NDT Plus - current issue

Citrate anticoagulation for continuous renal replacement therapy (CRRT) in patients with acute kidney injury admitted to the intensive care unit

Davenport, A., Tolwani, A. — Thu, 19 Nov 2009 11:11:32 PST

Continuous forms of renal replacement therapy (CRRT) have become established as the treatment of choice for supporting critically ill patients with acute kidney injury. Typically, these patients have activation of the coagulation cascades, peripheral mononuclear cells and platelets, but also a reduction in natural anticoagulants, and are therefore prothrombotic. For continuous modes of renal replacement therapy to be effective, in terms of both effective solute clearance and also fluid removal, the extracorporeal circuits must operate continuously. Thus, preventing clotting in the CRRT circuit is a key goal to effective patient management. As these patients may also be at increased risk of bleeding, regional anticoagulation with citrate is increasing in popularity, particularly following the introduction of commercially available CRRT machines and fluids specifically designed for citrate anticoagulation. Although regional anticoagulation with citrate provides many advantages over other systemic anticoagulants, excess citrate may lead to both metabolic complications, ranging from acidosis to alkalosis and may also potentially expose patients to electrolyte disturbances due to hyper- and hyponatraemia and hyper- and hypocalcaemia.

Renal involvement in Neimann-Pick Disease

Grafft, C. A., Fervenza, F. C., Semret, M. H., Orloff, S., Sethi, S. — Thu, 19 Nov 2009 11:11:32 PST

We describe the renal biopsy findings in a 14-year-old girl with Neimann-Pick disease. The renal biopsy showed chronic changes involving all components of the parenchyma, including focal global glomerulosclerosis, tubular atrophy, interstitial fibrosis and vascular sclerosis. On light microscopy, significant findings included foamy podocytes, vacuolated tubular epithelial cells and collections of foam cells in the interstitium. Electron microscopy was confirmatory which showed myelin-like inclusions in podocytes, endothelial cells, tubular epithelial cells and small nerves. The findings are similar to Fabry's disease, except that small nerve involvement appears to be unique to Neimann Pick disease.

Nephrotic syndrome associated with immune thrombocytopenia revealing Kimura's disease in a non-Asian male

Noel, N., Meignin, V., Rosenstingl, S., Ronco, P., Boffa, J.-J. — Thu, 19 Nov 2009 11:11:32 PST

We report the case of a young Caucasian man presenting with diffuse oedema and nephrotic syndrome. Clinical examination revealed multiple lymphadenopathies. Histological examination was consistent with the diagnosis of Kimura's disease. A renal biopsy showed focal segmental glomerulosclerosis. Immune thrombocytopenia and signs of humoral autoimmunity were discovered. Corticosteroid treatment induced remission of nephrotic syndrome but relapses occurred 12 and 18 months after onset of treatment while the patient was receiving 20 mg prednisone once a day. To our knowledge, this is the first case of Kimura's disease and nephrotic syndrome associated with B-cell autoreactivity.

Isolated microalbuminuria as the first clinical presentation of Fabry disease in an adult heterozygous female

Thu, 19 Nov 2009 11:11:32 PST

Fabry disease (FD) is a rare X-linked disorder characterized by low or absent activity of the lysosomal enzyme -glycosidase-A that leads to progressive accumulation of glycosphingolipids in different organs and tissues. Clinical manifestations vary from classic to atypical forms characterized by one prevalent organ involvement, and a renal variant has been described in men but not in women. However, little is known about renal manifestation in females affected by FD. We herein report a case of a 22-year-old female with isolated and persistent microalbuminuria as the only sign of FD. In light of the importance of early recognition and treatment of FD organ damage, this case should call for future studies to determine how to assess organ damage, investigate the existence of a ‘renal variant’ in FD female patients and determine when best to start enzyme replacement therapy (ERT).

A case of adult atypical haemolytic uraemic syndrome related to anti-factor H autoantibodies successfully treated by plasma exchange, corticosteroids and rituximab

Lionet, A., Provot, F., Glowacki, F., Fremeaux-Bacchi, V., Hazzan, M. — Thu, 19 Nov 2009 11:11:32 PST

Complement factor H auto-antibodies (CFH-ab) are a rare cause (6–10%) of atypical haemolytic uraemic syndrome (aHUS). All observations previously described were retrospective and occurred in children or teenagers. We report the first case of aHUS associated with anti-CFH antibodies in an adult patient who was successfully treated by plasma exchange, corticosteroids and rituximab.

MPO-ANCA crescentic glomerulonephritis complicated by membranous nephropathy: MPO demonstrated in epimembranous deposits

Thu, 19 Nov 2009 11:11:32 PST

An elderly woman presented with haematuria and proteinuria accompanied by elevated serum myeloperoxidase (MPO)-specific anti-neutrophil cytoplasmic antibodies (MPO-ANCA). A renal biopsy revealed mild mesangial proliferation with fibrocellular crescent formation and a membranous glomerular lesion. Immunofluorescence microscopy using FITC-labelled rabbit anti-human MPO antibodies revealed granular MPO deposition along the glomerular capillary walls (GCW) with a staining profile similar to that of glomerular IgG deposition. The one-year follow-up renal biopsy revealed minimal IgG and undetectable MPO deposition. Both MPO and MPO-ANCA might have been responsible for the IgG immune depositions along the GCW in this patient.

Acute renal failure, systemic lupus erythematosus and thrombotic microangiopathy following treatment with beta-interferon for multiple sclerosis: case report and review of the literature

Hansen, T., New, D., Reeve, R., Donne, R., Stephens, W. — Thu, 19 Nov 2009 11:11:32 PST

We report a man with type 1 diabetes mellitus, autoimmune hypothyroidism and a tentative diagnosis of multiple sclerosis. Following treatment with beta interferon, he developed systemic lupus erythematosus with pericarditis, pleural effusions, cerebral infarction associated with anti-phospholipid antibody and acute renal failure due to thrombotic microangiopathy. He responded well to immunosuppression and anticoagulation. These complications may represent the most severe autoimmune reaction to beta interferon reported to date.

Recurrent intestinal bleeding treated by double-balloon endoscopy in haemodialysis patients

Yamazaki, O., Hanafusa, N., Yamada, A., Noiri, E., Fujita, T. — Thu, 19 Nov 2009 11:11:32 PST

Gastrointestinal (GI) bleeding is a common and troublesome complication of end-stage renal disease (ESRD). Patients often have various lesions in the small bowel and in either upper or lower GI tracts. Recently developed double-balloon endoscopy (DBE) enables observation of the entire small intestine through a combination of anterograde and retrograde approaches. Moreover, DBE is useful not only for diagnosis of small intestinal lesions; it provides a mode of treating the disease. This article presents patients with several small intestinal diseases from our facility. Their bleeding sources were identified using DBE. We also report two representative cases of angiodysplasia that had been diagnosed and treated successfully using DBE. One case particularly underscored the usefulness of the combination of capsule endoscopy (CE) and DBE as an electively diagnostic approach for patients with GI bleeding. Small intestinal bleeding is often observable repeatedly in a single patient, as described for case 1. In such circumstances, DBE can treat the lesions successfully without surgical procedures. In this report, ESRD patients, in whom comorbid conditions made it difficult to perform surgical procedures, receive great benefit from DBE.

Refractory uraemic pleuropericarditis treated successfully with corticosteroid therapy

Lee, S.-Y., Hong, G.-y., Chung, J. G., Yang, D. H., Kim, H.-J. — Thu, 19 Nov 2009 11:11:32 PST

Uraemic pleuritis and pericarditis are frequently observed in chronic renal failure patients and tend to improve with continued haemodialysis. However, certain cases have been reported that do not respond to continued haemodialysis alone. A 67-year-old female on long-term haemodialysis was diagnosed with uraemic pleuropericarditis and treated with intensive haemodialysis and given a non-steroidal anti-inflammatory drug to which she showed no response. We report a case of uraemic pleuropericarditis refractory to traditional therapy, which was treated successfully with corticosteroid therapy.

Renal clear cell carcinoma emerging in a transplanted kidney 3 years after return to dialysis. Case report and review of the literature

Elazary, R., Schlager, A., Appelbaum, L., Zamir, G., Nir, I. — Thu, 19 Nov 2009 11:11:32 PST

We present a female patient with end-stage renal disease who was referred to the emergency department with sudden, excruciating pain over the right lower abdomen and flank. Radiologic evaluation following admission revealed a mass, solid in nature, located at the upper pole of the transplanted kidney. The patient was treated with empiric antibiotics and analgesics, and her symptoms subsided over the course of the week. Based on the clinical course and radiological findings, a self-limiting, spontaneous haemorrhage was thought to be the cause of the patient's symptoms. Nevertheless, background malignancy could not be ruled out. Therefore, an interval, elective graft nephrectomy was scheduled. Pathology confirmed the diagnosis of renal clear cell carcinoma.

Improvement of cardiac function after kidney transplantation with dilated cardiomyopathy and long dialysis vintage

Mimura, I., Kawarazaki, H., Momose, T., Shibagaki, Y., Fujita, T. — Thu, 19 Nov 2009 11:11:32 PST

Patients with long dialysis vintage have low cardiac output for various reasons. Although kidney transplantation is known to improve cardiac mortality, patients are sometimes evaluated as contraindicated for transplantation because of cardiac risk. We successfully performed kidney transplantation for a patient with a long dialysis vintage and dilated cardiomyopathy. Sequential ¹²³I-metaiodobenzylguanidine (¹²³I-MIBG) scintigraphy suggested that amelioration of uraemia improved cardiac function. Kidney transplantation for patients with severely impaired cardiac function is safe and effective under careful perioperative monitoring irrespective of dialysis vintage. Sequential ¹²³I-MIBG scintigraphy can be used as an evaluation tool for the improvement in cardiac function.

Hereditary nephrogenic diabetes insipidus: a major conundrum during labour and delivery

Castillo, E., Magee, L. A., Bichet, D., Halperin, M. — Thu, 19 Nov 2009 11:11:32 PST

Star fruit: simultaneous neurotoxic and nephrotoxic effects in people with previously normal renal function

Thu, 19 Nov 2009 11:11:32 PST

C-peptide and combined kidney-pancreas transplantation

Bhargava, R., Mitsides, N., Saif, I., MacDowall, P., Woywodt, A. — Thu, 19 Nov 2009 11:11:32 PST

'Stone'-blindness

Sundaram, M., Mohapatra, A., John, G. T. — Thu, 19 Nov 2009 11:11:32 PST

The 'Double Dutch' Doppler

Mitsides, N., Maginnis, P., Woywodt, A. — Thu, 19 Nov 2009 11:11:32 PST

Secondary hyperoxaluria and urinary crystal casts after intestinal resection

Almeida, J. R., Lutz, F. B., de Carvalho, E. D., da Silva, P. R. A. — Thu, 19 Nov 2009 11:11:32 PST

Metastatic pulmonary calcification in a patient with long dialysis vintage

Yazawa, M., Shibagaki, Y., Konno, Y., Yasuda, T., Kimura, K. — Thu, 19 Nov 2009 11:11:32 PST

Haematuria and hydronephrosis caused by Castleman's disease

Lee, T. H., Kim, W., Jeong, Y. B., Jang, K. Y., Park, S. K. — Thu, 19 Nov 2009 11:11:32 PST

Calcification of the liver in a patient on renal replacement therapy diagnosed with systemic calciphylaxis

Ladino, M., Sadhu, S., Ortega, L. M. — Thu, 19 Nov 2009 11:11:32 PST

Occult hepatitis B virus infection in a Sicilian chronic dialysis population

Li Cavoli, G., Ferrantelli, A., Tralongo, A., Schillaci, O., Rotolo, U. — Thu, 19 Nov 2009 11:11:32 PST

H1N1 infection and acute kidney injury in the critically ill

Trimarchi, H., Greloni, G., Campolo-Girard, V., Rosa-Diez, G. — Thu, 19 Nov 2009 11:11:32 PST

Thalidomide-induced heart block in a dialysis patient

Anwar, S., Chawathey, K., Holt, S. — Thu, 19 Nov 2009 11:11:32 PST

Adherence to guideline recommendations for infection prophylaxis in peritoneal dialysis patients

Badve, S. V., Smith, A., Hawley, C. M., Johnson, D. W. — Thu, 19 Nov 2009 11:11:32 PST

A single-dose vancomycin application after standard protocol in peritoneal dialysis patients with recurrent peritonitis

Usta, M., Ersoy, A., Ucar, E. — Thu, 19 Nov 2009 11:11:32 PST

Biocompatibility of peritoneal dialysis solutions determined by genomics of human leucocytes: a cross-over study

Thu, 19 Nov 2009 11:11:32 PST

Crescentic glomerulonephritis in a patient with advanced lung cancer during erlotinib therapy

Kurita, N., Mise, N., Fujii, A., Ikeda, S., Sugimoto, T. — Thu, 19 Nov 2009 11:11:33 PST

The 2007 ERA-EDTA Registry Annual Report--a Precis

Stel, V. S., Kramer, A., Zoccali, C., Jager, K. J. — Thu, 19 Nov 2009 11:11:33 PST

Promoting scientific collaboration and education in cardiovascular-renal medicine: EURECAM: An ERA-EDTA-based working group

Thu, 19 Nov 2009 11:11:33 PST