 1991), renal biopsy was performed. This showed expansion of the mesangial matrix and irregularly thickened capillary walls with a bubble-like appearance because of lipid deposits consisting of two components (partly lucent vacuolated areas and partly deeply osmiophilic areas). Magnification of the latter deposits showed curvilinear and serpiginous striated membranous structure. Hemodialysis was started in 1990 and has been continued for over 20 years until August 2010. Clinical problems have included AV shunt failure requiring 4 operations and 13 percutaneous transcatheter angioplasty procedures, as well as episodes of hemolytic anemia that subsided after infusion of fresh frozen plasma. Cardiovascular events have not yet occurred, although severe calcification of abdominal aorta has been detected by computed tomography.Correspondence to:
Y. Tsuchiya, MD
Nephrology Center
Toranomon Hospital Kajigaya
1-3-1, Kajigaya, Takatsu
Kawasaki, Kanagawa, 213-8587, Japan
Email: [email protected]
Nephrology Education
Calciphylaxis in a patient with acute kidney injury and alcoholic cirrhosis
P. Wichienkuer, W. Naugler and R. Wusirika
Page No. 499
Abstract
Clinical Nephrology, Vol. 76 – No. 6/2011 (499-503)
Calciphylaxis in a patient with acute kidney injury and alcoholic cirrhosis
P. Wichienkuer1, W. Naugler2 and R. Wusirika3
1Department of Medicine, 2Division of Gastroenterology, and 3Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
Calciphylaxis is a rare disorder characterized by painful skin necrosis and calcification of small vessels which is seen mainly in the dialysis population. We describe a case of a patient with alcoholic cirrhosis developing calciphylaxis during an episode of acute kidney injury. We also review the literature in prior cases and postulate that unrecognized renal dysfunction in cirrhotic patients may have played a role in the development of this uncommon disorder. Our patient had complete recovery of the lesions with conservative treatment which coincided with recovery of her renal function. This case serves to highlight how small changes in creatinine levels in patients with cirrhosis may represent larger and clinically relevant changes in actual renal function that predispose these patients to calciphylaxis.Correspondence to:
R. Wusirika, MD
Division of Nephrology and Hypertension
Department of Medicine
Oregon Health and Science University
Mail Code: PP262
3314 S.W. U.S. Veterans Hospital Rd.
Portland, OR 97239-2940, USA
Email: [email protected]
Letter to the Editor
Transition of severe diffuse mesangial hypercellularity to minimal change disease in a child with steroid-resistant nephrotic syndrome
S. Fujinaga, T. Watanabe, A. Endo, D. Hirano, Y. Ohtomo, T. Shimizu and K. Kaneko
Page No. 504
Abstract
Transition of severe diffuse mesangial hypercellularity to minimal change disease in a child with steroid-resistant nephrotic syndrome
S. Fujinaga1, T. Watanabe1, A. Endo1, D. Hirano1, Y. Ohtomo2, T. Shimizu3 and K. Kaneko4
1Divisions of Nephrology Saitama Children’s Medical Center, Saitama, 2Department of Pediatrics, Juntendo Nerima Hospital, 3Department of Pediatrics, Juntendo University School of Medicine, Tokyo, and 4Department of Pediatrics, Kansai Medical University, Osaka, Japan
Correspondence to:
S. Fujinaga, MD, PhD
Division of Nephrology
Saitama Children’s Medical Center
2100 Magome, Iwatsuki-ku
Saitama-city Saitama 339 8551, Japan
Email: [email protected]
