Volume 90 (2018), No. 2/2018(August)
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Original
Variability of serum phosphorus and its association with mortality among hemodialysis patients
Minxia Zhu, Linbin Dou, Mingli Zhu, Shang Liu, Yaping Zhan, Jiayue Lu, Zhaohui Ni, Jiaqi Qian, Hong Cai, and Weiming Zhang
Page No. 79
Abstract
Clinical Nephrology, Vol. 90 – No. 2/2018 (79-86)
Variability of serum phosphorus and its association with mortality among hemodialysis patients
Minxia Zhu1#2, Linbin Dou1#2, Mingli Zhu2, Shang Liu1#2, Yaping Zhan1#2, Jiayue Lu1#2, Zhaohui Ni2, Jiaqi Qian2, Hong Cai1,2, and Weiming Zhang1#2
1Department of Nephrology, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, China, and 2Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
Objective: To determine the relationship between the variability of serum phosphorus and mortality among maintenance hemodialysis (MHD) patients. Materials and methods: A total of 502 MHD cases were studied from the Shanghai Renal Registry Network. Serum phosphorus variability was indicated by a coefficient of variation (CV). According to the CV median of serum phosphorus, patients were divided into two groups: a high-variability group (CV ≥ 0.226 mmol/L) and a low-variability group (CV < 0.226 mmol/L). Average phosphorus ≤ 1.78 mmol/L was defined as the standard phosphorus group and serum phosphorus > 1.78 mmol/L was defined as the non-standard phosphorus group. The relationship between serum phosphorus variability and all-cause and cardiovascular disease (CVD) mortality was assessed. Results: In the 502 MHD cases, the average age of patients was 63.9 ± 14.60 years, and dialysis vintage was 82.0 (43.0 – 139.0) months. 118 patients (23.5%) died, succumbing to all-cause mortality, while 64 patients (14.3%) died from CVD. The high-variability group had increased all-cause mortality (27.7% vs. 19.3%, p = 0.028). Death from CVD was increased in the high-variability group, but had no statistical significance (15.4% vs. 10.0%, p = 0.082). Cox regression analysis showed that older age, low hemoglobin levels, a higher phosphorus CV, and low serum albumin were independent risk factors for all-cause and CVD mortality. The standard group with low-phosphorus variability had a decreased mortality compared with the non-standard group with high variability (15.3 vs. 29.2%, p = 0.047 and 6.0 vs. 15.0%, p = 0.033, respectively). The Kaplan-Meier method revealed that patients with low phosphorus variability had a decreased all-cause and CVD mortality (p = 0.023 and p = 0.047, respectively) compared with high phosphorus variability patients. Conclusion: Higher phosphorus CV was independently correlated with all-cause and CVD mortality. Low phosphorus variability with on-target levels resulted in decreased patient mortality. Thus, stable serum phosphorus levels may improve survival in MHD patients.
Correspondence to:
Weiming Zhang, MD
Department of Nephrology, Renji Hospital
Jiaotong University School of Medicine
Shanghai, China
or
Hong Cai, MD
Department of Nephrology, Renji Hospital,
Jiao Tong University, School of Medicine
Shanghai, China
Email: Weimingzh1965@
163.com
or [email protected]
Original
Outcomes of transcatheter aortic valve implantation compared with surgical aortic valve replacement in geriatric patients with chronic kidney disease
Linda Shavit, Shuli Silberman, Rachel Tauber, Ofer Merin, Daniel Bitran, and Daniel Fink
Page No. 87
Abstract
Clinical Nephrology, Vol. 90 – No. 2/2018 (87-93)
Outcomes of transcatheter aortic valve implantation compared with surgical aortic valve replacement in geriatric patients with chronic kidney disease
Linda Shavit1*, Shuli Silberman2*, Rachel Tauber2, Ofer Merin2, Daniel Bitran2, and Daniel Fink2
1Adult Nephrology Unit and 2Department of Cardiac Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
Background: Transcatheter aortic valve implantation (TAVI) is a less invasive treatment modality for patients with severe aortic valve stenosis (AS) who are at a higher risk if they have surgery. Preoperative chronic kidney disease (CKD) influences outcomes of cardiac surgery and is associated with a higher mortality and more complicated hospital course. The aims of our study were to evaluate the comparative outcomes of TAVI versus surgical aortic valve replacement (SAVR) in geriatric patients with preoperative CKD. Materials and methods: We prospectively collected data on patients > 75 years of age who underwent either SAVR or TAVI at Shaare Zedek Medical Center, Jerusalem, Israel. The outcomes studied were postoperative acute kidney injury (AKI), in-hospital and long-term mortality, and major neurologic and infectious morbidity. Results: A total of 318 patients were analyzed, of those, 199 and 119 underwent SAVR and TAVI, respectively. In patients with CKD, there was no statistically significant difference in postoperative AKI. SAVR patients had significantly higher in-hospital mortality (OR 5.9; 95% CI 1.6 – 29.6, p = 0.02), postoperative infection (OR 4.2; 95% CI 1.6 – 12.4, p = 0.005), and longer duration of hospital stay. Mortality at 1 and 2 years was lower in the SAVR group, although the difference was not statistically significant (p = 0.059). Conclusion: For elderly patients with CKD who are at a higher risk if they have surgery. TAVI offers a good alternative with lower procedural risk.
*Dr. Shavit and Dr. Silberman contributed equally to this manuscript.Correspondence to:
Linda Shavit, MD
Adult Nephrology Unit
Shaare Zedek Medical Center
PO Box 3235, Jerusalem 91031, Israel
Email:
[email protected]
Original
Patient-reported outcomes (PROs) argue against the limited use of peritoneal dialysis in end-stage renal disease
Carola W.H. de Fijter, Anouk T.N. van Diepen, Fariba Amiri, Friedo W. Dekker, and Ray T. Krediet
Page No. 94
Abstract
Patient-reported outcomes (PROs) argue against the limited use of peritoneal dialysis in end-stage renal disease
Carola W.H. de Fijter1, Anouk T.N. van Diepen2, Fariba Amiri1, Friedo W. Dekker3, and Ray T. Krediet2
1Department of Internal Medicine Onze Lieve Vrouwe Gasthuis, 2Department of Nephrology Academic Medical Center University of Amsterdam, Amsterdam, and 3Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
Aim: Approximately 40% of dialysis patients are durably treated with peritoneal dialysis (PD) in our teaching hospital. Patients’ perspectives were studied by patient-reported outcome measurements (PROMs) to find possible explanations for why the generally-reported decline in the use of PD hardly occurred in our facility. Materials and methods: All 75 prevalent adult dialysis patients hemodialysis (HD) duration 27, PD 16 months) were included. All had received predialysis care and education for > 6 month. Cross-sectional sociodemographic and clinical data, SF-36, KDQOL-SF, and predialysis anxiety/depression scores were collected in February 2016. Differences in PROMs between PD and HD patients were analyzed. Results: Despite more comorbidity in the PD population, generally-used dialysis parameters were adequate and similar between HD (n = 42) and PD (n = 33) patients as was annual mortality. Many factors associated with a predialysis modality choice for PD were absent. A higher anxiety/depression score was found in pre-HD compared to pre-PD patients. PROMs were returned by 97%. PD patients performed better on a number of PROMs than their HD counterparts. Conclusion: This single-center cross-section with a modest number of patients but an almost 100% patient response shows that having 40% of patients on PD is possible with excellent results in terms of patient-reported outcomes. A structured patient education with attention to personal needs of patients, an adequate infrastructure for PD, and a dedicated team with ongoing patient support are key factors. Sharing best practices may help to slow down or even reverse the decline of PD, which is a pity both for patients and society.
Correspondence to:
Carola W.H. de Fijter, MD, PhD
Department of Internal Medicine OLVG
Oosterpark 9, 1091 AC Amsterdam,
The Netherlands
Email: [email protected]
Original
Changing incidence of factitious renal stone disease
Fady Ghali, Lawrence M. Dagrosa, Rachel A. Moses, Michal Ursiny, Brian H. Eisner, and Vernon M. Pais Jr.
Page No. 102
Abstract
Changing incidence of factitious renal stone disease
Fady Ghali1, Lawrence M. Dagrosa2, Rachel A. Moses2, Michal Ursiny3, Brian H. Eisner3, and Vernon M. Pais Jr.2
1Geisel School of Medicine, Dartmouth. Hanover, 2Section of Urology, Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, and 3Department of Urology, Massachusetts General Hospital, Boston, MA, USA
Purpose: We sought to describe patterns of factitious urinary stone submission over time by investigating a contemporary stone analysis database and comparing two distinct time points. Materials and methods: We retrospectively reviewed a single stone analysis lab database at two time points, 1990 and 2010, and compared total incidence of factitious stone submission, as well as gender patterns and type of factitious stone submitted. Results: A total of 27,014 stones were analyzed, 16,216 (60%) from 1990 and 10,798 (40%) from 2010 with a decrease in total incidence from 2.6% (428/16,216) in 1990 to 1.2% (131/10,798) in 2010 (p < 0.001). In 1990, women were significantly more likely to submit a factitious stone (RR 1.5, 95% CI 1.4 – 1.7, p < 0.001), while in 2010 there was no gender difference (RR 0.9, 95% CI 0.8 – 1.03, p < 0.05). Plant material and geologic material represented the most common factitious stone types respectively, in both 1990 and 2010. Conclusion: In the largest contemporary review of spurious urinary stones, we find a decreased incidence and increased gender equivalence of factitious urinary stones in 2010 compared to 1990.
Correspondence to:
Fady Ghali, MD
4520 Executive Dr #111, San Diego, CA 92121, USA
Email: [email protected]
Original
The impact of residual renal function on quality of life in patients with peritoneal dialysis
Wei Zhou, Weifeng Hu, Guofeng Han, Huiling Wang, Jinyuan Zhang, and Changlin Mei
Page No. 106
Abstract
Clinical Nephrology, Vol. 90 – No. 2/2018 (106-111)
The impact of residual renal function on quality of life in patients with peritoneal dialysis
Wei Zhou1#2, Weifeng Hu2, Guofeng Han2, Huiling Wang2, Jinyuan Zhang2, and Changlin Mei1
1Department of Nephrology, Changzheng Hospital, Second Military Medical University, and 2Division of Nephrology, Jimin Hospital, Shanghai, China
Background: Residual renal function (RRF) is a crucial factor that plays an important role in peritoneal dialysis (PD) patients, but whether RRF influences the quality of life (QOL) of PD patients is still controversial. The aims of this study were to explore the effects of RRF on QOL in patients with continuous ambulatory peritoneal dialysis (CAPD) and analyze the related factors that might affect patients’ QOL. Materials and methods: All 120 adult patients in this study received regular CAPD treatment for at least 3 months. Patients were divided into two groups: an RRF group (residual glomerular filtration (rGFR) ≥ 1 mL×min–1×(1.73m2)–1) and a non-RRF group (rGFR < 1 mL×min–1×(1.73m2)–1). The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) was used as a reference to calculate the scores of CAPD patients for assessing their QOL. Multiple- and single-linear regression analysis was performed to analyze correlation degree of several SF-36-related indexes. Results: The indexes of age, gender, cause of disease, complication, body mass index (BMI), systolic and diastolic blood pressure (SBP and DBP), hemoglobin (HB), cholesterol, triglycerides, high- and low-density lipoprotein, normalized protein catabolic rate (nPCR), and cardiothoracic ratio (CTR) showed no difference between the two groups (RRF and non-RRF). Comparing with RRF group, the patients without RRF showed a significant difference on indexes of PD duration, urine volume, ultrafiltration volume, dialysis dose, serum albumin, potassium, Kt/V (urea reduction ratio), creatinine, calcium, phosphate, C-reactive protein (CRP), and parathyroid hormone (PTH). Single-linear regression analysis that achieved total score of SF-36 showed no correlation with rGFR, but there was a correlation of SF-36 score with CRP, creatinine, CTR, albumin, and ultrafiltration volume. Conclusion: These results suggested that there was no correlation between RRF and QOL in CAPD patients, but chronic inflammation, fluid overload, and malnutrition were considered as the main factors that affect patients’ QOL.
Correspondence to:
Prof. Changlin Mei, Master
Department of Nephrology
Changzheng Hospital Second Military Medical University
415 Fengyang Road, Shanghai 200003, China
Email: [email protected]
Original
Incidence and timing of inadvertent nephrostomy catheter displacement in patients with ureteral obstruction
Naoya Niwa, Kazuhiro Matsumoto, Eiji Kikuchi, Satoshi Yazawa, Toshikazu Takeda, Shinya Morita, Takeo Kosaka, Kazunobu Shinoda, Ryuichi Mizuno, Toshiaki Shinojima, Hiroshi Asanuma, and Mototsugu Oya
Page No. 112
Abstract
Clinical Nephrology, Vol. 90 – No. 2/2018 (112-116)
Incidence and timing of inadvertent nephrostomy catheter displacement in patients with ureteral obstruction
Naoya Niwa, Kazuhiro Matsumoto, Eiji Kikuchi, Satoshi Yazawa, Toshikazu Takeda, Shinya Morita, Takeo Kosaka, Kazunobu Shinoda, Ryuichi Mizuno, Toshiaki Shinojima, Hiroshi Asanuma, and Mototsugu Oya
Keio University School of Medicine, Department of Urology, Shinjuku-ku, Tokyo, Japan
Introduction: To evaluate nephrostomy catheter displacement, we assessed the cumulative nephrostomy catheter displacement rate in patients with percutaneous nephrostomy and compared the nephrostomy displacement rates between pigtail and balloon catheters. Materials and methods: Between 2003 and 2011, 87 patients who underwent percutaneous nephrostomy catheter placement and more than one subsequent catheter replacement were retrospectively identified. We evaluated their inadvertent nephrostomy catheter displacement. Results: 20 patients (23.0%) experienced incidental nephrostomy catheter displacement during the follow-up period. Kaplan-Meier analysis revealed that the 1-year nephrostomy catheter displacement-free survival rate was 62 ± 9%. No significant independent risk factors for predicting nephrostomy catheter displacement were identified, including the type of catheter. The median time from initial placement to displacement of pigtail catheters was shorter than that of balloon catheters. Conclusion: There were no significant differences in the nephrostomy catheter displacement-free survival rates between the two types of catheters. Regardless of the type of catheter, our results indicated that careful handling and guiding during catheter placement are important for all patients because of the high risk of inadvertent events.
Correspondence to:
Kazuhiro Matsumoto, MD
Keio University School of Medicine
Department of Urology
Shinanomachi 35, Shinjuku-ku, Tokyo 160-8582, Japan
Email: [email protected]
Original
Gram-negative bloodstream infections in hemodialysis patients: A retrospective study
Orit Shimon, Hefziba Green, Noa Eliakim-Raz, Benaya Rozen-Zvi, Haim Ben-Zvi, Iris Zohar, Jihad Bishara, and Dafna Yahav
Page No. 117
Abstract
Clinical Nephrology, Vol. 90 – No. 2/2018 (117-124)
Gram-negative bloodstream infections in hemodialysis patients: A retrospective study
Orit Shimon1*, Hefziba Green2#3*, Noa Eliakim-Raz2#4, Benaya Rozen-Zvi2#3, Haim Ben-Zvi3#5, Iris Zohar6, Jihad Bishara2#4, and Dafna Yahav2#4
1Medicine E, 2Department of Nephrology and Hypertension, Rabin Medical Center, Beilinson Hospital, Petah Tikva, 3Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, 4Infectious Diseases Unit, 5Laboratory of Clinical Microbiology, and 6Medicine B, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
Background: Bloodstream infections (BSIs) are an important cause of hospitalizations and mortality among hemodialysis (HD) patients. Epidemiology of these infections is changing, with increasing rates of Gram-negative pathogens, including resistant ones. Few studies have focused on the characteristics and outcomes of these infections. Objective: We aimed to document the causative pathogens of BSIs in HD patients and their clinical outcomes during 2008 – 2015, and to compare risk factors, clinical features, appropriateness of therapy, and outcomes between patients with Gram-negative vs. Gram-positive BSIs. Materials and methods: A single-center retrospective cohort study. Charts of 120 HD patients hospitalized with first BSI were reviewed. Results: A total of 120 patients were included, 61 episodes of Gram-negative (51.8%) and 59 episodes of Gram-positive bacteria (49.2%). Source of infection was significantly more likely to be urinary or abdominal among patients with Gram-negative infection. Otherwise, no statistically significant differences were documented between groups in terms of baseline characteristics, presentation of infection and outcomes. Most Gram-negative BSIs were caused by enterobacteriaceae, followed by <i>Pseudomonas</i> spp. Previous clinical or surveillance cultures added little to accurate prediction of the causative organism. Conclusion: In a cohort of HD patients with BSI, no significant differences were found between Gram-negative and Gram-positive BSIs, besides source of infection. A urinary or abdominal source strongly suggests a Gram-negative pathogen. Otherwise, patient’s characteristics, clinical presentation, and previous cultures, all cannot accurately predict the causative pathogen of BSI, and broad-spectrum antibiotics should be used empirically.
*OS and HG contributed equally to this article.Correspondence to:
Dafna Yahav, MD,
Infectious Diseases Unit, Rabin Medical Center
Beilinson Hospital
39 Jabotinsky Road, Petah-Tikva 49100, Israel
Email: [email protected]
NephroPharmacology
Chemotherapeutic agents eligible for prior dosing in pancreatic cancer patients requiring hemodialysis: a systematic review
Alexander Hann, Evelyn Nosalski, Patrick C. Hermann, Jan Egger, Thomas Seufferlein, and Frieder Keller
Page No. 125
Abstract
Clinical Nephrology, Vol. 90 – No. 2/2018 (125-141)
Chemotherapeutic agents eligible for prior dosing in pancreatic cancer patients requiring hemodialysis: a systematic review
Alexander Hann1, Evelyn Nosalski1, Patrick C. Hermann1, Jan Egger2#3, Thomas Seufferlein1, and Frieder Keller1
1Department of Internal Medicine I, Ulm University, Ulm, Germany,
2Institute for Computer Graphics and Vision, Graz University of Technology, and 3Computer Algorithms for Medicine Laboratory, Graz, Austria
Aims: New chemotherapeutic agents prolong survival of patients with pancreatic ductal adenocarcinoma (PDAC). Although their incidence is rising, patients with end-stage renal disease (ESRD) requiring hemodialysis (HD) are not included in the phase III trials evaluating the effects of these chemotherapies. Many experts recommend applying chemotherapy after HD using a reduced dose. Alternatively, the concept of prior dosing allows for the application of dialyzable chemotherapeutic drugs using a normal dose, with an HD followed shortly after to mimic normal renal function. In this work, we provide guidance for clinicians on how to use chemotherapy in patients with PDAC on HD and how to identify substances suitable for prior dosing. Materials and methods: We systematically searched PubMed, from inception to September 2016, for published studies describing patients with ESRD on HD who received chemotherapies commonly applied in PDAC, including gemcitabine, fluorouracil (5-FU), capecitabine, oxaliplatin, irinotecan, docetaxel, erlotinib, sunitinib, S-1, and afatinib. Applied dosages, described toxicities, application time relative to HD, and pharmacokinetic measurements of the drug and its metabolites were assessed. Quantitative analysis of the drug plasma concentrations, including half-life during and in between HD and fraction of the drug eliminated during HD, were assessed. Results: We identified 56 studies describing 128 patients with ESRD undergoing HD during chemotherapeutic treatment. Quantitative pharmacokinetic analysis revealed that the following substances are dialyzable and thus suitable for application using the prior-dosing method: gemcitabine, 5-FU, oxaliplatin, irinotecan, and S-1. Conclusion: This work supports the application of dialyzable chemotherapeutic agents in patients with PDAC in standard dose when HD is performed shortly after the infusion.
Correspondence to:
Dr. Alexander Hann, MD
Department of Internal Medicine I
Ulm University
Albert-Einstein-Allee 23,
89081 Ulm, Germany
Email: [email protected]
Nephrology Education
A case of infection-related glomerulonephritis with massive eosinophilic infiltration
Masahiro Okabe, Tsuyoshi Takamura, Akiko Tajiri, Nobuo Tsuboi, Masahiro Ishikawa, Makoto Ogura, Ryuji Ohashi, Takashi Oda, and Takashi Yokoo
Page No. 142
Abstract
Clinical Nephrology, Vol. 90 – No. 2/2018 (142-147)
A case of infection-related glomerulonephritis with massive eosinophilic infiltration
Masahiro Okabe1, Tsuyoshi Takamura1, Akiko Tajiri1, Nobuo Tsuboi1, Masahiro Ishikawa2, Makoto Ogura1, Ryuji Ohashi3, Takashi Oda4, and Takashi Yokoo1
1Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, 2Department of Nephrology, Kawaguchi Municipal Medical Center, Kawaguchi, 3Department of Diagnostic Pathology, Nippon Medical School Hospital, Tokyo, and 4Department of Nephrology, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
Infection-related glomerulonephritis (IRGN) is rarely complicated with eosinophil infiltration into the glomerulus. Here we report a case of eosinophilic proliferative glomerulonephritis related with infection. A 70-year-old man with respiratory symptoms displayed hypereosinophilia, hypocomplementemia, impaired renal function, and nephrotic syndrome. Renal biopsy revealed endocapillary proliferative glomerulonephritis with immunostaining for immunoglobulin G and complement 3, and subepithelial hump-like electron-dense deposits, thus fulfilling the criteria for IRGN. Immunostaining for the nephritis-associated plasmin receptor (NAPlr) in the glomerulus confirmed the diagnosis of IRGN. Of note, eosinophils infiltrated into the glomerular subendothelial spaces, renal tubules, peritubular capillaries, and the interstitium in the kidney as well as in the alveolar walls and pulmonary arteries in the lung. Corticosteroid therapy rapidly improved hypereosinophilia as well as respiratory symptoms and renal function. Urinary protein exertion was decreased, and serum level of complement and albumin was increased. These findings suggest that eosinophil infiltration might play a prominent role in respiratory and renal disorders. Severe endothelial damage of glomeruli and tubulointerstitial nephritis, caused by eosinophil-rich inflammation, might significantly contribute to exacerbation of renal insufficiency.
Correspondence to:
Masahiro Okabe, MD, PhD,
Division of Nephrology and Hypertension
Department of Internal Medicine
Jikei University School of Medicine
3-25-8 Nishi-Shimbashi,
Minato-ku, Tokyo 105-8461, Japan
Email: [email protected]
Nephrology Education
Extensive brain infarction and acute kidney injury in a young adult with methanol intoxication: A case report and review of the literature
George Vasquez-Rios, Hani Alkhankan, Boutros Peter Sawaya, and Javier A. Neyra
Page No. 148
Abstract
Clinical Nephrology, Vol. 90 – No. 2/2018 (148-154)
Extensive brain infarction and acute kidney injury in a young adult with methanol intoxication: A case report and review of the literature
George Vasquez-Rios1#2, Hani Alkhankan1, Boutros Peter Sawaya1, and Javier A. Neyra1
1Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky College of Medicine, Lexington, KY, and 2Department of Internal Medicine, School of Medicine, Saint Louis University, Saint Louis, MO, USA
Introduction: Methanol intoxication is an infrequent cause of poisoning in the United Sates. It can present with prominent stroke-like features and acute kidney injury. Despite the life-threatening nature of this condition, it is poorly identified by clinicians. We aim to present a case of rapidly progressive mental decline and renal involvement, discuss a diagnostic work-up and provide a critical review on therapeutic strategies. Case presentation: A 24-year-old patient presented to the emergency department with acute encephalopathy and diffuse muscular rigidity. His studies were relevant for severe anion gap metabolic acidosis, extensive brain infarction, and acute kidney injury. After excluding infections, drug intoxication, and environmental exposure, his serum methanol levels were found to be high. The patient was effectively treated with renal replacement therapy and survived with residual neurological sequelae. Conclusions: Methanol intoxication should be in the differential diagnosis of patients with brain infarction and high anion gap metabolic acidosis. Early use of renal replacement therapy may be life-saving and should be tailored on an individual basis.
Correspondence to:
George Vasquez-Rios, MD
Department of Internal Medicine
Saint Louis University School of Medicine
Internal Medicine Residency Training Program
3635 Vista Ave. 14 Floor, Desloge Towers
St. Louis, MO 63110-0250, USA
Email: [email protected]
Neph
Education
Nephritis-associated plasmin receptor (NAPlr) positive glomerulonephritis caused by Aggregatibacter actinomycetemcomitans bacteremia: A case report
Yohei Komaru, Kunihiro Ishioka, Takashi Oda, Takayasu Ohtake, and Shuzo Kobayashi
Page No. 155
Abstract
Clinical Nephrology, Vol. 90 – No. 2/2018 (155-160)
Nephritis-associated plasmin receptor (NAPlr) positive glomerulonephritis caused by Aggregatibacter actinomycetemcomitans bacteremia: A case report
Yohei Komaru1, Kunihiro Ishioka1, Takashi Oda2, Takayasu Ohtake1, and Shuzo Kobayashi1
1Department of Nephrology, Immunology, and Vascular Medicine, Shonan Kamakura General Hospital, Kanagawa, and 2Department of Nephrology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
Infection-related glomerulonephritis (IRGN) develops after various infections. It was previously thought to be caused by Streptococcus species alone but can also be caused by other pathogens. Nephritis-associated plasmin receptor (NAPlr) was discovered as a candidate nephritis-inducing factor in acute post-streptococcal glomerulonephritis. More recently, renal lesions caused by other pathogens were found to be positive for the same molecular marker. We report the case of a 64-year-old man who experienced repeated fever for several months and presented with progressively-deteriorating renal function. He had previously undergone aortic valve replacement. Aggregatibacter actinomycetemcomitans, a component of the oral flora, was detected in a blood culture. Renal biopsy showed diffuse proliferative glomerulonephritis. Immunofluorescence staining of the kidney specimen was positive for immunoglobulins, complements, and NAPlr. The patient was diagnosed with infectious endocarditis and IRGN. Six weeks of intravenous antibiotic therapy improved the patient’s clinical condition and kidney function. In this case, IRGN was caused by a rare pathogen. This is the first published case to show NAPlr positivity in the glomeruli after systemic infection with the periodontal bacteria, Aggregatibacter actinomycetemcomitans. This case and subsequent research might expand the concept of IRGN, anchored by NAPlr as a key diagnostic biomarker.
Correspondence to:
Yohei Komaru, MD
Department of Nephrology, Immunology, and Vascular Medicine
Shonan Kamakura General Hospital
1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
Email: [email protected]
