Volume 79 (2013), No. 3/2013(March)
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Original
Electronic health records: a new tool to combat chronic kidney disease?
Sankar D. Navaneethan, Stacey E. Jolly, John Sharp, Anil Jain, Jesse D. Schold, Martin J. Schreiber Jr and Joseph V. Nally Jr
Page No. 175
Abstract
Clinical Nephrology, Vol. 79 – No. 3/2013 (175-183)
Electronic health records: a new tool to combat chronic kidney disease?
Sankar D. Navaneethan1,2, Stacey E. Jolly2,3, John Sharp4, Anil Jain3,5, Jesse D. Schold1,4, Martin J. Schreiber Jr1 and Joseph V. Nally Jr1,2
1Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, 2Cleveland Clinic Lerner College of Medicine of CWRU, 3Department of Internal Medicine, Medicine Institute, 4Department of Quantitative Health Sciences, Cleveland Clinic, and 5Explorys Corporation, Cleveland, OH, USA
Electronic health records (EHRs) were first developed in the 1960s as clinical information systems for document storage and retrieval. Adoption of EHRs has increased in the developed world and is increasing in developing countries. Studies have shown that quality of patient care is improved among health centers with EHRs. In this article, we review the structure and function of EHRs along with an examination of its potential application in CKD care and research. Well-designed patient registries using EHRs data allow for improved aggregation of patient data for quality improvement and to facilitate clinical research. Preliminary data from the United States and other countries have demonstrated that CKD care might improve with use of EHRs-based programs. We recently developed a CKD registry derived from EHRs data at our institution and complimented the registry with other patient details from the United States Renal Data System and the Social Security Death Index. This registry allows us to conduct a EHRs-based clinical trial that examines whether empowering patients with a personal health record or patient navigators improves CKD care, along with identifying participants for other clinical trials and conducting health services research. EHRs use have shown promising results in some settings, but not in others, perhaps attributed to the differences in EHRs adoption rates and varying functionality. Thus, future studies should explore the optimal methods of using EHRs to improve CKD care and research at the individual patient level, health system and population levels.Correspondence to:
Sankar D. Navaneethan, MD, MPH
Department of Nephrology and Hypertension
Glickman Urological and Kidney Institute
9500 Euclid Avenue-Q7, Cleveland Clinic
Cleveland, 44195 OH, USA
Email: [email protected]
Original
Implementation and first results of a German Chronic Kidney Disease Registry
Werner Kleophas, Brian Bieber, Bruce M. Robinson, Johannes Duttlinger, Danilo Fliser, Gerhard Lonnemann, L. Christian Rump, Ronald L. Pisoni, Friedrich K. Port and Helmut Reichel
Page No. 184
Abstract
Implementation and first results of a German Chronic Kidney Disease Registry
Werner Kleophas1,7, Brian Bieber2, Bruce M. Robinson2,3, Johannes Duttlinger4, Danilo Fliser5, Gerhard Lonnemann6, L. Christian Rump7, Ronald L. Pisoni2, Friedrich K. Port2 and Helmut Reichel8 on behalf of the FNDN study group
1Gemeinschaftspraxis Karlstraße, Düsseldorf, Germany, 2Arbor Research Collaborative for Health, Ann Arbor, MI, USA, 3University of Michigan, Ann Arbor, MI, USA, 4Nephrologisches Zentrum Offenburg, Offenburg, 5Universität des Saarlandes, Homburg/Saar, 6Gemeinschaftspraxis Eickenhof 15, Langenhagen, 7Klinik für Nephrologie, Heinrich-Heine-Universität, Düsseldorf, and 8Nephrologisches Zentrum, Villingen-Schwenningen, Villingen-Schwenningen, Germany
Advanced chronic kidney disease (CKD) is gaining increasing medical and economical importance, but little information exists about treatment variation and the impact of routine clinical treatments on survival, quality of life, and cost. We demonstrate the first results of a national electronic registry of nephrology clinic data that will serve as a resource for the prospective observation of CKD patients in Germany. A large network of German nephrologist practices is currently joining the project. Routinely obtained clinical data for non-dialysis dependent CKD patients are documented in health records electronically, and elements from these data are extracted using QuaNT (Qualitätssicherung Nephrologie und Transplantation) to create a centralized database. Here, we report cross-sectional data from 59 participating nephrology clinics and 6,187 patients with CKD Stage 3 – 5 in 2011. Mean age ± standard deviation (SD) was 72 ± 12 years. The distribution of CKD 3, 4, and 5 (non-dialysis) was 60%, 33%, and 8%, respectively. The major renal diseases were hypertension/vascular nephropathy (47%) and diabetic nephropathy (26%). Reninangiotensin-system inhibitor prescription was 78%. Vitamin D prescription was 50%, phosphate binders 6%, iron (oral or i.v.) 19%, and erythropoietin-stimulating agents 14%. This electronic registry follows clinical nephrology care and outcomes for CKD patients in Germany, and increased participation is anticipated. As a component of the initiative, variation in patient care will be studied to identify best treatment practices in analyses integrated into the international CKD Outcomes and Practice Patterns Study (CKDopps).Correspondence to:
PD Dr. Werner Kleophas
Gemeinschaftspraxis Karlstraße
Karlstraße 17-19
40210 Düsseldorf, Germany
Email: [email protected]
Original
Increased plasma osteoprotegerin concentrations in Type 1 diabetes with albuminuria
Shen-tian Wang, Jian-min Xu, Meng Wang, Fu-lian Chen and Gang Ding
Page No. 192
Abstract
Clinical Nephrology, Vol. 79 – No. 3/2013 (192-198)
Increased plasma osteoprotegerin concentrations in Type 1 diabetes with albuminuria
Shen-tian Wang, Jian-min Xu, Meng Wang, Fu-lian Chen and Gang Ding
Department of Endocrinology, Affiliated Yidu Central Hospital of Weifang Medical College, Weifang, China
Objective: The aim of the present study was to determine the plasma osteoprotegerin (OPG) levels in Type 1 diabetic patients with albuminuria. Methods: A total of 80 Type 1 diabetic subjects and 30 control subjects were enrolled. Diabetic subjects were divided into normoalbuminuric group, microalbuminuric group and macroalbuminuric group according to urinary albumin excretion rate (UAER) and serum creatinine measurements. Plasma osteoprotegerin level was measured by enzyme-linked immunoassay. Results: The serum OPG levels were significantly elevated in patients with microalbuminuria (3.62 ± 0.70 ng/l) and macroalbuminuria (4.45 ± 0.76 ng/l) as compared with patients with normoalbuminuria (2.77 ± 0.78 ng/l) and control subjects (2.29 ± 0.37 ng/l). And the plasma osteoprotegerin level in macroalbuminuric group was also higher than that in microalbuminuria group. The plasma osteoprotegerin level had a positive correlation with the fasting plasma glucose (FPG), 2-h plasma glucose (2hPG), glycohemoglobin A1c (HbA1C), highly sensitive C-reactive protein (hsCRP)and UAER. Multivariate regression analysis revealed that the plasma osteoprotegerin level was an independent factor associated with albuminuria in Type 1 diabetes. Conclusions: The plasma values of osteoprotegerin were elevated in Type 1 diabetic patients with nephropathy and gradually increased with the severity, so there is a association between plasma osteoprotegerin levels and the presence and severity of diabetic nephropathy. This finding supports the growing concept that osteoprotegerin may act as an important regulatory molecule in the angiopathy, and particularly, that it may be involved in the development of nephropathy in Type 1 diabetes.Correspondence to:
Dr. Shen-tian Wang
Department of Endocrinology
Affiliated Yidu Central Hospital
Weifang Medical College
Linglongshan Nan Road 4138
Weifang 262500, Shandong Province, China
Email: [email protected]
Original
Analysis of 24-hour ambulatory blood pressure monitoring in patients with diabetic nephropathy: a hospital-based study
Junhui Li, Feng Wang, Guihua Jian, Nan Ma, Ying Fan, Gang Yu, Qin Xue, Xuping Gao and Niansong Wang
Page No. 199
Abstract
Clinical Nephrology, Vol. 79 – No. 3/2013 (199-205)
Analysis of 24-hour ambulatory blood pressure monitoring in patients with diabetic nephropathy: a hospital-based study
Junhui Li*, Feng Wang*, Guihua Jian, Nan Ma, Ying Fan, Gang Yu, Qin Xue, Xuping Gao and Niansong Wang
Department of Nephrology, Shanghai Sixth People’s Hospital, Shanghai Jiaotong University, Shanghai, China
*Li Junhui and Wang Feng contributed equally to this work.
Background and aims: The present study was designed to characterize and compare the ambulatory blood pressure changes of patients with Type 2 diabetic nephropathy (DN) and non-diabetic chronic kidney disease (CKD), and to investigate the features of ambulatory blood pressure in patients with Type 2 diabetic nephropathy (DN) in comparison with those of non-diabetic chronic kidney disease (CKD) in our medical center. Materials and methods: 62 patients with Type 2 diabetic nephropathy (DN) in compliance with the diagnosis criteria of CKD were enrolled in the study, without renal replacement therapy. Their 24-h ambulatory blood pressure monitoring (ABPM) results were observed and compared with the ambulatory blood pressure results of 152 non-diabetic CKD patients with matching age, sex, renal function and other aspects. Results: Analysis of ABPM data from 62 patients with Type 2 DN and 152 patients with nondiabetic CKD indicated: 1. The average 24-h systolic blood pressure (SBP), daytime and nighttime systolic blood pressure (SBP) in the patients with DN were all significantly higher than those of patients with non-DN. 2. Blood pressure variability did not differ considerably between the two groups; nighttime blood pressure decline was small in both groups, but not significantly different. 3. The systolic blood pressure loads in the patients with DN were all significantly higher than those of patients with non-DN. 4. The prevalence of abnormal Circadian BP rhythm was 90.3% in patients with DN, which did not differ considerably from the patients with non-DN represented by 81.6%. 5. The nighttime SBP was correlated with 24-h urinary protein in patients with both non-DN and DN. Conclusions: Systolic blood pressure control of patients with intermediate or advanced diabetic nephropathy was worse than that of patients with non-diabetic CKD, and non-dipping rhythm was quite common. The nighttime SBP correlated with 24-h urinary protein excretion.Correspondence to:
Prof. Nian-Song Wang
Department of Nephrology
The Sixth People’s Hospital
Shanghai Jiao Tong University
School of Medcine
600, Yi Shan Rd, Shanghai 200233, China
Email: [email protected]
Original
The validation of estimated glomerular filtration rate (eGFR) equation for renal transplant recipients
Natavudh Townamchai, Kearkiat Praditpornsilpa, Tawatchai Chawatanarat, Yingyos Avihingsanon, Khajohn Tiranathanagul, Pisut Katavetin, Paweena Susantitaphong, Talerngsak Kanjanabuch, Kriang Tungsanga and Somchai Eiam-Ong
Page No. 206
Abstract
Clinical Nephrology, Vol. 79 – No. 3/2013 (206-213)
The validation of estimated glomerular filtration rate (eGFR) equation for renal transplant recipients
Natavudh Townamchai1*, Kearkiat Praditpornsilpa1*, Tawatchai Chawatanarat2, Yingyos Avihingsanon1, Khajohn Tiranathanagul1, Pisut Katavetin1, Paweena Susantitaphong1, Talerngsak Kanjanabuch1, Kriang Tungsanga1 and Somchai Eiam-Ong1
1Division of Nephrology, Department of Medicine, and 2Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital The Thai Red Cross Society, Bangkok, Thailand
*contributed equally
Background: The re-expressed Modification of Diet in the Renal Disease (MDRD) equation and the Chronic Kidney Disease Epidemiology (CKD-EPI) equation were developed to estimate glomerular filtration rate in non-transplant chronic kidney disease (CKD) patients. The Nankivell equation was created to estimate GFR in transplant recipients. However, none of these formulas have been validated in Asian renal transplant patients. Several recently published studies have highlighted the need to adapt estimated glomerular filtration rate (eGFR) equations to the race of their patients. Although the eGFR equation for Thai CKD has been derived, it has not been validated for transplant recipients. Our study aimed validating the Nankivell equation, re-expressed MDRD equation, CKD-EPI, re-expressed MDRD equation with Thai racial factor correction, as well as the Thai eGFR equation in Thai renal transplant recipients. Methods: A total of 97 adult Thai renal transplant recipients were studied. The 99mTc-DTPA plasma clearance was used as a reference GFR. The serum creatinine was determined by IDMS reference enzymatic methods (CrEnz). Results: The mean reference GFR and CrEnz were 67.86 ± 20.72 ml/min/1.73 m2 and 1.23 ± 0.59 mg/dl. The bias estimated by Bland-Altman analysis can be expressed as –12.11 ± 15.87 ml/ min/1.73 m2 for the Nankivell equation, 2.72 ± 13.90 ml/min/1.73 m2 for the re-expressed IDMS-traceable MDRD equation, –2.59 ± 14.16 ml/min/1.73 m2 for the CKD-EPI equation, –7.05 ± 17.34 ml/min/1.73 m2 for the Thai re-expressed MDRD with Thai racial factor, and –8.62 ± 16.00 ml/min/1.73 m2 for the Thai eGFR equation. The CKD-EPI equation provided the best accuracy and precision in terms of Pearson correlation coefficient, mean difference, error, and accuracy within 10%, 20%, and 30%. Conclusions: The equations derived mainly from Caucasian and/or non-transplant status can be applied to Thai transplantation recipients with some bias. The CKD-EPI had the least bias compared with other eGFR equations. Correspondence to:
Natavudh Townamchai, MD
Division of Nephrology, Department of Medicine
Faculty of Medicine, Chulalongkorn University
Bangkok 10330, Thailand
Email: [email protected]
Original
Effect of atorvastatin on IgA nephropathy in the rat
Ze’ev Katzir, Elena Leibovitch, Hanan Vaknin, Letizia Schreiber, Esther Berger, Zipora Matas, Asora Fux, Mona Boaz, Alexander Briliant and Alexander Biro
Page No. 214
Abstract
Clinical Nephrology, Vol. 79 – No. 3/2013 (214-220)
Effect of atorvastatin on IgA nephropathy in the rat
Ze’ev Katzir1, Elena Leibovitch1, Hanan Vaknin2, Letizia Schreiber2, Esther Berger2, Zipora Matas3, Asora Fux3, Mona Boaz4, Alexander Briliant1 and Alexander Biro1
1Institute of Nephrology, 2Pathology Institute, 3Biochemistry Laboratory and 4Epidemiology Unit, E. Wolfson Medical Center, Holon, Israel
Background: IgA nephropathy (IgAN) is the most common chronic glomerulonephritis in humans and is a major cause of end-stage kidney disease worldwide. There is no agreement on the exact underlying mechanism or therapeutic intervention for this disorder. Mesangial proliferation typifies the renal histopathology in IgAN. Statin drugs, as prenylationinhibitors, have been shown to have an antiproliferative effect on renal mesangial cells and to reduce IgAN-associated glomerulusclerosis and proteinuria. The aim of this study is to examine the effect of atorvastatin on kidney function, proteinuria and kidney histology changes in IgANinduced rats. Methods: IgAN was induced in Wistar-Kyoto rats by bovine γ-globulin (BGG). Four groups of rats were treated in metabolic cages: 1) control; 2) atorvastatin (2 mg/kg body weight/day through nasogastric tube) – treated rats; 3) IgAN-rats; 4) IgAN-rats treated with atorvastatin. Urine volume, urine protein excretion, blood urea and creatinine concentrations in addition to creatinine clearance were examined every 14 days, throughout the duration of the study (56 days). All kidneys from sacrificed rats were examined for histology including glomerular cell nuclei count and immunofluorescence. Results: There were no differences in blood creatinine concentrations between the groups. Creatinine clearance was lower on the 42nd day and proteinuria was higher on Days 14, 42 and 56, in rats in Group 3 compared to all others; additionally, histology examination revealed a higher glomerular cell nuclei count in this group. Immunofluorescence was equally positive for IgA in mesangial cells in the kidneys from rats of Groups 2, 3 and 4. Conclusions: Atorvastatin attenuates kidney-function impairment, proteinuria and mesangial cell proliferation in BGG model of IgANinduced rats.Correspondence to:
Ze’ev Katzir, MD
Institue of Nephrology
E. Wolfson Medical Center
Halochamim Street, 58100 Holon, Israel
Email: [email protected]
Original
The impact of anemia on renal recovery and survival in acute kidney injury
Susie L. Hu, Fuad R. Said, David Epstein and Madaiah Lokeshwari
Page No. 221
Abstract
Clinical Nephrology, Vol. 79 – No. 3/2013 (221-228)
The impact of anemia on renal recovery and survival in acute kidney injury
Susie L. Hu1, Fuad R. Said2, David Epstein3 and Madaiah Lokeshwari4
1Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, 2Milford Regional Medical Center, Milford, MA, 3White Plains Hospital, White Plains, NY, and 4Department of Medicine, Saint Vincent Hospital, Worcester, MA, USA
Background: Anemia occurs frequently among patients who develop acute kidney injury likely due to abnormal erythropoietic activity. Anemia has been associated with increased mortality among hospitalized patients, but its impact on renal recovery or survival is poorly characterized among patients with acute kidney injury. We aim to assess if anemia is associated with lower renal recovery and poorer survival. Methods: A retrospective cohort of 211 patients was examined. Anemia and other patient characteristics were assessed as potential risk factors for the presence of renal recovery or death. Additionally, renal recovery, dialysis requirement and survival were compared between those with mild versus severe anemia. Results: 86% of patients with acute kidney injury (AKI) developed acute anemia which generally occurred at the time of acute kidney injury. Anemia did not appear to be associated with lack of renal recovery or death, but rather underlying comorbid conditions and severity of illness were more likely to be associated with renal recovery or death, respectively. Neither renal recovery nor survival differed among patients with mild versus severe anemia as measured by fall in hemoglobin or nadir hemoglobin. Conclusions: New onset anemia does not appear to be associated with lack of renal recovery or death among patients with acute kidney injury.Correspondence to:
Susie L. Hu, MD
Division of Kidney Disease and Hypertension
Department of Medicine
Warren Alpert Medical School of Brown University
Rhode Island Hospital
593 Eddy Street, Providence, RI 02903, USA
Email: [email protected]
Nephrology Education
AA amyloid nephropathy with predominant vascular deposition in Crohn’s disease
Noriaki Kurita, Nagaaki Kotera, Yu Ishimoto, Mototsugu Tanaka, Shinji Tanaka, Nobuo Toda, Akiko Fujii, Kiyonori Kobayashi, Tokuichiro Sugimoto and Naobumi Mise
Page No. 229
Abstract
Clinical Nephrology, Vol. 79 – No. 3/2013 (229-232)
AA amyloid nephropathy with predominant vascular deposition in Crohn’s disease
Noriaki Kurita1, Nagaaki Kotera1, Yu Ishimoto1, Mototsugu Tanaka1, Shinji Tanaka1, Nobuo Toda2, Akiko Fujii3, Kiyonori Kobayashi4, Tokuichiro Sugimoto1 and Naobumi Mise1
Division of 1Nephrology and 2Gastroenterology, Department of Medicine and 3Department of Diagnostic Pathology, Mitsui Memorial Hospital, Tokyo, and 4Department of Gastroenterology, Kitasato University East Hospital, Kanagawa, Japan
A 44-year-old man with a 17-year history of Crohn’s disease (CD) was referred to our nephrology department on suspicion of drug-induced nephrotoxicity. Over the preceding 18 months, he had slowly progressive renal insufficiency with slight urinary abnormalities. His disease activity had been well controlled up to that point with 5-aminosalicylic acid and azathiopurine. Laboratory examination revealed slight proteinuria without hematuria and an elevated serum creatinine level of 1.4 mg/dl. Pathological examination revealed amyloid A (AA) deposition in the kidney, predominantly in the arterial and arteriolar walls with little to none in the glomerular capillaries. AA amyloidosis is typically accompanied by glomerular amyloid deposition and massive proteinuria. In the present case, however, vascular amyloid deposition was predominant, and the renal function was deteriorated with slight urinary abnormalities. The present case confirmed the importance of conducting a definitive pathological diagnosis of renal insufficiency in CD patients.Correspondence to:
Noriaki Kurita, MD, FJSIM
Department of Healthcare Epidemiology
Graduate School of Medicine and Public Health
Kyoto University
Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
Email: [email protected]
Nephrology Education
A patient with persistent renal AL amyloid deposition after clinical remission by HDM/SCT therapy
Hiroshi Okuyama, Hideki Yamaya, Toshihiro Fukusima and Hitoshi Yokoyama
Page No. 233
Abstract
Clinical Nephrology, Vol. 79 – No. 3/2013 (233-236)
A patient with persistent renal AL amyloid deposition after clinical remission by HDM/SCT therapy
Hiroshi Okuyama1, Hideki Yamaya1, Toshihiro Fukusima2 and Hitoshi Yokoyama1
1Division of Nephrology, 2Division of Hematology and Immunology, Kanazawa Medical University School of Medicine, Ishikawa, Japan
A 62-year-old female patient was admitted to our hospital for evaluation of nephrotic syndrome. Monoclonal gammopathy (IgG λ type) and urinary Bence Jones proteins were detected in the serum and urine by the immunofixation method. The initial renal biopsy revealed amyloid deposition in mesangial area, glomerular capillary walls and arterioles by Congo-red staining, and amyloid fibers were detected by electron microscopy. On the bone marrow test, plasma cells accounted for 8.6%. Based on these findings, we diagnosed as AL amyloidosis associated with multiple myeloma. We treated her by high-dose intravenous injection therapy of melphalan combined with autologous peripheral blood stem cell transplantation. She achieved complete hematologic response 27 months later, however. Urine M-protein disappeared 2 months after treatment, and proteinuria slowly disappeared 17 months after treatment. On the other hand, amyloid fibers remained in renal biopsied tissues at 17 and 53 months after therapy. Electron microscopic examination also revealed the similar amyloid fibers in glomeruli. These findings suggest that, in this case, immunoglobulin light chains may cause directly and/or indirectly glomerular epithelial injury and nephrotic range proteinuria rather than via amyloid fiber formation.Correspondence to:
Hiroshi Okuyama, MD, Assistant Professor
Division of Nephrology
Kanazawa Medical University School of Medicine
1-1 Daigaku Uchinada, Ishikawa 920-0293 Japan
Email: [email protected]
Nephrology Education
Iron infusion and deposition in the kidney
Ramin Tolouian, Babak Rajabi, Darius Boman, Jorge Bilbao and Ajay Gupta
Page No. 237
Abstract
Clinical Nephrology, Vol. 79 – No. 3/2013 (237-240)
Iron infusion and deposition in the kidney
Ramin Tolouian1, Babak Rajabi1, Darius Boman2, Jorge Bilbao2 and Ajay Gupta3
1Division of Nephrology, Department of Internal Medicine, 2Department of Pathology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, and 3Rockwell Medical, Wixom, MI, USA
Background: Parenteral iron therapy is the mainstay of treating iron deficiency anemia in chronic kidney disease (CKD) patients. Methods: Retrospective case study of iron staining of renal tissues in 2 CKD patients who had received intravenous iron prior to the renal biopsy. Results: Following the infusion of ferumoxytol, iron staining of renal biopsy demonstrated blue curvilinear deposition of iron in the tissue macrophages (histocytes) and interstitium of the kidney. Renal iron deposition was not observed in a patient administered intravenous iron dextran. Conclusion: We postulate that the higher molecular weight of ferumoxytol and different carbohydrate components may lead to deposition and trapping of the ironcarbohydrate complexes in the reticuloendothelial system of the kidney. Potential renal toxicity from iron induced oxidant stress, especially in patients with underlying chronic kidney disease, merits further investigation.Correspondence to:
Ramin Tolouian, MD, Assistant Professor of Medicine
Paul L. Foster School of Medicine
Texas Tech University Health Science Center
4800 Alberta Avenue, El Paso, TX 79905, USA
Email: [email protected]
Nephrology Education
A purpose-built simulator for percutaneous ultrasound-guided renal biopsy
Alexander Woywodt, Thien How and Michael Schulz
Page No. 241
Abstract
Clinical Nephrology, Vol. 79 – No. 3/2013 (241-245)
A purpose-built simulator for percutaneous ultrasound-guided renal biopsy
Alexander Woywodt1, Thien How2 and Michael Schulz3
1Department of Nephrology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, 2Department of Clinical Engineering, University of Liverpool, and 3Department of Nephrology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, Merseyside, UK
Aims: To construct a simple and affordable simulator for ultrasoundguided percutaneous renal biopsy. Material and methods: The kidney biopsy phantom was constructed by embedding a porcine kidney in gelatine. Silicon carbide and aluminium oxide were used as scattering particles in order to mimic the ultrasound appearance of human tissues. Two porcine ribs were also embedded. A latex sheet was placed over the top of the gel layer to resemble skin. The simulator was used and feedback from participants obtained during a renal ultrasound course with an international audience of middle-grade trainees from adult and pediatric nephrology, many of whom had never done a renal biopsy. Biopsy was carried out a single-use biopsy gun. Results: All participants were able to perform a biopsy and obtain a satisfactory sample. All trainees felt that our simulator was very realistic. 94% of participants agreed that the simulator would help to allay their fears in relation to renal biopsy The total cost of the simulator was around £ 50,– for consumables per simulator. Conclusions: We describe a purpose-built and affordable simulator for percutaneous ultrasound-guided renal biopsy. We suggest that others evaluate our simulator used as part of a structured approach to teach this important procedure.Correspondence to:
Dr. Alexander Woywodt, MD, FRCP
Consultant, Renal Physician/Honorary Senior Lecturer
Department of Nephrology
Lancashire Teaching Hospitals NHS Trust
Royal Preston Hospital
Sharoe Green Lane, Preston, PR2 9HT, UK
Email: [email protected]
Nephrology Education
Henoch-Schönlein purpura nephritis in a patient with IgG4-related disease: A possible association
Kiyoaki Ito, Kazunori Yamada, Ichiro Mizushima, Motohiko Aizu, Hiroshi Fujii, Kazuaki Mizutomi, Masami Matsumura, Kenshi Hayashi, Masakazu Yamagish, Hisanori Umehara, Yutaka Yamaguchi, Michio Nagata and Mitsuhiro Kawano
Page No. 246
Abstract
Clinical Nephrology, Vol. 79 – No. 3/2013 (246-252)
Henoch-Schönlein purpura nephritis in a patient with IgG4-related disease: A possible association
Kiyoaki Ito1, Kazunori Yamada1, Ichiro Mizushima1, Motohiko Aizu1, Hiroshi Fujii1, Kazuaki Mizutomi2, Masami Matsumura3, Kenshi Hayashi4, Masakazu Yamagishi4, Hisanori Umehara5, Yutaka Yamaguchi6, Michio Nagata7 and Mitsuhiro Kawano1
1Division of Rheumatology, Department of Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, 2Department of Internal Medicine, Kaga City Hospital, Kaga, 3Research Center for Medical Education, 4Division of Cardiology, Department of Internal Medicine, Graduate School of Medicine, Kanazawa University, Kanazawa, 5Hematology and Immunology, Kanazawa Medical University, Ishikawa, 6Yamaguchi’s Pathology Laboratory, Matsudo, Chiba, and 7Department of Kidney and Vascular Pathology, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
We report a case of Henoch- Schönlein purpura nephritis (HSPN) associated with tubulointerstitial nephritis (TIN) and chronic sclerosing sialoadenitis. The patient is a 75-year-old Japanese woman who had bilateral submandibular gland swelling, palpable purpura on the lower legs, and decreased renal function with hematoproteinuria and marked hypocomplementemia, but no skin lesion suggestive of systemic lupus erythematosus (SLE), and did not fulfill the classification criteria for SLE. Her serum IgG4 level was high and immunostaining of renal biopsies revealed marked infiltration by IgG4-positive plasma cells in the interstitium, confirming the diagnosis of IgG4- related disease. On the other hand, glomeruli showed endocapillary proliferative glomerulonephritis with mesangial IgA and C3 deposition demonstrated by immunofluorescence staining, which were typical glomerular lesions for HSPN. The glomerular and tubulointerstitial lesions responded to steroid therapy dramatically, and her renal function recovered to within the normal range within a month. This case suggests a possible new association between HSPN and IgG4-related disease.Correspondence to:
Mitsuhiro Kawano, MD
Division of Rheumatology
Department of Internal Medicine
Graduate School of Medical Science
Kanazawa University
Takara-machi 13-1, Kanazawa
Ishikawa 920-8641, Japan
Email: [email protected]
