Course and outcome of dialysis pericarditis in diabetic patients treated with maintenance hemodialysis

INTRODUCTION

This observational study investigated the course and outcome of dialysis pericarditis in diabetic dialysis patients, as previous reports found that in contrast to uremic pericarditis, which responds in most cases to intensive hemodialysis, dialysis pericarditis resolves with intensification of hemodialysis in fewer cases.

METHODS

From 2002 through 2006, 88 maintenance hemodialysis patients (47 diabetic and 41 non-diabetic) were referred for management of dialysis pericarditis.

RESULTS

Dialysis pericarditis in 85.1% of diabetic and 82.9% of non-diabetic patients improved following institution of intensive hemodialysis. For the few unresponsive and critical cases, 8.5% of diabetic and 7.3% of non-diabetic patients received pericardiocentesis, whereas 6.4% of diabetic and 9.8% of non-diabetic patients received surgical drainage. In terms of outcome, 85.1, 4.3 and 10.6% of diabetic patients were alive without recurrence, alive with recurrence and deceased, respectively. There was no significant difference with their non-diabetic counterparts, for which the percentages were 87.8, 4.9 and 7.3%, respectively (p > 0.05). Kaplan-Meier analysis did not find any significant difference in survival as well (p > 0.05).

CONCLUSION

Whether used in diabetics or not, intensive hemodialysis remains the primary and most effective dialysis pericarditis treatment, whereas pericardiocentesis or surgical drainage should be reserved for the few unresponsive and critical cases.

Blood eosinophilia, corticoadrenal insufficiency and eosinophilic cystitis

Blood eosinophilia generally indicates an underlying allergic, infectious or hematologic disease. Corticoadrenal insufficiency is known to be another cause of blood eosinophilia. Eosinophilic cystitis is a rare disease in which the bladder wall is infiltrated by eosinophils; however, the etiology of eosinophilic cystitis remains unclear. We report a case of corticoadrenal insufficiency with blood eosinophilia developing gross hematuria and eosinophilic cystitis. The patient was treated with medical therapy, including oral corticosteroids, obtaining excellent results.

Blood lead levels, malnutrition, inflammation, and mortality in patients with diabetes treated by long-term hemodialysis

BACKGROUND

Blood lead levels (BLLs) are associated with mortality in the general population. The clinical significance of BLLs in long-term hemodialysis (HD) patients with diabetes is unknown.

STUDY DESIGN

A cross-sectional and 1-year prospective study.

SETTINGS & PARTICIPANTS

211 patients with diabetes on long-term HD therapy at 3 centers.

PREDICTOR

BLLs measured before HD at baseline, categorized as abnormal (>20 microg/dL), high normal (10 to 20 microg/dL), and low normal (<10 microg/dL).

OUTCOMES & MEASUREMENTS

Malnutrition, defined as serum albumin level less than 3.6 g/dL, and inflammation, defined as high-sensitivity C-reactive protein level greater than 3 mg/dL, for cross-sectional analyses. Mortality and cause of death for longitudinal analyses.

RESULTS

34, 112, and 65 patients had abnormal, high-normal, and low-normal BLLs at baseline. At baseline, patients with abnormal BLLs had a greater proportion of malnutrition (14.7% versus 1.5% and 11.6%; P = 0.01) and inflammation (76.5% versus 52.3% and 50.9%; P = 0.01) than those with low- and high-normal BLLs. Backward stepwise regression analysis found that high-sensitivity C-reactive protein level correlated positively and albumin level correlated negatively with BLLs after other confounders were adjusted. At the end of follow-up, 16 patients had died. Kaplan-Meier analysis showed that patients with an abnormal BLL had greater mortality than those with low and low-normal BLLs (P = 0.004).

LIMITATIONS

Small sample size, sparse outcomes, and limited follow-up.

CONCLUSIONS

BLL may contribute to inflammation and nutritional status in long-term HD patients with diabetes on long-term HD therapy and may relate to 1-year mortality in these patients.

The quality of hemodialysis in patients with mental retardation

BACKGROUND

Mentally retarded renal failure patients receiving hemodialysis (HD) comprise a small group of HD patients. There was no previous study describing how to manage these patients during HD and if they could achieve adequate dialysis quality.

METHODS

We reported seven cases of mentally retarded patients with renal failure among 1224 patients receiving hemodialysis. Demographic and medical data were obtained from chart reviews and hospital information system. Parameters for dialysis quality were calculated.

RESULTS

These mentally retarded patients ranged from 19 to 34 years of age (mean: 27.5 +/- 5.0 year-old), with six females and one male. The HD duration ranged from 24 to 84 months (mean: 54.6 +/- 27.2 months). The most common problem the medical stuff would encounter when they care mentally retarded dialysis patients is the maintenance of a smooth HD process due to the non-cooperation of these patients. Physical restriction or sedative agents such as diazepam, alprazolam, or chloral hydrate were prescribed in these patients for their irritability during HD session. All seven patients had good family support and care. The dialysis adequacy and nutritional parameters of these patients all met the guidelines suggested by the National Kidney Foundation Dialysis Outcome Quality Initiative (K/DOQI).

CONCLUSION

Mentally retarded uremic patients can have good dialysis quality.

Transforming growth factor-beta1 decreases epithelial sodium channel functionality in renal collecting duct cells via a Smad4-dependent pathway

BACKGROUND

Transformation growth factor-beta1 (TGF-beta1) inhibits transepithelial sodium transport and suppresses the epithelial sodium channel (ENaC) in many different types of epithelial cells; however, the molecular mechanism of this effect in the kidney is still not clear. The aim of this study was to examine the regulation of transepithelial sodium transport by TGF-beta1 in renal cells.

METHODS

We derived stable mouse cortical collecting duct cell lines that overexpressed Smad4 or N-termianl truncated Smad4, and studied the effects of TGF-beta1 on them. The equivalent electrical current (I(eq)) was taken as representing transepithelial current and the amiloride sensitive short circuit current (AmsIsc) as representing the ENaC activity. We used real-time PCR to quantify the expression of ENaC and measurement of the luciferase activity of cells transiently transfected with a mouse alpha-ENaC promoter to assess the alpha-ENaC promoter activity. Result. The administration of TGF-beta1 decreased I(eq), mainly as a result of the decrease of AmsIsc, and it correlated with inhibition of the alpha-ENaC mRNA expression. The overexpression of Smad4 led to a decrease in AmsIsc, alpha-ENaC mRNA and alpha-ENaC promoter activity, but the overexpression of the N-terminal truncated Smad4 did not induce these changes. The TGF-beta1-induced reduction of AmsIsc was alleviated in the N-terminal truncated Smad4-overexpressed cells.

CONCLUSION

It appears that the N-terminus region of Smad4 is indispensable in Smad4-mediated inhibition of the transepithelial sodium transport. TGF-beta1 may decrease the ENaC functionality via a Smad4-dependent pathway.

The gastrointestinal tract stem cell niche

The gastrointestinal epithelium is unique in that cell proliferation, differentiation, and apoptosis occur in an orderly fashion along the crypt-villus axis. The intestinal crypt is mainly a proliferative compartment, is monoclonal and is maintained by stem cells. The villus represents the differentiated compartment, and is polyclonal as it receives cells from multiple crypts. In the small intestine, cell migration begins near the base of the crypt, and cells migrate from here emerging onto the villi. The basal crypt cells at position 5 are candidate stem cells. As the function of stem cells is to maintain the integrity of the intestinal epithelium, it must self-renew, proliferate, and differentiate within a protective niche. This niche is made up of proliferating and differentiating epithelial cells and surrounding mesenchymal cells. These mesenchymal cells promote the epithelial- mesenchymal crosstalk required to maintain the niche. A stochastic model of cell division has been proposed to explain how a single common ancestral stem cell exists from which all stem cells in a niche are descended. Our group has argued that these crypts then clonally expand by crypt fission, forming two daughters' crypts, and that this is the mechanism by which mutated stem cells or even cancer stem cell clones expand in the colon and in the entire gastrointestinal tract. Until recently, the differentiation potential of stem cells into adult tissues has been thought to be limited to cell lineages in the organ from which they were derived. Bone marrow cells are rare among adult stem cells regarding their abundance and role in the continuous, lifelong, physiological replenishment of circulating cells. In human and mice experiments, we have shown that bone marrow can contribute to the regeneration of intestinal myofibroblasts and thereby after epithelium following damage, through replacing the cells, which maintain the stem cells niche. Little is known about the markers characterizing the stem and transit amplifying populations of the gastrointestinal tract, although musashi-1 and hairy and enhancer of split homolog-1 have been proposed. As the mammalian gastrointestinal tract develops from the embryonic gut, it is made up of an endodermally-derived epithelium surrounded by cells of mesoderm origin. Cell signaling between these two tissue layers plays a critical role in coordinating patterning and organogenesis of the gut and its derivatives. Many lines of evidence have revealed that Wnt signaling is the most dominant force in controlling cell proliferation, differentiation, and apoptosis along the crypt-villus axis. We have found Wnt messenger RNAs expression in intestinal subepithelial myofibroblasts and frizzled messenger RNAs expression in both myofibroblasts and crypt epithelium. Moreover, there are many other factors, for example, bone morphogenetic protein, homeobox, forkhead, hedgehog, homeodomain, and platelet-derived growth factor that are also important to stem cell signaling in the gastrointestinal tract.

Long-term outcome of repeated lead chelation therapy in progressive non-diabetic chronic kidney diseases

BACKGROUND

Previous research suggest that repeated lead-chelation therapy decelerates progression of renal insufficiency in non-diabetic (non-DM) patients with high-normal body lead burden (BLB). Study findings are limited by relatively short-term follow-up and small sample size.

METHODS

A total of 116 non-DM patients with chronic kidney diseases (serum creatinine level of 1.5-3.9 mg/dl), high-normal BLB (>60 microg and <600 microg) and no lead exposure history were randomly assigned to a chelation or control group in this 4-year clinical trial. For 3 months, the 58 chelation group patients received initial lead-chelation therapy with calcium disodium EDTA, and the 58 control group patients received placebos. During the ensuing 48 months, repeated chelation therapy was administered weekly to chelation group patients unless, on repeated testing, BLB was <60 microg; the control group patients received weekly placebo infusions for 5 weeks at 6-month intervals.

RESULTS

Mean change in the glomerular filtration rate (GFR) in the chelation group was -1.8 +/- 8.8 ml/min/1.73 m(2), as compared with -12.7 +/- 8.4 ml/min/1.73 m(2) in the control group (P <0.0001) at study end. Chelation group rates of decline in the GFR was lower than that in the control group, although they had similar decline rates before chelation. At study end, 18 patients, including 15 control group patients, had elevated serum creatinine levels to two times the baseline values. Both Cox and Kaplan-Meier analysis demonstrated repeated chelation therapy was the important determining factor of progression of renal insufficiency.

CONCLUSIONS

Repeated chelation therapies can, over a four-year period, slow progression of renal insufficiency in non-DM patients with high-normal BLB.

The cellular origin and proliferative status of regenerating renal parenchyma after mercuric chloride damage and erythropoietin treatment

OBJECTIVES

In this study, we have sought to establish the cellular origin and proliferative status of the renal parenchyma as it regenerates after damage induced by mercuric chloride, with or without erythropoietin treatments, that might alter the response.

MATERIALS AND METHODS

Female mice were irradiated and male whole bone marrow was transplanted into them. Six weeks later recipient mice were assigned to one of four groups: control, mercuric chloride treated, erythropoietin treated and treated with mercuric chloride plus erythropoietin.

RESULTS

Tubular injury scores were high 3 days after mercuric chloride and had recovered partially after 14 days, in line with serum urea nitrogen levels. Confocal microscopy confirmed the tubular location of bone marrow-derived cells. A 'four-in-one' analytical technique (identifying cell origin, tubular phenotype, tubular basement membranes and S-phase status) revealed that tubular necrosis increased bone marrow derivation of renal tubular epithelium from a baseline of approximately 1.3% to approximately 4.0%. Erythropoietin increased the haematocrit, but no other effects were detected.

CONCLUSION

As 1 in 12 proximal tubular cells in S-phase was derived from bone marrow, we conclude that in the kidney, the presence of bone marrow-derived cells makes a minor but important regenerative contribution after tubular necrosis.

Does hepatitis C virus affect the reactivation of hepatitis B virus following renal transplantation?

BACKGROUND

Hepatitis B virus (HBV) is endemic in Taiwan. Transplantation followed by long-term immunosuppressive medications may precipitate HBV reactivation. Interference of hepatitis C virus (HCV) with HBV gene expression and replication has been confirmed in many studies involving non-transplant populations. This study investigates the incidence of HBV reactivation following renal transplantation and compares the clinical outcome, especially the liver outcome, of patients with or without HCV co-infection.

METHODS

Fifty-one of 512 renal transplant recipients were positive for hepatitis B surface antigen before surgery, and were followed for 81.6+/-7.5 (4-120) months. Seventeen of 51 patients acquired HCV before transplantation and six patients acquired HCV after renal transplantation.

RESULTS

At the end of this assessment, we had 28 patients who suffered HBV reactivation and another 23 patients who suffered no HBV reactivation. Initially, we found a significant difference of HCV carriage (P<0.05) between patients with (seven out of 28 or 25%) or without (21 out of 23 or 91.3%) HBV reactivation. Further inspection showed that 21 of the 28 patients without HCV co-infection and seven of the 23 patients with HCV co-infection suffered HBV reactivation. After comparison, we found a lower incidence of HBV reactivation in patients with HCV co-infection than in patients without HCV co-infection (P<0.05). In contrast to the latter, we found that patients with HCV co-infection suffering HBV reactivation tended to have a late onset of HBV reactivation (P<0.05). Otherwise, there was no difference in hepatitis severity, in terms of peak alanine aminotransferase, total bilirubin levels and hepatitis reactivation-related death, between these two groups of patients. Finally, a multivariable analysis also revealed that HCV carriage was indeed an independent variable leading to the reduced incidence of HBV reactivation in patients with HCV co-infection.

CONCLUSION

HCV might affect the reactivation of HBV by decreasing the incidence or delaying the onset of HBV reactivation in renal transplant recipients carrying both HBV and HCV.

Renal involvement in patients with polymyositis and dermatomyositis

Renal involvement in patients with polymyositis (PM)/dermatomyositis (DM) is previously thought to be uncommon, but two main types of renal lesion have been described. First, acute tubular necrosis with renal failure related to myoglobulinemia and myoglobulinuria is a well-recognised feature of acute rhabdomyolysis. Second, chronic glomerulonephritis has been infrequently reported in a small group of patients with PM/DM. This study aims at investigating the incidence, severity and prognosis of renal disease in PM/DM patients, admitted to a single centre in a 10-year interval. The hospital records of 65 Taiwanese patients with PM/DM, examined between 1992 and 2002, were studied retrospectively. Of the 65 patients, 14 were found to have suffered varying degree of renal involvement, and the incidence rate was 21.5%. All the 14 patients had varying degree of haematuria and proteinuria. Acute tubular necrosis with renal failure developed in four patients with PM and in five patients with DM. Renal biopsy in two DM patients with overt proteinuria revealed IgA nephropathy in one and membranous nephropathy in the other. We, therefore, concluded that renal involvement in PM/DM patients is not as uncommon as previously thought.

Outcome of renal transplantation in children with pericardiopleural effusion

INTRODUCTION

Children with end-stage renal disease may present with pericardiopleural effusion secondary to volume overload and overhydration. The present study was designed to investigate the efficacy and safety of renal transplantation in these pediatric patients.

METHODS

From 1981 to 2001, six of 20 patients (30%) under 18 years old who received renal transplants showed pericardiopleural effusion after serial pretransplant imaging studies. These patients also displayed associated diseases, such as congestive heart failure (n = 3), ascites (n = 2), and splenomegaly (n = 2). The recipients included five boys and one girl of mean age of 12.7 years (range, 8 to 17 years), all of whom had undergone hemodialysis before transplantation. The waiting time for grafts ranged from 1.3 to 6 years (mean = 2.6 years). Episodes of acute pulmonary edema had been observed in three patients pretransplant.

RESULTS

One recipient died with a functioning graft due to heart failure with acute pulmonary edema at 4 months after transplantation. Acute rejection episodes were observed in three, and chronic rejection in two children. The median follow-up was 11 years (range = 6 to 16 years) in the other five recipients, all of whom presently survive with functioning grafts. The posttransplant mean serum creatinine levels at 1 year, 3 years, and 5 years were 1.54 +/- 0.44, 1.74 +/- 0.56, and 1.92 +/- 0.56 mg/dL, respectively.

CONCLUSION

Renal transplantation in children displaying pericardiopleural effusion was associated with a high success rate. However, these patients must be followed closely with regular cardiopulmonary evaluation since their condition may deteriorate.

Does mycophenolate mofetil increase the incidence of infections in stable renal transplant recipients initially treated with a two-drug regimen?

BACKGROUND

A drug regimen including a calcineurin inhibitor (cyclosporine or tacrolimus) and prednisone has been the mainstay of maintenance immunosuppression in our renal transplant recipients for more than 10 years. After the introduction of mycophenolate mofetil (MMF), a new, potent immunosuppressant that may reduce the incidence of late rejection in renal transplant recipients, the immunosuppressive protocol in some recipients was changed to an MMF-based regimen. We sought to ascertain whether the addition of MMF lead to greater susceptibility to infectious complications.

PATIENTS AND METHODS

Between May 1991 and November 2002, all renal transplant recipients who received a two-drug regimen initially for more than 6 months were changed to an MMF-based regimen. The study includes patients with functional grafts for more than 6 months thereafter. Differences in the incidence, etiology, and outcome of infections were compared during the non-MMF versus the MMF periods.

RESULTS

Eighty patients of mean age of 38.6 years (range 13 to 69) included 43 men and 37 women. The mean daily MMF dose was 663 mg/patient (range 250 to 1500 mg). The mean follow-up time of non-MMF period and MMF periods were 3.4 and 2.1 years, respectively. The overall incidence of infections in the two periods was similar (0.2 infections/patient in the non-MMF period and 0.25 infections/patient in the MMF period, P = .57). No mortality was associated with these infectious complications. In conclusion, addition of MMF, a more potent immunosuppressive protocol, did not increase the incidence of infections in stable renal transplant recipients initially treated with a two-drug regimen.

Acute Poisoning with Emamectin Benzoate

BACKGROUND

Emamectin benzoate is the 4'-deoxy-4'-epi-methyl-amino benzoate salt of avermectin B1 (abamectin), which is similar structurally to natural fermentation products of Streptomyces avermitilis. Emamectin benzoate is being developed as a newer broad-spectrum insecticide for vegetables and has a very low application rate. The mechanism of action involves stimulation of high-affinity GABA receptors and a consequent increase in membrane chloride ion permeability. Animal studies indicate a wide margin of safety because mammalian species are much less sensitive due to lower GABA receptor affinities and relative impermeability of the blood-brain barrier. Notably, the literature has not reported human exposure resulting in toxicity.

CASE REPORT

This paper describes a case of acute poisoning with Proclaim insecticide (Syngenta, Taiwan), consisting of 2.15% w/w emamectin benzoate in 2, 6-bis (1, 1-dimethylethyl)-4-methyl-phenol and 1-hexanol. The clinical manifestation was transient gastrointestinal upset with endoscopy-proven gastric erosion and superficial gastritis, mild central nervous system depression, and aspiration pneumonia. No specific antidote exists for emamectin benzoate intoxication; this patient was treated successfully with gastric lavage, administration of activated charcoal, and empiric antibiotics. Drugs that enhance GABA activity such as barbiturates and benzodiazepines were avoided.

Bilateral renal infarction in chronic myelomonocytic leukemia on blast crisis

The major complications of myelodysplastic syndromes are related to cytopenia and evolution to acute myeloid leukemia. Bleeding episodes in MDS, although relatively uncommon, are often related to thrombocytopenia. Bleeding may be exacerbated by platelet dysfunction, which is also found frequently. Furthermore, the major hemostatic problem underlying hyperleukocytosis, as evident in patients with MDS on blast crisis, appears to be hemorrhage rather than thrombosis. Acute thromboembolism, which causes occlusion of blood supply and organ infarction, has rarely been observed in patients with MDS. Recently, we encountered an elderly female patient, who had chronic myelomonocytic leukemia with marked myelodysplasia, terminating in blast crisis and bilateral renal infarction. This complication rapidly led to oliguric acute renal failure and mortality.

Scrub typhus: a frequently overlooked cause of acute renal failure

Acute renal failure associated with scrub typhus infection is not rare as previously thought. The possibility of scrub typhus should be borne in mind when patients present with fever and varying degrees of acute renal failure, particularly if an eschar exists, along with a history of environmental exposure in an area like Taiwan, where scrub typhus is endemic. Prompt diagnosis and the use of appropriate antibiotics can rapidly alter the clinical course of the disease and prevent the development of serious or fatal complications. To illustrate the above point, this study reports 3 cases of scrub typhus associated with acute renal failure. They were seen at Chang Gung Memorial Hospital in a 2-year interval. Case 1 was referred from district hospital with clinical features of multiple organ dysfunctions, including shock, fever, acute respiratory failure, acute renal failure, and acute hepatitis. Case 2 was admitted with the chief problems of shock, fever, acute renal failure, and DIC. Case 3 visited our outpatient clinic due to fever, maculopapular rash and acute renal failure. In all these patients, the diagnosis was confirmed using immunofluorescence techniques, which showed that Orientia tsutsugamushi had an IgM titer of 1:80 or greater. Notably, despite having varying degrees of acute renal deterioration, the patients responded very well to doxycycline therapy and recovered completely. Additionally, a total of 4 similar cases of scrub typhus associated with acute renal failure were reviewed from the past literature.

Unexpected IgA nephropathy during the treatment of a young woman with idiopathic dermatomyositis: case report and review of the literature

This article reports the unexpected discovery of IgA nephropathy in a 26-year-old Chinese woman 1.5 years after the onset of idiopathic dermatomyositis. The patient was taking immunosuppressive agents, prednisolone 25 mg and azathioprine 75 mg daily. Glomerulonephritis associated with idiopathic polymyositis/dermatomyositis is rare. A review of the medical literature indicates that the most common pattern seen in idiopathic polymyositis is mesangial proliferative glomerulonephritis. However, both membranous and mesangial proliferative glomerulonephritis are often seen in idiopathic dermatomyositis. It is still not clear, however, whether the humorally- mediated immune process in dermatomyositis and the cell-mediated immune process in polymyositis can explain the different patterns of occurrence of glomerular lesions in these two closely related disease entities.

Acute rhabdomyolysis after gemfibrozil therapy in a pregnant patient complicated with acute pancreatitis and hypertriglycerdemia while receiving continuous veno-venous hemofiltration therapy

Gemfibrozil therapy alone can induce severe myopathy and rhabdomyolysis. This catastrophic complication had been frequently reported in renal failure patients. Dosage reduction is therefore compulsory in patients with compromised renal function, no matter which type of renal replacement therapy they receive. This study's patient clearly demonstrates that gemfibrozil can induce severe rhabdomyolysis, even in patients receiving CVVH, if the dosage is not properly adjusted.