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Abstract

Y. Mori, H. Yamashita, Y. Umeda,Y.U. Uchiyama-Tanaka, A. Nose,N. Kishimoto, Y. Kijima, T. Nagata,M. Mori, H. Matsubara, H. Yoshida and T. Iwasaka

¹Department of Medicine II, Kansai Medical University, Osaka, and
²Department of Clinical Laboratory Medicine, Fukui Medical University,
Fukui, Japan
An otherwise healthy 20-year-old woman presented with an erythematous rash on her face as well as arthralgia and anemia. She also had systemic edema, proteinuria and hypertension. Laboratory data on admission showed hypocomplementemia, human parvovirus B19 (HPV) DNA and both immunoglobulin (Ig) M and IgG antibodies to HPV in her serum. Renal biopsy specimens showed features of endocapillary glomerulonephritis under light microscopy. Electron microscopy showed massive subendothelial electron-dense deposits. No cause was probable other than immune complex-mediated glomerulonephritis associated with HPV infection. In a review of this and similar cases reported in the literature, several characteristic features come to light: female dominance, onset in the second or third decade of life, hypocomplementemia, histologic renal endocapillary and/or mesangioproliferative glomerulonephritis with subendothelial deposits and spontaneous recovery.

Abstract

H. Sashiyama, Y. Irie, Y. Ohtake, K. Nakajima, H. Yoshida, T. Sakai and K. Okuda

¹San-ai Memorial Hospital, and ²Industrial Intoxication Center, Tokyo Rosai Hospital, Tokyo, Japan
Acute renal failure with hearing loss due to sodium bromate intoxication is described. A 48-year-old woman who ingested permanent wave neutralizer in a suicide attempt and developed anuria was admitted to our hospital for hemodialysis. Bromate intoxication was suspected and hemodialysis was carried out; she required maintenance dialysis 3 times a week. Irreversible severe sensorineural hearing loss continued and peripheral polyneuropathy developed in the lower limbs. We measured the concentration of bromine in the serum before and after the first hemodialysis and found its removal rate to be 61.3%. This is the first report that proved the utility of hemodialysis for bromate intoxication in a clinical setting.

Abstract

N. Kishimoto, Y. Mori, H. Yamahara, Y. Kijima, A. Nose, Y. Uchiyama-Tanaka, T. Tokoro, T. Nagata, Y. Umeda, N. Takahashi, H. Yoshida and H. Matsubara

¹Division of Cardiology and Nephrology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, ²Department of Medicine II, Kansai Medical University, Osaka, and ³Division of Nephrology, University of Fukui Hospital, Fukui, Japan
Renal deterioration often occurs in cases of infectious endocarditis (IE), but, IE- associated nephritis with rapidly progressive glomerulonephritis (RPGN) is rare. Patients with severe infection (e.g., IE) sometimes show positivity for cytoplasmic antineutrophil cytoplasmic antibodies (C-ANCA). Therefore, diagnosis and treatment are very difficult in cases of RPGN with IE and positivity for C-ANCA. Such cases are rare, only 12 have been reported in the English literature. Herein, we describe the case of a 50-year-old man who presented with RPGN with IE and tested positively for C-ANCA. He was referred to our hospital because of leg edema, purpura and renal dysfunction. Laboratory tests revealed serum creatinine elevation and positivity for C-ANCA and proteinase 3-specific (PR3)-ANCA. RPGN and acute renal failure were diagnosed. Hemodialysis and steroid therapy were started. Streptococcus oralis was isolated by blood culture. Transthoracic echocardiography revealed grade III mitral valve insufficiency with two vegetations. Therefore, IE was diagnosed. The steroid therapy was stopped, and antibiotic therapy was begun. Because there was no improvement, surgical therapy was performed. The operation was successful, but the patient died of brain hemorrhage. Our experience in this case indicates C/PR3-ANCA positive RPGN must be ruled out in patients with infectious disease, particularly IE, together with renal symptoms, and renal biopsy should be performed. Correspondence to:
Y. Mori, MD Division of Cardiology and Nephrology Department of Medicine Kyoto Prefectural University of Medicine 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
Email: [email protected]

Abstract

K. Katano, Y. Hayatsu, T. Matsuda, R. Miyazaki, K. Yamada, M. Kawano, N. Takahashi, H. Kimura and H. Yoshida

¹Department of Internal Medicine, Fujita Memorial Hospital, Fukui, ²Department of Internal Medicine, Division of Rheumatology, Kanazawa University Graduate School of Medicine, Kanazawa and ³Division of Nephrology, Faculty of Medicine, Fukui University, Fukui, Japan
Renal lesions of IgG4-related disease have been reported recently. Most of them are tubulointerstitial nephritis, and a definite glomerulonephritis complicating IgG4-related disease is very rare. We report here a case of definite glomerulonephritis and concurrent tubulointerstitial nephritis complicating retroperitoneal fibrosis with a high serum level of IgG4. A 68-year-old Japanese woman was referred to our hospital for investigation of anasarca. We diagnosed her disease as a nephrotic syndrome and left hydroureteronephrosis due to retroperitoneal fibrosis. Her laboratory data revealed a high serum level of IgG4, renal injury, hypoproteinemia, hypocomplementemia, a positive finding of circulating immunocomplex (CIC), and negative findings of autologous antibodies suggesting systemic lupus erythematosus (SLE) or Sjögren’s syndrome (SS). A diagnosis of SLE or SS could not be made clinically. Right renal biopsy revealed endocapillary proliferative glomerulonephritis with crescent formation and concurrent tubulointerstitial nephritis. Infiltration of plasma cells in interstitium was more conspicuous than seen with ordinary tubulointerstitial nephritis, and in most of them IgG4 was positive. We placed a percutaneous nephrostomy catheter in her left kidney, and prescribed prednisolone and cyclosporine. The responses to prednisolone and cyclosporine therapies were very good. Further studies are needed to clarify the relationship between glomerulonephritis and IgG4-related disease. However, when considering renal lesions of IgG4-related disease, we think that hypocomplementemia, a positive finding of CIC, negative findings of autologous antibodies suggesting SLE or SS, conspicuous interstitial infiltration of IgG4-positive plasma cells, and a good response to steroid or immunosuppressant therapy are key points.Correspondence to:
K. Katano, MD, Department of Internal Medicine, Fujita Memorial Hospital, 4-15-7, Houei, Fukui, 910-0004, Japan
Email: [email protected]

Abstract

K. Yokoyama, H. Yoshida, N. Matsuo, Y. Maruyama, Y. Kawamura, R. Yamamoto, K. Hanaoka, M. Ikeda, H. Yamamoto, M. Nakayama, Y. Kawaguchi and T. Hosoya

¹Division of Kidney and Hypertension, Department of Internal Medicine,
Jikei University School of Medicine, Tokyo and ²Research Division of Dialysis and Chronic Kidney Disease, Tohoku University Graduate School of Medicine, Sendai Miyagi, Japan
Background: Encapsulating peritoneal sclerosis (EPS) is a serious complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD). The aim of this study was to find a predictor for EPS. Methods: Patients with EPS who were detected by a historical cohort study using clinical data of 219 CAPD patients at our hospital. We recruited 25 patients with EPS who were compared with the patients without EPS who were matched for age and dialysis period as controls. Differences between the two groups (non-EPS group and EPS group) with respect to age, gender, primary disease, dialysis period, serum urea nitrogen, serum creatinine, β₂MG, CRP and PET (peritoneal equilibration test) category (determined by the peritoneal function testing) were analyzed. Results: According to multiple regression analysis, a high β₂MG level was an independent risk factor for EPS (odds ratio 1.162, 95% confidence interval 1.026 – 1.317, p = 0.018). Other clinical markers did not show positive significance. A ROC (receiver operating characteristic) curve was prepared to evaluate the suitability of β₂MG measurement as a screening test. The sensitivity was 64% and the specificity was 80% when a β₂MG level of 37.0 mg/dl was taken as the cut-off value. The odds ratio for occurrence of EPS was 8.8 when β₂MG level was in the range of 35 – 40 mg/dl, 13.5 when β₂MG level was > 40 mg/dl and 1 when β₂MG level was < 30 mg/dl. Conclusion: These findings suggest that β₂MG is useful as a screening test for the onset of EPS, and that β₂MG and accumulation of middle-molecular uremic substances may be related to the pathophysiology of EPS.Correspondence to:
K. Yokoyama, MD, Division of Kidney and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
Email: [email protected]

Abstract

N. Takahashi¹, H. Kimura¹, R. Kitai², M. Sato³, M. Yoneda³, C. Yamamoto¹, D. Mikami¹, M. Kuriyama³, T. Kubota², H. Itoh⁴ and H. Yoshida¹

¹Department of General Medicine, Division of Nephrology, School of Medicine, Faculty of Medical Sciences, ²Department of Sensory and Locomotor Medicine, Division of Neurosurgery, ³Second Department of Internal Medicine (Neurology), and ⁴Department of Pathological Sciences, Division of Tumor Pathology, School of Medicine, Faculty of Medical Sciences, University of Fukui, Japan
We report a 56-year-old man with microscopic polyangiitis (MPA) who developed acute exacerbation of a chronic subdural hematoma (SDH). Laboratory data demonstrated elevation of myeloperoxidase antineutrophil cytoplasmic antibody (MPOANCA) and rapidly progressing renal dysfunction. Renal biopsy showed crescentic glomerulonephritis (GN) with membranous nephropathy (MN). He was treated with corticosteroids, antithrombotic agents, and an immunosuppressant. One month after initiation of treatment, he had a mild headache. One month later, he developed acute SDH. Although he recovered completely after the operation, he finally died of bacterial infection. On autopsy, a scar of vasculitis was confirmed in the leptomeninges as well as in the kidney and lung. Although SDH is a rare complication in MPA, nephrologists must pay more attention to the initial symptoms before a hematoma attack such as headache, especially in patients using antithrombotic agents.Correspondence to:
H. Yoshida, MD, PhD, Professor
Division of Nephrology
Department of General Medicine
School of Medicine
Faculty of Medical Sciences
University of Fukui
Fukui, 910-1193, Japan
Email: [email protected]

Abstract

Clinical Nephrology, Vol. 74 – No. 1/2010 (74-80)

Tubulointerstitial nephritis with IgM-positive plasmacytoid large lymphocyte infiltration in a patient with primary biliary cirrhosis and Sjögren's syndrome

N. Takahashi¹, H. Kimura¹, Y. Kawajiri¹, D. Mikami¹, C. Yamamoto¹, K. Kasuno¹, N. Imai², T. Kuroda², S. Nishi², M. Yamamoto³ and H. Yoshida¹

¹Division of Nephrology, Department of General Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, ²Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, and ³Department of Internal Medicine, Fukui Kosei Hospital, Fukui, Japan
We report a 38-year-old woman diagnosed with tubulointerstitial nephritis (TIN) on renal biopsy, followed by being diagnosed with primary biliary cirrhosis (PBC) and Sjögren’s syndrome (SS). Immunohistochemically, the cellular infiltrates in TIN were mainly composed of small lymphocytes and IgM-positive plasmacytoid large lymphocytes. IgM-positive plasmacytoid large lymphocytes were not identical with, but colocalized with CD3- or CD20-positive lymphocytes. TIN in patients with PBC is very rare and little is known about immunohistochemical characteristics of infiltrating cells in this setting. To our knowledge, this is the first report demonstrating predominant infiltrating of IgM-positive plasmacytoid large lymphocytes in TIN due to PBC and SS.Correspondence to:
H. Yoshida, MD, PhD, Professor
Division of Nephrology
Department of General Medicine
Faculty of Medical Sciences
University of Fukui
Fukui, 910-1193, Japan
Email: [email protected]

Abstract

Clinical Nephrology, Vol. 74 – No. 3/2010 (209-216)

Clinical impact of a combined therapy of peritoneal dialysis and hemodialysis

N. Matsuo¹, K. Yokoyama¹, Y. Maruyama¹, Y. Ueda¹, H. Yoshida¹, Y. Tanno¹, R. Yamamoto¹, H. Terawaki¹, M. Ikeda¹, K. Hanaoka¹, H. Yamamoto¹, M. Ogura¹, S. Watanabe², Y. Kimura¹ and T. Hosoya¹

¹Division of Kidney and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, and ²Department of Internal Medicine, Kobari General Hospital, Chiba, Japan
Aims: Although peritoneal dialysis (PD) is recommended as the first-line treatment for end-stage renal disease, limitations exist to achieving good clinical status when the residual renal function (RRF) has declined. Combined therapy with PD and hemodialysis (HD) is the treatment of choice for patients who cannot control body fluid status and/or cannot obtain adequate solute removal by PD alone. The aim of this study was to evaluate the clinical efficacy of this combined therapy. Methods: In this retrospective study, 53 patients on PD and diagnosed with underdialysis and/or overhydration with declining RRF were recruited. Parameters of volume control, uremic solute removal, anemia, and predictors for encapsulating peritoneal sclerosis (EPS) were compared before and 1 year after combined therapy. Results: The patients’ hydration status improved significantly with reductions in atrial natriuretic peptide and blood pressure. Serum creatinine and beta2 microglobulin also decreased significantly. The hemoglobin level increased remarkably from 8.2 ± 1.6 to 10.7 ± 1.2 g/dl (p < 0.01) and the reticulocyte count also increased significantly, even though at the same time the dose of recombinant human erythropoietin decreased significantly. The dialysate to plasma creatinine ratio obtained from the fast peritoneal equilibration test (PET) decreased significantly from 0.65 ± 0.11 to 0.59 ± 0.13, and the level of interleukin 6 in PET drainage also significantly decreased. Furthermore, serum C-reactive protein and fibrinogen decreased significantly. Conclusions: Combined therapy with PD and HD is an effective way to control fluid status and to correct inadequate solute removal, leading to improvement in inflammation, peritoneal function and anemia.Correspondence to:
Dr. N. Matsuo
Division of Kidney and Hypertension
Department of Internal Medicine
The Jikei University School of Medicine
3-25-8 Nishi-shimbashi Minato-ku
Tokyo 105-8461, Japan
Email: [email protected]

Abstract

Clinical Nephrology, Vol. 75 – No. 1/2011 (1-7)

Difference in coronary artery intima and media calcification in autopsied patients with chronic kidney disease

H. Yoshida¹, K. Yokoyama¹, T. Yaginuma¹, I. Ohkido¹, H. Yamamoto¹, Y. Utsunomiya¹, M. Kawakami² and T. Hosoya¹

¹Division of Kidney and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, and ²Department of Pathology, Seirei Sakura Citizen Hospital, Sakura, Japan
Background: In patients with chronic kidney disease (CKD), coronary artery calcification occurs at two distinct sites in the vessel wall: the intima and the media. Arterial media calcification (AMC), a nonocclusive condition, affects hemodynamics differently compared to arterial intima calcification (AIC), which occurs in atherosclerotic plaques. Arterial calcification is considered a cell-regulated process resembling intramembranous bone formation. The purpose of this retrospective observational study was to clarify the morphological differences between AIC and AMC and to evaluate the role of vascular smooth muscle cells (VSMCs) and macrophages in AIC and AMC formation. Methods: We histologically analyzed 14 tissue specimens from 14 autopsies of patients with CKD Stage 5D who underwent hemodialysis and 5 specimens from 5 patients with CKD Stage 2 – 3 (90 ml/min/1.73 m² > estimated GFR >= 30 ml/min/1.73 m²). We performed immunohistochemical staining of osteopontin (OPN) as a marker for bone matrix protein, alpha-smooth muscle actin (alphaSMA) for VSMCs, Cbfa1/Runx2 as a marker for osteoblastic differentiation of VSMCs, and CD68 for macrophages. Results: In the CKD 2/3 group, we also found AIC and AMC. OPN and CD68 expression in the CKD 2/3 group was similar to that in the CKD 5D group. Although we did not find Cbfa1/Runx2 positive cell expression in the CKD 2/3 group, we did find it in the CKD 5D group. We found CD68-positive cells predominantly in AIC and absent in AMC in both groups. Conclusions: These findings suggest that the influence of Cbfa1/Runx2 pathway in coronary artery calcification depends on the CKD Stage. Expression of CD68-positive cells depends on the location of the coronary artery calcification.Correspondence to:
H. Yoshida, MD
Division of Kidney and Hypertension
Department of Internal Medicine
The Jikei University School of Medicine
3-25-8, Nishi-Shinbashi, Minato-ku
Tokyo, 105-8471, Japan
Email: [email protected]

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