Volume 80 (2013), No. 4/2013(October)
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Original
Pravastatin and cardiovascular outcomes stratified by baseline eGFR in the lipid- lowering component of ALLHAT
Mahboob Rahman, Charles Baimbridge, Barry R. Davis, Joshua I. Barzilay, Jan N. Basile, Mario A. Henriquez, Anne Huml, Nelson Kopyt, Gail T. Louis, Sara L. Pressel, Clive Rosendorff, Sithiporn Sastrasinh and Carol Stanford
Page No. 235
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 (235-248)
Pravastatin and cardiovascular outcomes stratified by baseline eGFR in the lipid- lowering component of ALLHAT
Mahboob Rahman1, Charles Baimbridge2, Barry R. Davis2, Joshua I. Barzilay3, Jan N. Basile4, Mario A. Henriquez5, Anne Huml1, Nelson Kopyt6, Gail T. Louis7, Sara L. Pressel2, Clive Rosendorff8, Sithiporn Sastrasinh9, Carol Stanford10 for the ALLHAT Collaborative Research Group11
1Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, 2The University of Texas School of Public Health, Houston, TX, 3Kaiser Permanente of Georgia, Tucker, GA, 4Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, 5Bronx Nephrology Hypertension, Bronx, NY, 6Lehigh Valley Hospital, Allentown, PA, 7Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, 8Mount Sinai School of Medicine, New York, NY, and the James J. Peters Veterans Affairs Medical Center, Bronx, NY, 9Veterans Affairs New Jersey Health Care System, East Orange, NJ, 10University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA and 11A list of the ALLHAT Collaborative Research Group members has been published previously, in JAMA. 2002; 288: 2981-2997.
Background/Aims: The role of statins in preventing cardiovascular outcomes in patients with chronic kidney disease (CKD) is unclear. This paper compares cardiovascular outcomes with pravastatin vs. usual care, stratified by baseline estimated glomerular filtration rate (eGFR). Methods: Post-hoc analyses of a prospective randomized open-label clinical trial; 10,151 participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (lipid-lowering component) were randomized to pravastatin 40 mg/day or usual care. Mean follow-up was 4.8 years. Results: Through Year 6, total cholesterol declined in pravastatin (–20.7%) and usualcare groups (–11.2%). Use of statin therapy in the pravastatin group was 89.8% (Year 2) and 87.0% (Year 6). Usual-care group statin use increased from 8.2% (Year 2) to 23.5% (Year 6). By primary intention-to-treat analyses, no significant differences were seen between groups for coronary heart disease (CHD), total mortality or combined cardiovascular disease; findings were consistent across eGFR strata. In exploratory “as-treated” analyses (patients actually using pravastatin vs. not using), pravastatin therapy was associated with lower mortality (HR = 0.76 (0.68 – 0.85), p<0.001) and lower CHD (HR = 0.84 (0.73 – 0.97), p = 0.01), but not combined cardiovascular disease (HR = 0.95 (0.88 – 1.04), p = 0.30). Total cholesterol reduction of 10 mg/dl from baseline to Year 2 was associated with 5% lower CHD risk. Conclusions: In hypertensive patients with moderate dyslipidemia, pravastatin was not superior to usual care in preventing total mortality or CHD independent of baseline eGFR level. However, exploratory “as-treated” analyses suggest improved mortality and CHD risk in participants using pravastatin, and decreased CHD events associated with achieved reduction in total cholesterol. Potential benefit from statin therapy may depend on degree of reduction achieved in total and LDL-cholesterol and adherence to therapy.Correspondence to:
Sara L. Pressel, MS
The University of Texas, School of Public Health
Coordinating Center for Clinical Trials
1200 Herman Pressler St., Suite W908
Houston, TX 77030, USA
Email: [email protected]
Original
The role of renal damage on cardiac remodeling in patients with diabetic nephropathy
Yi-De Zhang, Hou-Yong Dai, Hong-Lang Xie, Qiao-Lin Zhou and Zhi-Hong Liu
Page No. 249
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 (249-255)
The role of renal damage on cardiac remodeling in patients with diabetic nephropathy
Yi-De Zhang1*, Hou-Yong Dai1*, Hong-Lang Xie2, Qiao-Lin Zhou3 and Zhi-Hong Liu2
1Department of Nephrology, Affiliated Hospital, Nantong University, Nantong, 2Research Institute of Nephrology, Jinling Hospital, Nanjin University School of Medicine, Nanjing, and 3Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
*Both authors contributed equally.
Background: Cardiovascular damage and diabetic nephropathy are major complications in patients with Type 2 diabetic nephropathy (T2DN); however, the role of renal damage on cardiac remodeling is not yet fully known. Methods: A retrospective research was conducted in 254 T2DN patients. All were divided into three groups according to urinary albumin excretion (UAE): the normoalbuminuria group (UAE < 30 mg/g, n = 18), the microalbuminuria group (UAE 30 – 300 mg/g, n = 99) and the macroalbuminuria group (UAE > 300 mg/g, n = 137). The parameters of cardiac remodeling, left atrial diameter (LAD), left ventricular diameter at the end of diastole (LVDd), interventricular septum (IVS), posterior wall of left ventricle (PWLV) and ejection fraction (EF), were determined by Doppler echocardiography. The effects of renal damage on cardiac remodeling were analyzed. Results: Among the 254 patients, LAD and LVDd enlargement was found in 180 (70.86%) and 53 (20.86%) patients, respectively; 46 cases (18.11%) suffered from both LAD and LVDd enlargement. Compared with normal LAD/LVDd groups, creatinine clearance (Ccr) and hemoglobin (Hb) were significantly lower in the left atrial (LA) and left ventricular (LV) dilated groups. LAD was positively correlated with mesangial sclerosis, tubular-interstitial lesions, interstitial fibrosis, as well as tubular basement membrane thickness (r = 0.273, 0.208, 0.176, 0.155, p < 0.05, respectively). Moreover, in comparison to patients with LA enlargement, more severe renal damage was detected in patients with LV enlargement. Conclusion: There is a strong correlation between echocardiographic parameters and kidney lesions in patients with T2DN in China; the more severe the renal damage, the more severe the cardiac structural alteration. Renal damage contributes to cardiac remodeling, which may provide new insights into the pathogenesis of cardiovascular complications ,in diabetes mellitus.Correspondence to:
Zhi-Hong Liu, MD, Professor of Medicine Research
Institute of Nephrology, Jinling Hospital, Nanjing
University School of Medicine
Nanjing 210002, China
Email: [email protected]
Original
Estimated glomerular filtration rate variability and risk of end-stage renal disease among patients with Stage 3 chronic kidney disease
Robert M. Perkins, H. Lester Kirchner, James E. Hartle and Ion D. Bucaloiu
Page No. 256
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 (256-262)
Estimated glomerular filtration rate variability and risk of end-stage renal disease among patients with Stage 3 chronic kidney disease
Robert M. Perkins1,2, H. Lester Kirchner3, James E. Hartle4 and Ion D. Bucaloiu4
1Nephrology Department, 2Bassett Research Institute, Bassett Medical Center, Cooperstown, NY, 3Division of Medicine, and 4Department of Nephrology, Geisinger Medical Center, Danville, PA, USA
Background/Aims: Dynamic changes in estimated glomerular filtration rate (eGFR) predict death among patients with chronic kidney disease (CKD). Whether variability in serial eGFR measurements is associated with risk of end stage renal disease (ESRD) has not been reported. Methods: We retrospectively analyzed the risk of ESRD as a function of eGFR variability (defined as the absolute value of the difference between the obtained clinical eGFR value at a given time and the eGFR value estimated by the linear regression line at the same time point) among a cohort of patients with Stage 3 CKD. The study population was comprised of adult primary care patients enrolled at Geisinger Clinic between January 1, 2004 and December 31, 2006, with Stage 3 CKD and a minimum of 4 serum creatinine results during this 3-year window, and without history of solid-organ transplant or metastatic cancer. Cohort members were followed through March 31, 2011 for ESRD (identified through linkage with the USRDS dataset of ESRD, or first outpatient eGFR < 15 ml/min/1.73 m2). A multivariate Cox proportional hazard model (adjusted for demographic factors, co-morbid conditions, medications, hospital-associated acute kidney injury, proteinuria, kidney function, and serum albumin, among other factors) was developed to test the association of eGFR variability with ESRD. Results: 4,219 patients met study criteria. Those with greater eGFR variability were more likely to have diabetes, cardiovascular disease, and better baseline kidney function than those with lesser variability. 193 (4.6%) of the overall cohort developed ESRD during a median follow-up of 3.8 years, while 596 (14.1%) died prior to study end without ESRD. Results of the multivariate-adjusted Cox proportional hazard model showed that eGFR variability is not associated with ESRD (HR 1.00 for the highest-variability quartile, relative to the lowest; 95% CI 0.66 – 1.51). Conclusion: eGFR variability does not predict ESRD among patients with Stage 3 CKD.Correspondence to:
Robert M. Perkins, MD
Bassett Research Institute and Department of Nephrology
One Atwell Drive, Cooperstown, NY 13326, USA
Email: [email protected]
Original
The association of Klotho gene polymorphism with the mortality of patients on maintenance dialysis
Gang Jee Ko, Young Mo Lee, Eun A Lee, Ji Eun Lee, So Yon Bae, Sang Won Park, Man Sik Park, Heui Jung Pyo and Young Joo Kwon
Page No. 263
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 (263-269)
The association of Klotho gene polymorphism with the mortality of patients on maintenance dialysis
Gang Jee Ko1, Young Mo Lee1, Eun A Lee1, Ji Eun Lee2, So Yon Bae3, Sang Won Park1, Man Sik Park4, Heui Jung Pyo1, Young Joo Kwon1 and W.D.P.A
1Department of Internal Medicine, Korea University College of Medicine, Seoul, 2Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, 3Institute of Kidney Disease Research,4Department of Statistics, Sungshin Woman’s University, Seoul, and Western Dialysis Physician Association of Seoul (W.D.P.A), Korea
Despite medical progress, high morbidity and mortality rates have persisted in patients with end-stage renal disease (ESRD). The role in atherosclerosis and cardiovascular disease of klotho, an aging process-related gene, has been highlighted. Genetic variation in klotho has been reported to be a risk factor for coronary artery disease and ischemic stroke. Regarding the significance of cardiovascular disease for the outcome of ESRD patients, we investigated whether genetic variation of klotho was associated with mortality in ESRD patients on hemodialysis. 478 patients on maintenance hemodialysis for more than 3 months at dialysis facilities affiliated with the Western Dialysis Physician Association were enrolled in September 2004. Patient survival was checked annually until September 2007. Genotypings of klotho in terms of G395A in the promoter region, C1818T in exon 4, and KL-VS was performed. 45 deaths (11.2%) occurred over 3 years. Mortality was higher in the GA+AA group than in the GG group (18.9% vs. 6.7%, respectively, p < 0.001). Kaplan-Meier analysis also revealed that the survival of the GA+AA group was worse than that of GG group (p = 0.002). Cox’s proportional hazards regression analysis showed that age, A allele carrier status in G395A of klotho, hemoglobin, albumin and HDL cholesterol levels were the significant factors affecting survival of hemodialysis patients. The A allele of the G395A polymorphism of klotho may be associated with the risk of mortality in Korean hemodialysis patients. Age, hemoglobin, albumin and HDLC were also significant prognostic factors for survival in the present study.Correspondence to:
Young Joo Kwon
Division of Nephrology
Department of Internal Medicine, Korea University
College of Medicine
Guro 2-dong, Guro-gu, 152-703, Seoul, Korea
Email: [email protected]
Original
Clinical outcomes and mortality in peritoneal dialysis patients: A 10-year retrospective analysis in a single center
Abdulkadir Unsal, Yener Koc, Taner Basturk, Tamer Sakaci, Elbis Ahbap, Ayse Sinangil, Sennur Kose Budak, Mustafa Sevinc, Ekrem Kara and Baris Doner
Page No. 270
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 (270-279)
Clinical outcomes and mortality in peritoneal dialysis patients: A 10-year retrospective analysis in a single center
Abdulkadir Unsal, Yener Koc, Taner Basturk, Tamer Sakaci, Elbis Ahbap, Ayse Sinangil, Sennur Kose Budak, Mustafa Sevinc, Ekrem Kara and Baris Doner
Clinic of Nephrology, Sisli etfal Research and Educational Hospital, Istanbul, Turkey
Aim: To evaluate the clinical outcome, identify predictors of patient and technique survival in our peritoneal dialysis (PD) patients in the western region of Turkey. Methods: We included all patients who initiated therapy between 2001 and 2010. Socio-demographic characteristics such as who helped to administer the PD as well as conditions under which PD was chosen by patients were investigated from patients’ files. Hemodialysis (HD) history and duration, additional systemic diseases, and end-stage renal disease etiologies of all patients were recorded. Clinical data such as blood pressure, amount of ultrafiltration, and laboratory parameters were evaluated before initiation of PD and during the last monitoring period. Infectious complications and their incidences were investigated. Patient and technique survival were investigated for every patient. Results: 322 patients started PD treatment during the study period. 23 patients were excluded. Data from the remaining 299 patients (167 female, mean follow-up time 38.5 ± 26.8 months, mean age 44.7 ± 15.9 years) were evaluated retrospectively. It was determined that 87.3% of the patients made their PD exchanges without help from anyone. 79.9% of patients chose PD as their personal preference. 48 patients had HD history before PD. Peritonitis incidences and catheter exit site/tunnel infection attacks were 27 ± 23 and 32.3 ± 24.9 patient-months, respectively. During the follow-up period, 199 patients (80 patients transferred to HD, 78 patients died and, 41 patients had transplantation) were withdrawn from PD. The most frequent causes of death were cardiovascular events and peritonitis and/or sepsis, whereas most frequent causes of transfer to HD were peritonitis and/or sepsis. Mean survival time was 49.9 ± 2.6 months. The estimation of survival rate was 85.2%, 66.5% and 45.3% at 1, 3, and 5 years, respectively. Preference for PD (RR: 4.77, p < 0.001), presence of HD history (RR: 2.08, p = 0.04), presence of diabetes mellitus (RR: 2.13, p = 0.01), low pretreatment serum albumin (RR: 0.32, p < 0.001), and low serum parathormone levels at last visit (RR: 0.99, p = 0.04) were predictors of mortality. Mean technique survival duration was 48.5 ± 2.4 months. The estimation of technique survival by Kaplan-Meier analyses was 92%, 67% and 43% at 1, 3, and 5 years, respectively. Technique survival was associated with preference for PD (RR: 0.45, p < 0.001), presence of diabetes mellitus (RR: 1.92, p = 0.003), and pretreatment serum albumin levels (RR: 0.58, p = 0.003). Conclusion: Patient survival in the presented institute is similar to that reported in Western countries. Compulsory choice of PD, presence of HD history, presence of diabetes, low pretreatment serum albuminm, and low serum parathormone levels at last visit were the strongest predictors of death. Risk factors for technique failure were compulsory choice of PD, presence of diabetes, low pretreatment serum albumin.Correspondence to:
Dr. Yener Koc Clinic of Nephrology, Sisli etfal Research and Educational Hospital, Istanbul, Turkey
Email: [email protected]
Original
Predictors of publication of randomized controlled trials in nephrology
Ranjani N. Moorthi, Anna Lam, Navdeep Tangri, Manish M. Sood, Martin Wagner and Ahsan Alam
Page No. 280
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 (280-285)
Predictors of publication of randomized controlled trials in nephrology
Ranjani N. Moorthi1, Anna Lam2, Navdeep Tangri2, Manish M. Sood2, Martin Wagner3,4 and Ahsan Alam5
1Department of Medicine, Indiana University, School of Medicine, Indianapolis, IN, USA, 2Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada, 3Department of Medicine, University Hospital of Würzburg, 4Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany, and 5Department of Medicine, McGill University, Montreal, Quebec, Canada
Background and aims: Changes in clinical practice based on research findings are dependent on the dissemination of information, which is a goal at national meetings. Given that evidence for many interventions in nephrology is lacking, it is important to determine predictors of publication of randomized controlled trials (RCTs) presented as abstracts at national conferences. Materials and methods: All abstracts submitted to the American Society of Nephrology (ASN) meeting 2005 were reviewed to identify completed RCTs. Univariate logistic regression was used to compare characteristics between published RCTs until June 2010 and those not published. Time to publication was calculated. Results: 73 completed RCTs were presented out of 4,280 abstracts. 53% of these were published; median time to publication was 24 months (13.36 IQR). Oral presentations were published more frequently (OR 3.66, p = 0.01) as well as those with stated industry funding (OR 2.92, p = 0.03) and larger sample sizes (OR 2.1, p = 0.01). Blinded RCTs had ~ 4 times the odds of being published. Only ten RCTs used clinical endpoints such as death, hospitalizations etc.; however, all reached publication. Conclusions: Almost 50% of RCTs presented at the ASN 2005 meeting were not published within the studied time-frame. Well-conducted RCTs enhance the body of evidence needed to care for patients, if published. It is important to identify characteristics associated with non-publication, as above, to help us perform and report our studies better.Correspondence to:
Navdeep Tangri, MD, PhD, FRCPC
Department of Medicine and Department of Community Health Service
University of Manitoba 2PD-13
2300 McPhillips Street, Winnipeg MB R2V3M3, Canada
Email: [email protected]
Nephrology Education
Mild proteinuria in a patient with glomerularlimited intravascular large B-cell lymphoma
Jili Zhu, Honglei Chen, Guohua Ding and Cheng Chen
Page No. 286
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 (286-292)
Mild proteinuria in a patient with glomerularlimited intravascular large B-cell lymphoma
Jili Zhu1, Honglei Chen2, Guohua Ding1 and Cheng Chen1
1Department of Nephrology, Renmin Hospital of Wuhan University, and 2Department of Pathology, School of Basic Medical Science, Wuhan University, Wuhan, China
Intravascular large B-cell lymphoma (IVLBCL) is a rare type of non- Hodgkin lymphoma characterized by a disseminated intravascular proliferation of tumor cells in the lumina of small vessels. Although the kidney is one of the target organs of IVLBCL, lymphoma cells that localize only in glomeruli are extremely rare. We report a 55-year-old Chinese patient diagnosed as glomerular-limited IVLBCL by percutaneous renal biopsy. The patient was referred to our institution for further examination of mild proteinuria and anemia without lymphoma symptoms. He had daily urinary excretion of 0.65 g proteins with normal renal function. Percutaneous renal biopsy showed that lymphoid cell accumulation was encircled within the glomerular capillary lumina only in certain glomeruli, resulting in marked obstruction of capillary structure. However, almost all of the peritubular capillary and tubulointerstitium were intact. Immunohistochemical analysis confirmed the diagnosis of intravascular large B-cell lymphoma. Extensive systemic examinations showed no other organ involvement. With these characteristic changes, glomerularlimited IVLBCL were considered as an exceptional renal manifestation of intravascular lymphoma diagnosised by percutaneous renal biopsy.Correspondence to:
Dr. Jili Zhu
Department of Nephrology
Renmin Hospital of Wuhan University
238 Jiefang Road, Wuhan 430060, Hubei Province, China
Email: [email protected]
Nephrology Education
Differentiating scleroderma renal crisis from other causes of thrombotic microangiopathy in a postpartum patient
Muaz Abudiab, Megan L. Krause, Mary E. Fidler, Karl A. Nath and Suzanne M. Norby
Page No. 293
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 (293-297)
Differentiating scleroderma renal crisis from other causes of thrombotic microangiopathy in a postpartum patient
Muaz Abudiab1, Megan L. Krause1, Mary E. Fidler2, Karl A. Nath3 and Suzanne M. Norby3
1Department of Internal Medicine, 2Department of Laboratory Medicine and Pathology, and 3Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
Thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS), and scleroderma renal crisis (SRC) all present with features of thrombotic microangiopathy. Distinguishing among these entities is critical, however, as treatments differ and may be mutually exclusive. We describe the case of a 25-year-old woman with an undefined mixed connective tissue disease who presented 6 weeks post-partum with fever, transient aphasia, thrombocytopenia, hemolytic anemia, and acute kidney injury eventually requiring initiation of hemodialysis. Renal biopsy revealed thrombotic microangiopathy. Renal function did not improve despite immediate initiation of plasma exchange, and an angiotensin-converting enzyme (ACE) inhibitor was initiated following discontinuation of plasma exchange. At last follow up, she remained dialysis dependent. Due to the myriad causes of thrombotic microangiopathy and potential for diagnostic uncertainty, the patient’s response to therapy should be closely monitored and used to guide modification of therapy.Correspondence to:
Muaz M. Abudiab, MD
Mayo Clinic
200 First Street SW, Rochester, MN 55905, USA
Email: [email protected]
Nephrology Education
Acute interstitial nephritis following kudzu root juice ingestion
Jae Myun Jung, Soon Hyo Kwon1, Hyunjin Noh, Dong Cheol Han, Jin Seok Jeon and So Young Jin
Page No. 298
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 (298-300)
Acute interstitial nephritis following kudzu root juice ingestion
Jae Myun Jung1, Soon Hyo Kwon1, Hyunjin Noh1, Dong Cheol Han1, Jin Seok Jeon1 and So Young Jin2
1Department of Internal Medicine, and 2Department of Pathology, Soon Chun Hyang University Hospital, Seoul, Korea
Recently, the use of herbal remedies and complementary and alternative medicine has increased globally. Kudzu root (Pueraria lobata) is a plant commonly used in traditional medicine to promote health. A middle-aged woman consumed kudzu root juice to promote health and well-being for 10 days. Subsequently, she developed anorexia, epigastric discomfort and azotemia. These symptoms improved rapidly within several days after discontinuation of the suspected offending agent and conservative treatment. Acute interstitial nephritis was diagnosed by renal biopsy. To our knowledge, this is the first case report describing acute interstitial nephritis following the ingestion of kudzu root juice.Correspondence to:
Jin Seok Jeon, MD
Department of Internal Medicine
Division of Nephrology
Soon Chun Hyang University Hospital
59 Daesagwan-ro, Yongsan-gu, Seoul, 140-887, Korea
Email: [email protected]
Nephrology Education
Acute calciphylaxis precipitated by the initiation of hemodialysis
Gagangeet Sandhu, Pablo Casares, Aditi Ranade, James Jones, Levy I.S. Amar, Daniela Guisado, Germaine Chan and Steven D. Smith
Page No. 301
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 (301-305)
Acute calciphylaxis precipitated by the initiation of hemodialysis
Gagangeet Sandhu1, Pablo Casares1, Aditi Ranade2, James Jones1, Levy I.S. Amar3, Daniela Guisado3, Germaine Chan1 and Steven D. Smith1
1Division of Nephrology, Department of Medicine, 2Department of Pathology, St. Luke’s – Roosevelt Hospital Center, Columbia University College of Physicians & Surgeons, New York, 3Department of Biomedical Engineering, Columbia University New York, NY, USA
Calciphylaxis, or calcific uremic arteriopathy (CUA), is characterized by metastatic calcification in the media of small arteries and arterioles leading to cutaneous necrosis. It is most commonly seen in patients with end stage renal disease who have elevated serum calcium × phosphorus (Ca × P) product. Normalization of Ca × P product is considered paramount in the prevention and treatment of CUA. We describe a novel presentation of CUA in which a Stage-5 CKD patient developed signs and symptoms of CUA immediately after initiation of hemodialysis (HD). We postulate that an influx of calcium from the dialysate into the patient’s blood, in addition to correction of her acidosis, led to abundant substrate in a favorable milieu for Ca-P complex formation at the time of her first HD session. Our case is the first reported case of HD associated iatrogenic acute CUA. To avoid this complication, we should maintain adequate hydration,use lower calcium dialysate, and avoid vitamin D analogues and calcium-containing medications when initiating HD in patients with high Ca-P product. Since sodium thiosulfate is known to prevent precipitation of Ca-P complexes, its empiric use during initial HD treatments may be effective in preventing CUA, a potentially fatal disease.Correspondence to:
Gagangeet Sandhu, MD
St. Luke’s-Roosevelt Hospital Center
Division of Nephrology
1111 Amsterdam Avenue
New York, NY 10025, USA
Email: [email protected]
Nephrology Education
A case of chronic antibody-mediated rejection in the making
Vasiliki Bravou, Jack Galliford, Adam McLean, Michelle Willicombe, David Taube, Herbert T. Cook and Candice Roufosse
Page No. 306
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 (306-310)
A case of chronic antibody-mediated rejection in the making
Vasiliki Bravou1, Jack Galliford2, Adam McLean2, Michelle Willicombe2, David Taube2, Herbert T. Cook3 and Candice Roufosse3
1Department of Anatomy, School of Medicine, University of Patras, Patras, Greece, 2Imperial College Renal and Transplant Centre, and 3Department of Histopathology, Hammersmith Hospital, Imperial College, Healthcare NHS Trust, London, UK
A kidney transplant recipient developed chronic antibody-mediated rejection (ABMR) with clinically significant transplant glomerulopathy while under careful clinical monitoring. The patient developed a de novo donor-specific antibody (DSA) posttransplantation, and a protocol renal biopsy showed C4d deposition with no histological evidence of rejection. Subsequently he developed peritubular capillary basement membrane multilayering, with negative C4d and DSA. Finally, he developed proteinuria and transplant glomerulopathy, with reappearance of DSA and C4d. Despite having a de novo antibody and progressive antibody-mediated damage, this patient under close histological and serological surveillance did not fulfill Banff criteria for acute or chronic ABMR until his disease was advanced. This case illustrates the limitations of current Banff criteria in this setting, due to the fluctuating nature of DSA and C4d staining.Correspondence to:
Dr. Candice Roufosse
Consultant Histopathologist
Hammersmith Hospital, Dept Histopathology, G Block 1st Floor
DuCane Rd, W12 0HS, London, UK
Email: [email protected]
Letter to the Editor
Pericytes and renal microvascular disease induce renal fibrosis in CKD
Narisa Futrakul, Tawatchai Deekajorndech and Prasit Futrakul
Page No. 310
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 – Letters to the editor
Pericytes and renal microvascular disease induce renal fibrosis in CKD
Narisa Futrakul1, Tawatchai Deekajorndech1 and Prasit Futrakul2
1Renal Microvascular Research Group, King Chulalongkorn Memorial Hospital, Chulalongkorn University and 2Academy of Science, The Royal Institute of Thailand, and Bhumirajanagarindra Kidney Institute, Bangkok, Thailand
Correspondence to:
Narisa Futrakul
Renal Microvascular Research Group
1873 King Chulalongkorn Memorial Hospital
Chulalongkorn University, 10330 Bangkok, Thailand
Email: [email protected]
Letter to the Editor
Methylenetetrahydrofolate reductase gene polymorphisms in patients with nephrotic syndrome
Cengiz Beyan
Page No. 311
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 – Letters to the editor
Methylenetetrahydrofolate reductase gene polymorphisms in patients with nephrotic syndrome
Cengiz Beyan
Department of Hematology, Gulhane Military Medical Academy, Etlik, Ankara, Turkey
Correspondence to:
Prof. Cengiz Beyan, MD
Gulhane Military Medical Academy
Department of Hematology, Etlik
06018 Ankara, Turkey
Email: [email protected]; [email protected]
Letter to the Editor
A practical thrice weekly Ertapenem dosage regime for chronic hemodialysis patients?
Charles J.C. Geerlings, Peter de Man, Arie P. Rietveld, Daniel J. Touw and Jan W. Cohen Tervaert
Page No. 312
Abstract
Clinical Nephrology, Vol. 80 – No. 4/2013 – Letters to the editor
A practical thrice weekly Ertapenem dosage regime for chronic hemodialysis patients?
Charles J.C. Geerlings1, Peter de Man1, Arie P. Rietveld1, Daniel J. Touw2 and Jan W. Cohen Tervaert1
1Sint Franciscus Gasthuis, Rotterdam, and 2Apotheek Haagsche Ziekenhuizen, Den Haag, The Netherlands
Correspondence to:
Charles J.C. Geerlings, PharmD
Kleiweg 500, 3045 PM Rotterdam, The Netherlands
Email: [email protected]
