NDT Plus - Advance Access

Minimal change disease with interferon-beta therapy for relapsing remitting multiple sclerosis

Aravindan, A., Yong, J., Killingsworth, M., Suranyi, M., Wong, J. — Tue, 17 Nov 2009 02:56:29 PST

Interferon beta is widely used for the treatment of relapsing and remitting multiple sclerosis. Renal side effects including nephrotic syndrome have been increasingly described with interferon beta treatment. We describe an illustrative case of a patient who developed severe nephrotic syndrome due to minimal change disease in association with interferon beta therapy and showed partial remission following cessation of interferon beta and treatment with cortico- steroids.

Bone morphogenic protein-7: a new prognostic marker for acute kidney injury?

Kanbay, M., Covic, A. — Wed, 11 Nov 2009 00:06:07 PST

Lacking evidence for calcium-binding protein fetuin-A to be linked with chronic kidney disease-related pruritus (CKD-rP)

Mettang, T., Matterne, U., Roth, H. J., Weisshaar, E. — Fri, 06 Nov 2009 03:52:33 PST

Reversible proteinuria after adalimumab discontinuation in a patient with Crohn's disease

Katsanos, K. H., Theiakos, D., Vagias, I., Christodoulou, D., Tsianos, E. V. — Thu, 05 Nov 2009 01:49:05 PST

Severe hypogammaglobulinaemia and opportunistic infections after rituximab therapy in a renal transplant recipient

Kahveci, A., Asicioglu, E., Ari, E., Arikan, H., Tuglular, S., Ozener, C. — Thu, 05 Nov 2009 01:49:05 PST

Infectious complications are the leading causes of morbidity and mortality among renal transplant recipients. Hypogammaglobulinaemia may develop as a result of immunosuppressive therapy and is associated with an increased risk of opportunistic infections particularly in the 6-month post-transplant period. Rituximab, which is used for antibody-mediated rejection (AMR), may also contribute to the development of hypogammaglobulinaemia via B-cell depletion. Intravenous immunoglobulin replacement may be beneficial in this setting. With the following case report, we aim to increase the awareness of opportunistic infections and severe hypogammaglobulinaemia in renal transplant recipients treated with rituximab for acute AMR.

Haemodiafiltration--optimal efficiency and safety

Ledebo, I., Blankestijn, P. J. — Thu, 05 Nov 2009 01:49:04 PST

Haemodiafiltration (HDF) is the blood purification therapy of choice for those who want significant removal of uraemic solutes beyond the traditional range of small molecules. Combining diffusive and convective solute transport, a HDF treatment comprises the largest number of variables among blood purification therapies, and it is important to understand how they interact in order to optimize the therapy. This review discusses the parameters that determine the efficiency of HDF and how they can be controlled in the different forms of HDF and ‘HDF-like’ therapies practised today. The key to safe and effective HDF therapy is to have access to large volumes of high-quality fluids. Starting with ultrapure dialysis fluid, on-line preparation of a sterile, non-pyrogenic substitution solution can be made an integral part of the treatment, and we describe the necessary conditions for this. On-line HDF can provide the largest removal of the widest range of solutes among available dialysis therapies, and the potential clinical benefits of this are within practical reach for the increasing number of patients dialysed with high-flux membranes and ultrapure dialysis fluid.

A pilot in distress

Bennett, S., Mitsides, N., Dhaygude, A., Woywodt, A. — Tue, 03 Nov 2009 21:36:41 PST

Treat the patient not the lab value

Tolouian, R., Salameh, H. — Tue, 03 Nov 2009 21:36:40 PST

Problems of donor compatibility in a patient with sensitization to an alternate allelic variant of a 'self' HLA specificity

Koo, P., McKinley, K., Newstead, C., Clark, B. — Tue, 03 Nov 2009 21:36:39 PST

UK standards of deceased donor HLA typing and arrangements for reporting of recipient HLA antibody specificity can create a risk for ‘unexpected positive’ crossmatch that it is within the recipient centre's ability to avoid if high-confidence serum screening methods are in place. The case reported details investigations following an unexpected positive crossmatch due to an antibody directed against an allelic variant of a ‘self’ HLA specificity.

Kidney transplantation without reversal of warfarin

Mudge, D. W., Campbell, S. B., Ray, M. — Tue, 03 Nov 2009 21:36:38 PST

Some patients called for kidney transplantation are anticoagulated with warfarin for indications such as antiphospholipid syndrome, where the risk of thrombosis with reversal may be high. Traditionally, the approach has been reversal of warfarin and treatment perioperatively with intravenous unfractionated heparin. However, this may be complicated by either thrombosis or bleeding if the heparin dose is incorrect. We report the case of a peritoneal dialysis patient warfarinized for antiphospholipid syndrome who was successfully transplanted with an international normalized ratio of 2.1 with neither thrombosis nor bleeding. This may be an alternative to heparin for patients in whom anticoagulation must be maintained.

Successful treatment of spontaneous kidney graft decapsulation 18 years after renal transplantation: a case report

Myhre, H.-A., Oyen, O., Karbo, O., Midtvedt, K. — Tue, 03 Nov 2009 21:36:37 PST

Nutritional problems in adult patients with stage 5 chronic kidney disease on dialysis (both haemodialysis and peritoneal dialysis)

Heng, A.-E., Cano, N. J. M. — Mon, 19 Oct 2009 09:40:54 PDT

The EVEREST study: an international collaboration

Mon, 19 Oct 2009 09:40:52 PDT

Rates of initiation of renal replacement therapy (RRT), use of home modalities of treatment and patient outcomes vary considerably between countries. This paper reports the methods and baseline characteristics of countries participating in the EVEREST study (n = 46), a global collaboration examining the association between medical and non-medical factors and RRT incidence, modality mix and survival. Numbers of incident and prevalent patients were collected for current (2003–05) and historic (1983–85, 1988–90, 1993–95 and 1998–2000) periods stratified, where available, by age, gender, treatment modality and cause of end stage renal disease (diabetic versus non-diabetic). General population age and health indicators and national-level macroeconomic data were collected from secondary data sources. National experts provided primary data on renal service funding, resources and organization. The median (inter quartile range) RRT incidence per million of the population (pmp) was 130 pmp (102–167 pmp). The general population life expectancy at 60 was 22.1 years (19.7–23.1 years) and 6.9% had diabetes mellitus (5.4–9.0%). Healthcare spending as a percentage of gross domestic product was 8.1% (5.6–9.3%). Countries averaged nine dialysis facilities pmp (4–12 pmp), with 69.0% (43.9–99.0%) owned by the public or private not-for-profit sector. The number of nephrologists ranged from 0.5 to 48 pmp (median 12 pmp). The heterogeneity of EVEREST countries will enable modelling to examine the independent association between medical and non-medical factors on RRT epidemiology.

Colour Doppler twinkling in kidney stones: artefact or sign?

Andrulli, S., Turrin, A., Bigi, M. C., Ravani, P., Trinchieri, A., Locatelli, F. — Tue, 13 Oct 2009 21:19:55 PDT

The twinkling in colour Doppler images is created by a rapidly changing series of coloured horizontal bars that appear beyond the reflex surfaces. Spectral analyses show a typically rectangular time/velocity wave diagram, and an uncomfortably high-pitched audio signal saturates the echo system. The twinkling can be detected in the calcified areas of various tissues and is usually interpreted as an artefact; however, this report describes two cases suggesting that it may be valuable for the early diagnosis and follow-up of kidney stones. This observation may have important diagnostic, epidemiological and clinical implications.

Chronic kidney disease and end-stage renal disease--a review produced to contribute to the report 'the status of health in the European union: towards a healthier Europe'

Zoccali, C., Kramer, A., Jager, K. J. — Mon, 12 Oct 2009 22:36:26 PDT

The Report on the Status of Health in the European Union (EUGLOREH) is a project aimed at describing health problems in member states of the European Community. This project is an effort of more than 170 European experts and the collaboration of the health authorities or institutions from all EU Member States, major intergovernmental, International and European Organizations and Agencies. In this report, for the first time special emphasis is given to chronic diseases. Chronic kidney disease (CKD) is increasingly recognized as a major public health problem. However, with some notable exceptions, until now this disease has received scarce attention both at European level and at member states level. In 2007, the ERA-EDTA Registry was invited to contribute to EUGLOREH. The Registry made a major effort to gather published and unpublished information on the epidemiology of CKD and ESRD and to provide a comprehensive overview on CKD and ESRD in European countries. The review was completed in early 2008 and included into the final EUGLOREH published in the WEB as of 20 March 2009.

Mycotic aneurysm of the carotid artery in a chronic haemodialysis patient

Ko, W.-S., Chen, T.-H., Cheng, C.-Y. — Sat, 10 Oct 2009 03:43:50 PDT

Hypocomplementaemic immune complex tubulointerstitial nephritis

Gupta, A., Jothy, S., Somerville, P., Zaltzman, J. S. — Wed, 07 Oct 2009 07:23:42 PDT

We report a rare cause of rapidly progressive renal failure associated with low complement, positive ANA but negative anti DS-DNA. A renal biopsy demonstrated tubulointerstitial nephritis with positive immunoglobulin staining involving the interstitium and tubular basement membrane but glomerular sparing. A review of the literature and differential diagnosis are discussed.

Adrenal insufficiency in a haemodialysis patient

Suzuki, R., Morita, H., Nishiwaki, H., Yoshimura, A. — Tue, 06 Oct 2009 09:51:11 PDT

Marked increase in bone formation markers after cinacalcet treatment by mechanisms distinct from hungry bone syndrome in a haemodialysis patient

Goto, S., Fujii, H., Matsui, Y., Fukagawa, M. — Wed, 30 Sep 2009 09:34:17 PDT

A 59-year-old female who was on dialysis due to diabetic nephropathy was referred to our hospital for severe hyperparathyroidism refractory to intravenous vitamin D receptor activator treatment. With subsequent cinacalcet hydrochloride treatment, parathyroid hormone (PTH) levels were only slightly suppressed. However, progressive increases were observed in serum alkaline phosphatase (ALP) and bone-specific alkaline phosphatase (BAP) levels with mild hypocalcaemia. A bone biopsy, obtained immediately before surgical parathyroidectomy after 3 months of cinacalcet treatment, revealed no disappearance of osteoclasts. These data suggest that cinacalcet hydrochloride treatment may induce a marked promotion of bone formation by mechanisms distinct from hungry bone syndrome that usually develops after parathyroidectomy.

Post-renal transplant calciphylaxis: treatment of hyperparathyroidism by percutaneous ethanol injection therapy and parathyroidectomy

Park, N. Y., Jung, Y. S., Rim, H. — Fri, 25 Sep 2009 06:50:33 PDT

Turbid white urine

Vera, M., Molano, A., Rodriguez, P. — Fri, 25 Sep 2009 17:34:53 PDT

Turbid white urine ‘albinuria’ is defined as a urine discoloration described as milky or cloudy. One of the most frequent causes of turbid white urine is chyluria complicating filariasis (Table 1). The extant causes of albinuria are non parasitic and rare. Amongst their aetiologies stand excessive mineral sediment excretion such as calciuria and phosphaturia, massive pyuria and fungal infections, and rarely congenital malformations of the lymphatic vessels. Malingering is also possible, in patients adding milk to their urine. We observed a case of albinuria in which the diagnostic work up led to diagnosing an exceptional cause of chyluria in a patient living in a region of Colombia where filariasis is not endemic.

A case of bilateral renal arterial thrombosis associated with cryocrystalglobulinaemia

Leung, N., Buadi, F. K., Song, K. W., Magil, A. B., Cornell, L. D. — Thu, 24 Sep 2009 14:31:34 PDT

Cryocrystalglobulinaemia is an extremely rare complication of monoclonal gammopathy. Its presentation has features of both type I and II cryoglobulinaemia. Although peripheral and digital ischaemia is common, visceral ischaemia is rare. When it does occur, it is usually associated with multiple myeloma and has an extremely poor prognosis. We present a case of bilateral renal artery thrombosis associated with cryocrystalglobulinaemia in a patient without myeloma. More unusual, the cryocrystal protein in this case was associated with fibrinogen, which may have led to increased propensity towards thrombosis. Although the patient was unable to recover his kidney function, he remained alive on dialysis 2 years after the incident. The patient did not have any further ischaemic event despite no definitive therapy. This case represents an unusual presentation for this rare disease.

The effect of spontaneous twin pregnancy on renal transplant function and haemodynamics

Cheung, C. K., Bhandari, S. — Wed, 23 Sep 2009 07:49:49 PDT

Spontaneous twin pregnancy is rare in renal transplant recipients, and confers a significant risk, in terms of both transplant dysfunction and fetal complications. Physiological changes in renal haemodynamics may assist in predicting a favourable outcome, but have not been previously reported in these circumstances. We present a case of a successful outcome for both mother and babies, and detail the effects of the pregnancy on transplant function and haemodynamics within the transplant kidney. Without beneficial circumstances, twin pregnancy may be a high risk in renal transplant recipients and may lead to a poor outcome for both transplant and fetuses.

Hypokalaemia and the thyroid--is there a link?

de Carvalho, J. G. R., de Morais, A., Traple, F., Carvalho, M. — Sat, 19 Sep 2009 04:06:20 PDT

Peritubular capillary lesions in post-streptococcal acute glomerulonephritis

Usui, J., Ebihara, I., Kaneko, S., Kobayashi, M., Yamagata, K. — Sat, 19 Sep 2009 04:06:20 PDT

Fibrillary glomerulonephritis with prevalent IgA deposition associated with undifferentiated connective tissue disease: A case report

Nebuloni, M., Genderini, A., Tosoni, A., Caruso, S., di Belgiojoso, G. B. — Sat, 19 Sep 2009 04:06:19 PDT

We described a 41-year-old female patient, who presented with proteinuria occurring 5 years after the onset of an undifferentiated connective tissue disease (UCTD). At renal biopsy, a pattern of focal necrotizing glomerulonephritis with mesangial and parietal deposition of the IgA, C3 and K chains was observed. Electron microscopy showed organized fibrillary deposits in mesangial, subendothelial, intramembranous and subepithelial sites. Fibrils were randomly arranged, had no hollow core and had a diameter ranging between 10 and 23 nm. This case showed a rare combination of fibrillary glomerulonephritis and prevalent IgA deposition, in the clinical context of UCTD.

A general overview of malnutrition in normal kidney function and in chronic kidney disease

Heng, A.-E., Cano, N. J. M. — Wed, 16 Sep 2009 09:52:22 PDT

Ectopic ossification in the cranial dura mater in dialysis patients with secondary hyperparathyroidism

Oyama, Y., Kazama, J. J., Fukagawa, M., Arakawa, Y., Ezuka, I. — Wed, 09 Sep 2009 03:38:37 PDT

We report the case of a 69-year-old woman with secondary hyperparathyroidism who underwent maintenance haemodialysis therapy for 17 years and who presented with severe dural calcification and right subdural haematoma. Her dura mater displayed a rock barnacle-like appearance, and cerebral superficial arteries adhered to the sclerotic lesions. On the microscopic observation, calcified tissue with a clear lamellar structure and osteopontin immunoreactivity was observed. Tartrate-resistant acid phosphatase immunoreactive polynucleated giant cells infiltrated around the tissue. Such morphological properties are specific to the calcified tissue formed through a bone formation-like mechanism that is often observed in arterial media in patients with chronic kidney disease.

The importance of prevention of calciphylaxis in patients who are at risk and the potential fallibility of calcimimetics in the treatment of calciphylaxis for patients with secondary hyperparathyroidism

Khalpey, Z., Nehs, M. A., ElBardissi, A. W., Semel, M., Tullius, S. G. — Tue, 08 Sep 2009 08:01:45 PDT

A 43-year-old African American with end-stage renal disease (ESRD) associated with membranous nephropathy and a previously failed renal transplant had received cinacalcet to treat his secondary hyperparathyroidism. Serum calcium and phosphorus levels remained within normal limits, and serum parathyroid levels had dropped significantly following treatment initiation. However, within 7 months, the patient experienced extensive necrotic bilateral medial thigh ulcers. These were biopsied and found to be a result of calciphylaxis. The patient ultimately required an urgent subtotal parathyroidectomy and recovered well with completely healed ulcers.

Nephrotic syndrome and renal failure as an unusual presentation of solid tumour

Bonkain, F., Ena, G., Depierreux, M., Debelle, F. D., Nortier, J. L. — Thu, 03 Sep 2009 06:56:03 PDT

Glomerular diseases may occur as primary manifestation of cancer, especially in patients older than 60 years. Among glomerulopathies, membranous nephropathy is preferentially associated with respiratory and gastrointestinal tract adenocarcinomas, whereas minimal change disease is most often seen in haematological malignancies. Though breast cancer is one of the most frequent malignancies in women, paraneoplastic glomerular disease is rarely observed. We describe the case of a 79-year-old female patient who presented with nephrotic syndrome and renal failure. Breast cancer was found. Pathological studies of kidney and breast biopsy revealed a minimal change disease and an infiltrating ductal carcinoma, respectively.

Successful cinacalcet treatment of refractory secondary hyperparathyroidism due to multiple lung parathyroid adenomas

Sugi, O., Kimata, N., Miwa, N., Otsubo, S., Nitta, K., Akiba, T. — Tue, 01 Sep 2009 23:07:51 PDT

We describe a 56-year-old woman who presented with end-stage renal disease due to pregnancy-induced hypertension and secondary hyperparathyroidism (sHPT). She had started hemodialysis and underwent a subtotal parathyroidectomy (PTx). However, intact parathyroid hormone (iPTH) levels increased gradually. Eventually, she underwent a second PTx. However, therapy failed to significantly decrease iPTH levels. A third PTx was performed, but no pathological parathyroid tissue was found. Computed tomography scan indicated the presence of multiple ectopic lung nodules and 26 nodules were surgically removed from the left lung. Despite surgical treatment, iPTH levels remained high. Additional maxacalcitol failed to decrease iPTH levels, cinacalcet was then started. iPTH levels decreased and the cinacalcet dose could be reduced to maintenance doses of 60 mg/day. Throughout the 1.6 years of treatment, serum iPTH, alkaline phosphatase (ALP) and bone alkaline phosphatase (BAP) were normalized. As a consequence, bone pain gradually disappeared. Bone mineral density (BMD) was improved by administration of cinacalcet. In conclusion, cinacalcet was effective in this patient with refractory and inoperable sHPT. In addition, it improves their BMD and relieves bone pain.

Water balance disorders after neurosurgery: the triphasic response revisited

Hoorn, E. J., Zietse, R. — Mon, 31 Aug 2009 03:28:49 PDT

Water balance disorders after neurosurgery are well recognized, but detailed reports of the triphasic response are scarce. We describe a 55-year-old woman, who developed the triphasic response with severe hyper- and hyponatraemia after resection of a suprasellar meningioma. The case illustrates how sudden and dramatic the changes in water balance after neurosurgery can be. The biochemical profile suggested central diabetes insipidus and the syndrome of inappropriate antidiuretic hormone secretion. The underlying pathophysiology was further analysed using fractional excretions, measurements of renin, aldosterone and vasopressin and a metyrapone test. Diagnostic, therapeutic and preventive strategies for these intriguing but complex cases are proposed.

Adult-onset Still's disease associated with collapsing glomerulopathy

Wed, 26 Aug 2009 22:56:08 PDT

A young woman of African descent presented with fevers, arthralgia, lymphadenopathy and a skin rash. Modest proteinuria was also noted. The clinical picture suggested an acute HIV sero-conversion illness, and a renal biopsy showed a collapsing glomerulopathy compatible with that diagnosis. However, HIV serology proved persistently negative and a diagnosis of Adult Still's disease was subsequently made (by Yamaguchi criteria). Following steroid treatment, the patient's fever abated and her inflammatory markers returned to normal. Collapsing glomerulopathy is a rare but important complication of Adult Still's disease. Immunosuppressive treatment may be effective in improving renal outcome.

Late referral of patients with end-stage renal disease: an in-depth review and suggestions for further actions

Baer, G., Lameire, N., Van Biesen, W. — Wed, 29 Apr 2009 15:35:46 PDT

Late referral of patients with chronic kidney disease (CKD) is a known problem and a major challenge for practising nephrologists since decades. In this review we report about the reasons for late referral, its epidemiology and socioeconomic impact and the medical particularities of late referred patients. We furthermore highlight on the efforts which have been undertaken so far to avoid late referral and should be undertaken in future to face the ever growing numbers of chronic kidney disease patients.

Specific nutritional problems in acute kidney injury, treated with non-dialysis and dialytic modalities

Fiaccadori, E., Regolisti, G., Cabassi, A. — Wed, 11 Feb 2009 03:49:04 PST

Patients who develop AKI, especially in the intensive care unit (ICU), are at risk of protein–energy malnutrition, which is a major negative prognostic factor in this clinical condition. Despite the lack of evidence from controlled trials of its effect on outcome, nutritional support by the enteral (preferentially) and/or parenteral route appears clinically indicated in most cases of ICU-acquired AKI, independently of the actual nutritional status of the patient, in order to prevent deterioration in the nutritional state with all its known complications. Extrapolating from data in other conditions, it seems intrinsically unlikely that starvation of a catabolic patient is more beneficial than appropriate nutritional support by an expert team with the skills to avoid the potential complications of the enteral and parenteral nutrition methodologies. By the same token, it is ethically impossible to conduct a trial in which the control group undergoes prolonged starvation. The primary goals of nutritional support in AKI, which represents a well-known inflammatory and pro-oxidative condition, are the same as those for other critically ill patients with normal renal function, i.e. to ensure the delivery of adequate nutrition, to prevent protein–energy wasting with its attendant metabolic complications, to promote wound healing and tissue repair, to support immune system function, to accelerate recovery and to reduce mortality. Patients with AKI on RRT should receive a basic intake of at least 1.5 g/kg/day of protein with an additional 0.2 g/kg/day to compensate for amino acid/protein loss during RRT, especially when daily treatments and/or high efficiecy modalities are used. Energy intake should consist of no more than 30 kcal non-protein calories or 1.3 x BEE (Basal Energy Expenditure) calculated by the Harris–Benedict equation, with ~30–35% from lipid, as lipid emulsions. For nutritional support, the enteral route is preferred, although it often needs to be supplemented through the parenteral route in order to meet nutritional requirements.

Patients with primary membranous nephropathy lack auto-antibodies against LDL receptor, the homologue of megalin in human glomeruli

Sat, 31 Jan 2009 03:03:43 PST