Pyeloduodenal fistula successfully treated by endoscopic ligation without surgical nephrectomy: case report

A 74-yr-old woman presented with fever and abdominal discomfort. She was in a septic condition caused by urinary tract infection. Her computed tomogram of the abdomen revealed features of hydronephrosis with ureteral stones in both kidneys. During percutaneous nephrostomies, right pyeloduodenal fistula (PDF) was diagnosed. Elective surgery was originally planned but the patient was in a poor condition to undergo surgery. Instead, 2 times endoscopic clipping and ligation by endoloop were applied with parenteral antibiotics for the fistula lesion. On admission day 30, she was discharged from the hospital after confirmation of no more contrast leakage on fistulography. We reviewed the literature and discuss the etiologies, clinical presentations, diagnosis, and treatment of PDF.

Decreased renal function is an independent predictor of severity of coronary artery disease: an application of Gensini score

Coronary artery disease (CAD) is the leading cause of death in patients with chronic kidney disease (CKD).Although many studies have shown a higher prevalence of CAD among these patients, the association between the spectrum of renal dysfunction and severity of CAD remains unclear. In this study, we investigate the association between renal function and the severity of CAD. We retrospectively reviewed the medical records of 1,192 patients who underwent elective coronary angiography (CAG). The severity of CAD was evaluated by Gensini score according to the degree of luminal narrowing and location(s) of obstruction in the involved main coronary artery. In all patients, the estimated glomerular filtration rate (eGFR) was independently associated with Gensini score (β=-0.27, P < 0.001) in addition to diabetes mellitus (β=0.07, P = 0.02), hypertension (β=0.12, P < 0.001), low density lipoprotein (LDL)-cholesterol (β=0.08, P = 0.003), and hemoglobin (β=-0.07, P = 0.03) after controlling for other confounding factors. The result of this study demonstrates that decreased renal function is associated not only with the prevalence, but also the severity, of CAD.

Clinical features of patients with stress-induced cardiomyopathy associated with renal dysfunction: 7 case series in single center

Background

Stress-induced cardiomyopathy (sCMP) is characterized by transient wall-motion abnormalities involving the left ventricular apex and mid-ventricle that are precipitated by emotional or physical stress. As the heart and kidney influence each other’s function through bidirectional pathways, sCMP can induce renal dysfunction or be induced by renal dysfunction. This study reviewed the clinical characteristics and outcomes of patients with confirmed sCMP associated with renal dysfunction.

Methods

We conducted a retrospective analysis of the medical records of all patients from our institution who were diagnosed with sCMP from March 2010 to April 2012. Each patient’s demographic characteristics, presenting symptoms, triggering events, electrocardiographic characteristics, laboratory data, echocardiographic study findings, cardiac catheterization data, and outcomes were reviewed.

Results

Among 30 patients who were diagnosed with sCMP, 7 patients had associated renal dysfunction. Three patients were on maintenance hemodialysis (HD) and 4 patients had acute kidney injury (AKI). Their mean ejection fraction was 35.2% at initial echocardiography, and 57.2% at follow-up echocardiography. Pericardial effusion was detected in all HD patients initially; these patients were treated with intensive HD for suspected under-dialysis status. In patients with AKI, the mean peak serum creatinine was 4.17 mg/dL. Two patients were treated with continuous renal replacement therapy. One patient required maintenance HD, and 1 patient died. Two patients had full renal recovery to their baseline renal function at 7 and 14 days.

Conclusions

Patients with renal dysfunction including those with AKI and those undergoing HD can develop sCMP, renal function must be closely monitored in patients with sCMP. Additionally, it should be considered that patients on HD who develop sCMP may be under-dialyzed.

Erratum: Use of low-dose sulodexide in IgA nephropathy patients on renin-angiotensin system blockades [Volume 31, Issue 3, September 2012, Pages 163-169]

[This corrects the article DOI: 10.1016/j.krcp.2012.06.006.].

Use of low-dose sulodexide in IgA nephropathy patients on renin–angiotensin system blockades

Background

Methods

Results

Conclusion

Bladder rupture in immediate postrenal transplant period of uncertain cause

Bladder rupture in patients undergoing renal transplant is rare. A 26-year-old man underwent a deceased-donor renal transplant. Postoperatively, he showed a good clinical course, but after removal of the urethral catheter, he complained of pain in the lower aspect of the abdomen and in the left flank. Findings of abdominal computed tomography and retrograde cystography revealed an extraperitoneal bladder rupture. We did not identify specific causes for this condition and believe that the bladder rupture was spontaneous. However, we could not rule out the possibility of traumatic rupture by the double-J ureteral stent. We decided to manage this case conservatively, with an indwelling urethral catheter and antibiotics, instead of by surgical repair. Results of repeated serial cystography during the treatment showed decreased contrast extravasation, and cystographic findings at 6 weeks showed no leakage of contrast medium. We confirmed complete healing of the ruptured bladder and removed the urethral catheter. Since then, the patient has maintained good renal function without any complications.

An explorative analysis of secretory receptor for advanced glycation endproducts in primary focal segmental glomerulosclerosis

BACKGROUND

Despite remarkable medical progress, the main pathogenetic mechanisms of focal segmental glomerulosclerosis (FSGS) have not been fully delineated and its prognosis is poor at present. Recently, it was revealed that the receptor for advanced glycation endproducts (RAGE) was highly expressed at the base of podocytes with an up-regulation mainly in diabetic nephropathy. However, there is no report about the association between glomerulonephritis and RAGE. The aims of the current study were to explore the relationships between several clinical parameters and circulating soluble RAGE in primary FSGS and compare serum levels in primary FSGS with immunoglobulin A nephropathy (IgAN) and controls.

METHODS

A total of 35 subjects aged >18 years were enrolled. Thirty-five subjects consisted of three groups: primary FSGS (N = 15), IgAN (N = 10), and normal controls (N = 10). Laboratory measurements of serum carboxymethyl-lysin (CML), soluble RAGE (sRAGE), and endogenous secretory RAGE (esRAGE) were performed.

RESULTS

Serum esRAGE level in the FSGS group was higher than that in the IgAN group (0.55 ± 0.32 ng/mL vs. 0.27 ± 0.11 ng/mL, p = 0.013). There was no statistical difference between sRAGE and CML among the three groups. Within the FSGS group, esRAGE, but not sRAGE, was positively correlated with 24-h urinary protein (r = 0.553, p = 0.033) and negatively correlated with body mass index (r = -0.623, p = 0.013). In stepwise multiple regression analysis, body mass index and 24-h urinary protein were significant contributors to esRAGE within the FSGS group.

CONCLUSION

This study showed that only the serum level of esRAGE, not sRAGE, was higher in the FSGS group than in the IgAN and control groups. The amount of 24-h proteinuria was also related to the serum level of esRAGE in the FSGS group.

A case of severe acute kidney injury by near-drowning

Acute kidney injury (AKI) secondary to near-drowning is rarely described and poorly understood. Only few cases of severe isolated AKI resulting from near-drowning exist in the literature. We report a case of near-drowning who developed to isolated AKI due to acute tubular necrosis (ATN) requiring dialysis. A 21-yr-old man who recovered from near-drowning in freshwater 3 days earlier was admitted to our hospital with anuria and elevated level of serum creatinine. He needed five sessions of hemodialysis and then renal function recovered spontaneously. Renal biopsy confirmed ATN. We review the existing literature on near-drowning-induced AKI and discuss the possible pathogenesis.

Pandemic H1N1 influenza A viral infection complicated by atypical hemolytic uremic syndrome and diffuse alveolar hemorrhage

We report here on a case of a 27-year-old man with atypical hemolytic uremic syndrome and diffuse alveolar hemorrhage associated with influenza A H1N1 infection. Treatment with oseltamivir, plasma exchange and hemodiafiltration for the hemolytic uremic syndrome and meticulous supportive care with steroid pulse therapy for the pulmonary alveolar hemorrhage was successful in this case. We discuss the relationship between hemolytic uremic syndrome and influenza A and the underlying immunologic factors that should be tested in a patient with atypical hemolytic uremic syndrome. We also discuss using steroid therapy for patients with H1N1-related diffuse alveolar hemorrhage.

Genetic predisposition of donors affects the allograft outcome in kidney transplantation; polymorphisms of stromal-derived factor-1 and CXC receptor 4

Genetic interaction between donor and recipient may dictate the impending responses after transplantation. In this study, we evaluated the role of the genetic predispositions of stromal-derived factor-1 (SDF1) [rs1801157 (G>A)] and CXC receptor 4 (CXCR4) [rs2228014 (C>T)] on renal allograft outcomes. A total of 335 pairs of recipients and donors were enrolled. Biopsy-proven acute rejection (BPAR) and long-term graft survival were traced. Despite similar allele frequencies between donors and recipients, minor allele of SDF1 rs1801157 (GA+AA) from donor, not from recipients, has a protective effect on the development of BPAR compared to wild type donor (GG) (P = 0.005). Adjustment for multiple covariates did not affect this result (odds ratio 0.39, 95% C.I 0.20–0.76, P = 0.006). CXCR4 rs2228014 polymorphisms from donor or recipient did not affect the incidence of acute rejection. SDF1 was differentially expressed in renal tubular epithelium with acute rejection according to genetic variations of donor rs1801157 showing higher expressions in the grafts from GG donors. Contrary to the development of BPAR, the presence of minor allele rs1801157 A, especially homozygocity, predisposed poor graft survival (P = 0.001). This association was significant after adjusting for several risk factors (hazard ratio 3.01; 95% C.I = 1.19–7.60; P = 0.020). The allelic variation of recipients, however, was not associated with graft loss. A donor-derived genetic polymorphism of SDF1 has influenced the graft outcome. Thus, the genetic predisposition of donor should be carefully considered in transplantation.

Acute kidney injury due to menstruation-related disseminated intravascular coagulation in an adenomyosis patient: a case report

The authors report a case of acute kidney injury (AKI) resulting from menstruation-related disseminated intravascular coagulation (DIC) in an adenomyosis patient. A 40-yr-old woman who had received gonadotropin for ovulation induction therapy presented with anuria and an elevated serum creatinine level. Her medical history showed primary infertility with diffuse adenomyosis. On admission, her pregnancy test was negative and her menstrual cycle had started 1 day previously. Laboratory data were consistent with DIC, and it was believed to be related to myometrial injury resulting from heavy intramyometrial menstrual flow. Gonadotropin is considered to play an important role in the development of fulminant DIC. This rare case suggests that physicians should be aware that gonadotropin may provoke fulminant DIC in women with adenomyosis.

Effects of celecoxib and nordihydroguaiaretic acid on puromycin aminonucleoside-induced nephrosis in the rat

The selective cyclooxygenase-2 (COX-2) and 5-lipoxygenase (LOX) inhibitors might inhibit prostaglandin synthesis and reduce proteinuria. The present study was designed to investigate the anti-proteinuric effects of nordihydroguaiaretic acid (NDGA) as compared with celecoxib in puromycin aminonucleoside (PAN) nephrosis rats. Fifty five male Sprague-Dawley rats were divided into 4 groups; A, normal control; B, PAN group; C, PAN+COX-2 inhibitor (celecoxib) group; and D, PAN+5-LOX inhibitor (NDGA) group. After induction of PAN nephrosis through repeated injections of PAN (7.5 and 15 mg/100 g body weight), rats were treated with celecoxib, NDGA, or vehicle for 2 weeks. Twenty four hour urine protein excretions were significantly lower in PAN+celecoxib and PAN+NDGA groups than in PAN group. Serum creatinine (SCr) concentrations and 24 hr urine creatinine clearances (CCr) were not significantly different in the four groups. Electron microscopy showed that podocyte morphology was changed after the induction of PAN nephrosis and was recovered after celecoxib or NDGA administration. Celecoxib significantly recovered the expressions of nephrin, CD2AP, COX-2, and TGF-beta. NDGA also recovered TGF-beta expression, but did not alter the expressions of nephrin, CD2AP and COX-2. The present study suggested that celecoxib and NDGA might effectively reduce proteinuria in nephrotic syndrome without impairing renal function.

Post-treatment effects of erythropoietin and nordihydroguaiaretic acid on recovery from cisplatin-induced acute renal failure in the rat

5-lipoxygenase inhibitor and human recombinant erythropoietin might accelerate renal recovery in cisplatin-induced acute renal failure rats. Male Sprague-Dawley rats were randomized into four groups: 1) normal controls; 2) Cisplatin group-cisplatin induced acute renal failure (ARF) plus vehicle treatment; 3) Cisplatin+nordihydroguaiaretic acid (NDGA) group-cisplatin induced ARF plus 5-lipoxygenase inhibitor treatment; 4) Cisplatin+erythropoietin (EPO) group-cisplatin induced ARF plus erythropoietin treatment. On day 10 (after 7 daily injections of NDGA or EPO), urea nitrogen and serum Cr concentrations were significantly lower in the Cisplatin+NDGA and Cisplatin+EPO groups than in the Cisplatin group, and 24 hr urine Cr clearances were significantly higher in the Cisplatin+EPO group than in the Cisplatin group. Semi-quantitative assessments of histological lesions did not produce any significant differences between the three treatment groups. Numbers of PCNA(+) cells were significantly higher in Cisplatin, Cisplatin+NDGA, and Cisplatin+EPO groups than in normal controls. Those PCNA(+) cells were significantly increased in Cisplatin+NDGA group. These results suggest that EPO and also NDGA accelerate renal function recovery by stimulating tubular epithelial cell regeneration.

The prevalence of low triiodothyronine according to the stage of chronic kidney disease in subjects with a normal thyroid-stimulating hormone

BACKGROUND

We hypothesized that the prevalence of low T3 would be increased according to the increase in CKD stage. This study was performed to explore the prevalence in each stage of CKD and relationship with eGFR.

METHODS

A total of 2284 cases with normal thyroid-stimulating hormone (TSH) level were enrolled and retrospectively analysed during the recent period, from July 2005 to December 2007.

RESULTS

There was an increasing trend for the population of low T3 according to the increase of a CKD stage (eGFR > or = 90, 8.2%; > or = 60 eGFR < 90, 10.9%; > or = 30 eGFR < 60, 20.8%; > or = 15 eGFR < 30, 60.6%; eGFR < 15, 78.6%). Also, there was positive relationship between eGFR and serum T3 in male, female and total subjects. After adjusting for age and sex, compared with eGFR > or = 60 ml/min/ 1.73 m2, eGFR < 60 ml/min/1.73 m2 was associated with an increased odds of low T3 [odds ratio 2.40 (CI: 1.5315 to 3.1731)]. In multiple regression analysis, eGFR was positively related with T3 (standardized coefficient 0.143, R2 = 0.055, P < 0.001), independent of age and serum albumin.

CONCLUSION

This study showed that low T3 syndrome was highly prevalent in CKD and was a remarkable finding in early CKD. Furthermore, serum T3 levels were associated with severity of CKD even in the normal TSH level.

Recent clinical overview of renal and perirenal abscesses in 56 consecutive cases

BACKGROUND/AIMS

The aim of this study was to examine the recent clinical trends and antibiotic susceptibilities of the causative microorganisms in renal and perirenal abscesses, and to elucidate the factors associated with treatment strategies.

METHODS

We retrospectively analyzed 56 patients who were diagnosed with renal and perirenal abscesses at our hospital from January 2000 to September 2007.

RESULTS

The mean age of the patients was 53.5 years, and a female predominance of patients (75%) was observed. Diabetes mellitus (44.6%) was the most common predisposing condition. The mean duration of symptoms before diagnosis was 11.6 days, and fever (75%) was the most common symptom. Escherichia coli (44%) and Klebsiella pneumoniae (28%) were common pathogens, and the rates of susceptibility of E. coli isolates to ampicillin, cephalothin, cefotaxime, trimethoprim-sulfamethoxazole, ciprofloxacin, gentamicin, and imipenem were 18.2%, 27.3%, 72.7%, 72.7%, 63.6%, 63.6%, and 100%, respectively. Abscesses were classified according to the location as follows: renal abscess (n=31, 55.4%) and perirenal abscess +/- renal abscess (n=25, 44.6%). In the renal abscess group, the infection rate of gram-negative organisms was higher than in the perirenal abscess group. Patients were also divided according to the treatment modality: antibiotics only (n=20, 35.7%) and percutaneous intervention or surgery (n=36, 64.3%). Patients who had a perirenal abscess or a large renal abscess required more invasive treatment.

CONCLUSIONS

This study revealed somewhat different results from those of previous studies. Clinical and microbial differences were observed between the renal and perirenal abscess groups. Abscess location and the size of the renal abscess were the factors associated with treatment strategies.

Distinctive role of donor strain immature dendritic cells in the creation of allograft tolerance

Dendritic cells (DCs) are pivotal antigen-presenting cells and serve a unique role in initiating immunity. To test the hypothesis that pre-immunization of recipient with certain DC subsets of donor origin can influence graft outcome, we have studied the effects of immunization with allogeneic CD4(+)CD8(-)CD11c(+) dendritic cell (CD4(+)DC) and CD4(-)CD8(+)CD11c(+) dendritic cell (CD8(+)DC) on the allograft response. Although both immature CD4(+)DC and CD8(+)DC subsets from DBA/2 were able to prime naive allogeneic C57BL/6 (B6) T cells in mixed lymphocyte reaction (MLR), CD8(+)DC exerted more vigorous alloimmune responses than CD4(+)DC did. Also, CD4(+)DC-driven allogeneic T cell response was attenuated more significantly by anti-CD154 mAb than CD8(+)DC-driven response. Consistent with the MLR results, combined pre-treatment with CD4(+)DC, but not CD8(+)DC, plus anti-CD154 mAb produced donor strain-specific long-term graft survival and induced tolerance while treatment with CD8(+)DC plus anti-CD154 mAb created minimal prolongation of allograft survival in a pancreas islet transplant model (DBA/2-->B6). The beneficial effects exerted by CD4(+)DC and anti-CD154 mAb pre-treatment were correlated with T(h)1 to T(h)2 immune deviation and with the amplified donor-specific suppressive capacity by recipient CD4(+)CD25(+) T cells. These findings highlight the capacity of CD4(+)DC to modulate alloimmune responses, and suggest therapeutic approaches for the induction of donor-specific tolerance.