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Kiuchi Z, Tanaka E, Nunokawa S, Yoshida S, Hosaki A, Kogure T, Narita M. Pediatric frequent relapsing nephrotic syndrome with multiple cerebral infarctions accompanied by patent foramen ovale and cerebral venous sinus thrombosis: a case report. BMC Nephrol 2024; 25:146. [PMID: 38658845 PMCID: PMC11040989 DOI: 10.1186/s12882-024-03579-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 04/17/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Idiopathic nephrotic syndrome (NS) presents as a hypercoagulable state, of which thromboembolism (TE) is a well-known life-threatening complication. Although TE is more likely to occur in venous vessels than arterial vessels, arterial TE is important because it may cause after-effects, including tissue necrosis and cerebral infarction (CI); therefore, prompt diagnosis and appropriate treatment are required. We report a pediatric NS case with multiple CIs. CASE PRESENTATION A 14-year-7-month-old Japanese girl was diagnosed with frequent relapsing NS, accompanied by headache and disturbance of consciousness during the second relapse. Brain magnetic resonance imaging (MRI) and four-dimensional computed tomography revealed multiple CIs, vasogenic edema, and cerebral venous sinus thrombosis (CVST). The patient had no underlying thrombophilia other than hypercoagulability due to NS and prednisolone (PSL), and no cardiac arrhythmia; however, a right-to-left shunt through the patent foramen ovale (PFO) was observed with the Valsalva maneuver by echocardiography. Therefore, we assumed that a potential cause of multiple CIs might be an embolic stroke, caused by thrombosis formed from a hypercoagulable state due to NS and PSL treatment and reached through PFO. Antiplatelet and anticoagulant therapies were administered for TE. She was treated with PSL and mycophenolate mofetil (MMF) for NS. Rituximab (RTX) was administered to prevent NS relapse after complete remission (CR). She underwent transcatheter PFO closure at age 14 years and 9 months because we considered that the right-to-left shunt through the PFO would be one of the risks for recurrent cerebral embolism when NS relapses. One year after the onset of CIs, an MRI indicated that the CVST had resolved, leaving no neurological sequelae due to CI; therefore, anticoagulant therapy was discontinued. And then she has been in CR for NS with only MMF therapy. CONCLUSIONS CI is a serious complication in patients with NS. The pathogenesis of multiple CIs is various, including right-to-left shunt through PFO, in addition to the hypercoagulability due to NS. It is important to investigate and manage underlying risks such as PFO, besides preventing the relapses of NS by aggressive treatments using MMF and RTX, in patients with NS.
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Affiliation(s)
- Zentaro Kiuchi
- Department of Pediatrics, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611, Japan.
| | - Eriko Tanaka
- Department of Pediatrics, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611, Japan
| | - Saaya Nunokawa
- Department of Pediatrics, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611, Japan
| | - Sawako Yoshida
- Department of Pediatrics, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611, Japan
| | - Akira Hosaki
- Department of Pediatrics, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611, Japan
| | - Tomohito Kogure
- Department of Cardiology, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Masami Narita
- Department of Pediatrics, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka-Shi, Tokyo, 181-8611, Japan
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Zhang X, Sang X, Chen Y, Yu H, Sun Y, Liang X, Zheng X, Wang X, Yang H, Bi J, Zhang L, Wang P. VCAM-1 + hUC-MSCs Exert Considerable Neuroprotection Against Cerebral Infarction in Rats by Suppression of NLRP3-Induced Pyroptosis. Neurochem Res 2023; 48:3084-3098. [PMID: 37336824 DOI: 10.1007/s11064-023-03968-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/21/2023]
Abstract
Mesenchymal stem/stromal cells (MSCs) are spindle-like heterogeneous cell populations with advantageous bidirectional immunomodulatory and hematopoietic support effects. Vascular cellular adhesion molecule-1 (VCAM-1)+ MSCs have been reported to exhibit immunoregulatory and proangiogenic capacities. Here, we studied the effects of VCAM-1+ human umbilical cord (hUC)-MSCs on neuroprotection against cerebral infarction. Sprague-Dawley rats were subjected to middle cerebral artery occlusion (MCAO), and VCAM-1- and VCAM-1+ hUC-MSCs were intravenously injected into the rat 4 h post-MCAO surgery. Thereafter, modified neurological severity scores (mNSS) were determined, and the Morris water maze test, 2,3,5-triphenyltetrazolium chloride (TTC), hematoxylin and eosin (H&E), Nissl, TUNEL staining, and qRT-PCR were conducted. Following induction of oxygen-glucose deprivation/reoxygenation (OGD/R), SH-SY5Y cells were co-cultured with VCAM-1- and VCAM-1+ hUC-MSCs. CCK-8, flow cytometry, ELISA, and western blot analyses were performed in vitro. Compared with VCAM-1- hUC-MSCs, administration of VCAM-1+ hUC-MSCs revealed improved therapeutic efficacy against cerebral infarction in rats, as confirmed by lower mNSS scores and infarct volumes, as well as improved learning and memory capacities. In addition, VCAM-1+ hUC-MSCs exhibited improved efficacy against neurological defects in rats with cerebral infarction, accompanied by inhibition of the NLRP3-mediated inflammatory response. VCAM-1+ hUC-MSC co-culture improved the viability and diminished NLRP3-mediated inflammatory response in OGD/R-treated SH-SY5Y cells. Moreover, NLRP3 overexpression in SH-SY5Y cells prevented the beneficial effects of VCAM-1+ hUC-MSC co-culture. Overall, our findings demonstrated the relevance of VCAM-1+ hUC-MSC-based cytotherapy for preclinical neuroprotection against cerebral infarction.
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Affiliation(s)
- Xiao Zhang
- Department of Neurology, The Second Hospital of Shandong University, Jinan, 250033, China
| | - Xiaoyu Sang
- Department of Neurology, The Second Hospital of Shandong University, Jinan, 250033, China
| | - Yanting Chen
- Department of Neurology, The Second Hospital of Shandong University, Jinan, 250033, China
| | - Hao Yu
- School of Medicine, Nankai University, Tianjin, 300071, China
| | - Yuan Sun
- The Second Hospital of Shandong University, Jinan, 250033, China
| | - Xilong Liang
- Department of Biostatistics, School of Public Health, Yale University, 38 Crown Street, APT 203, New Haven, CT, 06510, USA
| | - Xiaolei Zheng
- Department of Neurology, The Second Hospital of Shandong University, Jinan, 250033, China
| | - Xiao Wang
- Department of Neurology, The Second Hospital of Shandong University, Jinan, 250033, China
| | - Hui Yang
- Department of Neurology, The Second Hospital of Shandong University, Jinan, 250033, China
| | - Jianzhong Bi
- Department of Neurology, The Second Hospital of Shandong University, Jinan, 250033, China
| | - Leisheng Zhang
- Department of Neurosurgery, Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, 250014, China.
- Key Laboratory of Molecular Diagnostics and Precision Medicine for Surgical Oncology in Gansu Province and NHC Key Laboratory of Diagnosis and Therapy of Gastrointestinal Tumor, Gansu Provincial Hospital, Lanzhou, 730000, China.
- Key Laboratory of Radiation Technology and Biophysics, Hefei Institute of Physical Science, Chinese Academy of Sciences, Hefei, 230031, China.
| | - Ping Wang
- Department of Neurology, The Second Hospital of Shandong University, Jinan, 250033, China.
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3
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Wang LX, Li WH, He F. Efficacy and Safety of Electroacupuncture in the Treatment of Cerebral Infarction: Systematic Review and Meta-Analysis. Appl Bionics Biomech 2022; 2022:1350501. [PMID: 35800118 PMCID: PMC9256421 DOI: 10.1155/2022/1350501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose The goal of this study was to see if electroacupuncture was effective and safe in the management of cerebral infarction. PubMed, Embase, Cochrane Library, and Web of Science were used to conduct a comprehensive literature survey. Methods Basic features of 7 studies were identified using the searching strategy. The investigation was found in PubMed, Embase, and Web of Science, with the most recent search being in March 2022. "Electroacupuncture," "cerebral infarction," and their permutations were among the MeSH terms and free words used. As literature, two reviewers independently used a standardized form to gather pertinent data from qualifying research. Results 157 literatures were identified and evaluated. Electroacupuncture improved the BI score in individuals with cerebral infarction (mean difference = 0.10, 95 percent CI: 0.00-0.20, p = 0.04). Electroacupuncture enhanced BI score in individuals with cerebral infarction (mean difference = 0.10, 95 percent CI: 0.00-0.20, p = 0.04). The effects of electroacupuncture increased Fugl-Meyer index in patients with cerebral infarction (mean difference = 25.92, 95% CI: 25.28-26.56, p < 0.00001). Electroacupuncture effects decreased CSS in patients with cerebral infarction in the experiment group (mean difference = -2.10, 95% CI: -2.53--1.67, p < 0.0001). Electroacupuncture also reduced CSS individuals with cerebral infarction in the control group; however, there was no statistically significant (risk difference = 0.06, 95 percent CI: 0.02-0.13, p = 0.12). Conclusion This study demonstrated that electroacupuncture helped decreased CSS in patients with cerebral infarction.
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Affiliation(s)
- Lan Xiang Wang
- Department of Rehabilitation Medicine, The 8th Medical Center of Chinese PLA General Hospital, China
| | - Wei Hong Li
- Beijing University of Chinese Medicine, China
| | - Fang He
- Department of Outpatient, The 8th Medical Center of Chinese PLA General Hospital, China
- Jia NO2 Niangniang Mansion, Xiangshan Road, Haidian District, Beijing 100093, China
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4
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Revythis A, Boussios S, Ganesh V, Sarkar R. Case of cerebral venous thrombosis on a patient with background of nephrotic syndrome. BMJ Case Rep 2022; 15:e248329. [PMID: 35236700 PMCID: PMC8895991 DOI: 10.1136/bcr-2021-248329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2022] [Indexed: 11/04/2022] Open
Abstract
Hypercoagulability is a well-described feature of nephrotic syndrome. The risk of developing a venous thrombus is higher at the time of diagnosis or shortly after. The resulting deep vein thrombosis involves the pulmonary, the deep veins of the lower limbs and renal veins, as described in the literature. We present a case of a man in his 20s with background of nephrotic syndrome, diagnosed at an age of 3 years old, with multiple relapses and on maintenance immunosuppression which is unusual, in two respects: First, the site of thrombosis was in the cerebral venous sinus and second, the onset of the thrombotic episode was years after the initial diagnosis. This case report also focuses on the perspective of the patient, who experienced a rare complication after more than two decades of living with the condition. In a literature search with the search words of 'nephrotic syndrome' AND 'cerebral venous thrombosis in adults', written in English and published from 1970 to 2/2021, we could only find a review article including 5 cases and 10 individual case reports, of which there were only 16 number of cerebral sinus venous thrombosis reported.
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Affiliation(s)
- Antonios Revythis
- Department of Respiratory Medicine, Medway Maritime Hospital, Gillingham, UK
| | - Stergios Boussios
- Department of Medical Oncology, Medway Maritime Hospital, Gillingham, UK
- School of Cancer & Pharmaceutical Sciences, King's College London Faculty of Life Sciences and Medicine, London, UK
| | | | - Rahuldeb Sarkar
- Intensive Care Unit, Medway Maritime Hospital, Gillingham, UK
- Faculty of Life Sciences, King's College London, London, UK
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5
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Feito MJ, Casarrubios L, Oñaderra M, Gómez-Duro M, Arribas P, Polo-Montalvo A, Vallet-Regí M, Arcos D, Portolés MT. Response of RAW 264.7 and J774A.1 macrophages to particles and nanoparticles of a mesoporous bioactive glass: A comparative study. Colloids Surf B Biointerfaces 2021; 208:112110. [PMID: 34555654 DOI: 10.1016/j.colsurfb.2021.112110] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 12/21/2022]
Abstract
Mesoporous bioactive glasses (MBGs) are bioceramics designed to induce bone tissue regeneration and very useful materials with the ability to act as drug delivery systems. MBGs can be implanted in contact with bone tissue in different ways, as particulate material, in 3D scaffolds or as nanospheres. In this work, we assessed the effects of particles of mesoporous bioactive glass MBG-75S and mesoporous nanospheres NanoMBG-75S on RAW 264.7 and J774A.1 macrophages, which present different sensitivity and are considered as ideal models for the study of innate immune response. After evaluating several cellular parameters (morphology, size, complexity, proliferation, cell cycle and intracellular content of reactive oxygen species), the action of MBG-75S particles and NanoMBG-75S on the polarization of these macrophages towards the pro-inflammatory (M1) or reparative (M2) phenotype was determined by the expression of specific M1 (CD80) and M2 (CD206, CD163) markers. We previously measured the adsorption of albumin and fibrinogen on MBG-75S particles and the production of pro-inflammatory cytokines as TNF-α and IL-6 by macrophages in response to these particles. This comparative study demonstrates that particles of mesoporous bioactive glass MBG-75S and mesoporous nanospheres NanoMBG-75S allow the appropriated development and function of RAW 264.7 and J774A.1 macrophages and do not induce polarization towards the M1 pro-inflammatory phenotype. Therefore, considering that these mesoporous biomaterials offer the possibility of loading drugs into their pores, the results obtained indicate their high potential for use as drug-delivery systems in bone repair and osteoporosis treatments without triggering an adverse inflammatory response.
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Affiliation(s)
- M J Feito
- Departamento de Bioquímica y Biología Molecular, Facultad de Ciencias Químicas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain.
| | - L Casarrubios
- Departamento de Bioquímica y Biología Molecular, Facultad de Ciencias Químicas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - M Oñaderra
- Departamento de Bioquímica y Biología Molecular, Facultad de Ciencias Químicas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - M Gómez-Duro
- Departamento de Bioquímica y Biología Molecular, Facultad de Ciencias Químicas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - P Arribas
- Departamento de Bioquímica y Biología Molecular, Facultad de Ciencias Químicas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - A Polo-Montalvo
- Departamento de Bioquímica y Biología Molecular, Facultad de Ciencias Químicas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - M Vallet-Regí
- Departamento de Química en Ciencias Farmacéuticas, Facultad de Farmacia, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre i+12, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain; CIBER de Bioingeniería, Biomateriales y Nanomedicina, CIBER-BBN, 28040 Madrid, Spain.
| | - D Arcos
- Departamento de Química en Ciencias Farmacéuticas, Facultad de Farmacia, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre i+12, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain; CIBER de Bioingeniería, Biomateriales y Nanomedicina, CIBER-BBN, 28040 Madrid, Spain
| | - M T Portolés
- Departamento de Bioquímica y Biología Molecular, Facultad de Ciencias Químicas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; CIBER de Bioingeniería, Biomateriales y Nanomedicina, CIBER-BBN, 28040 Madrid, Spain.
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6
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Boyer O, Schaefer F, Haffner D, Bockenhauer D, Hölttä T, Bérody S, Webb H, Heselden M, Lipska-Zie˛tkiewicz BS, Ozaltin F, Levtchenko E, Vivarelli M. Management of congenital nephrotic syndrome: consensus recommendations of the ERKNet-ESPN Working Group. Nat Rev Nephrol 2021; 17:277-289. [PMID: 33514942 PMCID: PMC8128706 DOI: 10.1038/s41581-020-00384-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 01/30/2023]
Abstract
Congenital nephrotic syndrome (CNS) is a heterogeneous group of disorders characterized by nephrotic-range proteinuria, hypoalbuminaemia and oedema, which manifest in utero or during the first 3 months of life. The main cause of CNS is genetic defects in podocytes; however, it can also be caused, in rare cases, by congenital infections or maternal allo-immune disease. Management of CNS is very challenging because patients are prone to severe complications, such as haemodynamic compromise, infections, thromboses, impaired growth and kidney failure. In this consensus statement, experts from the European Reference Network for Kidney Diseases (ERKNet) and the European Society for Paediatric Nephrology (ESPN) summarize the current evidence and present recommendations for the management of CNS, including the use of renin-angiotensin system inhibitors, diuretics, anticoagulation and infection prophylaxis. Therapeutic management should be adapted to the clinical severity of the condition with the aim of maintaining intravascular euvolaemia and adequate nutrition, while preventing complications and preserving central and peripheral vessels. We do not recommend performing routine early nephrectomies but suggest that they are considered in patients with severe complications despite optimal conservative treatment, and before transplantation in patients with persisting nephrotic syndrome and/or a WT1-dominant pathogenic variant.
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Affiliation(s)
- Olivia Boyer
- grid.412134.10000 0004 0593 9113Department of Pediatric Nephrology, Reference center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Hospital, APHP, Paris, France ,grid.508487.60000 0004 7885 7602Laboratory of Hereditary Kidney Diseases, Imagine Institute, INSERM U1163, Paris Descartes University, Paris, France
| | - Franz Schaefer
- grid.7700.00000 0001 2190 4373Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Dieter Haffner
- grid.10423.340000 0000 9529 9877Department of Pediatric Kidney, Liver and Metabolic Diseases, Children’s Hospital, Hannover Medical School, Hannover, Germany ,grid.10423.340000 0000 9529 9877Center for Congenital Kidney Diseases, Center for Rare Diseases, Hannover Medical School, Hannover, Germany
| | - Detlef Bockenhauer
- grid.424537.30000 0004 5902 9895UCL Department of Renal Medicine and Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Tuula Hölttä
- grid.15485.3d0000 0000 9950 5666Department of Pediatric Nephrology and Transplantation, The New Children’s Hospital, HUS Helsinki University Hospital, Helsinki, Finland
| | - Sandra Bérody
- grid.412134.10000 0004 0593 9113Department of Pediatric Nephrology, Reference center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Hospital, APHP, Paris, France
| | - Hazel Webb
- grid.424537.30000 0004 5902 9895UCL Department of Renal Medicine and Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Beata S. Lipska-Zie˛tkiewicz
- grid.11451.300000 0001 0531 3426Clinical Genetics Unit, Department of Biology and Medical Genetics, Medical University of Gdańsk, Gdańsk, Poland ,grid.11451.300000 0001 0531 3426Centre for Rare Diseases, Medical University of Gdańsk, Gdańsk, Poland
| | - Fatih Ozaltin
- grid.14442.370000 0001 2342 7339Department of Pediatric Nephrology and Nephrogenetics Laboratory, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Elena Levtchenko
- grid.5596.f0000 0001 0668 7884Division of Pediatric Nephrology, Department of Pediatrics, University Hospitals Leuven; Department of Development & Regeneration, University of Leuven, Leuven, Belgium
| | - Marina Vivarelli
- grid.414125.70000 0001 0727 6809Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
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Huang JA, Lin CH, Chang YT, Lee CT, Wu MJ. Nephrotic Syndrome is Associated with Increased Risk of Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:104322. [PMID: 31427188 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104322] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/07/2019] [Accepted: 07/25/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND To determine if the nephrotic syndrome (NS) is an independent risk factor of ischemic stroke. METHODS This is a retrospective nationwide cohort study through an analysis of the National Health Insurance Research Database in Taiwan. To evaluate the risk of stroke, the corresponding controls were selected at a 4:1 ratio in the number of subjects, and they were matched with the study group in age, gender, Charlson comorbidity index (CCI), and index date. RESULTS From a total of 16,245 surveyed subjects, ischemic stroke occurred in 1235 (7.6%) and hemorrhagic stroke in 129 (.74%) of them. The incidence of ischemic stroke was significantly higher in patients with NS (n = 3496) compared to control patients without NS (n = 13,984) (9.92 versus 7.10, per 1000 person-year, P < .001). In the multivariate analysis, the overall adjusted hazard ratio (aHR) of stroke in NS patients was 1.37 (95% CI, 1.21-1.54, P < .001). The risk factors of ischemic stroke were NS (aHR, 1.38 [95% confidence interval {CI}, 1.21-1.57]; P < .001), age greater than 45 years (aHR, 7.98 [95% CI, 6.47-9.48]; P < .001), male gender (aHR, 1.23 [95% CI, 1.10-1.38]; P < .001), CCI greater than or equal to 1 (aHR ≥ 1.25 in different CCI score groups, all at P ≤ .003), ischemic heart disease (aHR, 1.95 [95% CI, 1.67-2.29]; P < .001), heart failure (HR, 1.77 [95% CI, 1.30-2.42]; P < .001). Risk factors of hemorrhagic stroke were those aged greater than 45 years, or with systemic lupus erythematosus, but not NS. CONCLUSIONS We provided the first evidence that patients with NS had an increased risk of ischemic stroke.
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Affiliation(s)
- Jin-An Huang
- Department of Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yao-Tien Chang
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Ting Lee
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Ju Wu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Rong Hsing Research Center for Translational Medicine, Institute of Biomedical Science, College of Life Science, National Chung Hsing University, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, School of Medicine, China Medical University, Taichung, Taiwan.
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8
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Sugase T, Akimoto T, Kimura T, Yagisawa T, Kusano E, Nagata D. Acquired von Willebrand Syndrome Complicating Nephrotic Syndrome: A Case of a Patient With Membranous Nephropathy. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2018; 11:1179547618763371. [PMID: 29568223 PMCID: PMC5858607 DOI: 10.1177/1179547618763371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/14/2018] [Indexed: 01/28/2023]
Abstract
Acquired von Willebrand syndrome (AVWS) is a rare clinical entity presenting with heterogeneous hemorrhagic manifestations, although some subsets of patients with AVWS may be asymptomatic until they are exposed to major trauma, an invasive procedure, or surgery. We herein report one such case in a 73-year-old male patient with nephrotic syndrome with a prolonged active partial thromboplastin time. We initially did not deal with this distinct abnormal clotting profile seriously, but persistent bleeding after a retroperitoneoscopic-assisted renal biopsy that allowed us to ascribe his nephrotic syndrome to membranous nephropathy fortuitously led to the discovery of concurrent AVWS. We feel that an accurate and prompt diagnosis as well as awareness of the disease remain a challenge for physicians and therefore strongly recommend the further accumulation of experiences similar to our own in a prospective manner. This report underscores the pitfalls associated with determining the bleeding risk, including an insufficient assessment and improper weighting of an abnormal clotting profile prior to the invasive procedure. Several management concerns that emerged in the current case are also discussed.
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Affiliation(s)
- Taro Sugase
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Takaaki Kimura
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Shimotsuke, Japan
| | - Takashi Yagisawa
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Shimotsuke, Japan
| | - Eiji Kusano
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
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10
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Abstract
Complications involving the central and peripheral nervous system are frequently encountered in critically ill patients. All components of the neuraxis can be involved including the brain, spinal cord, peripheral nerves, neuromuscular junction, and muscles. Neurologic complications adversely impact outcome and length of stay. These complications can be related to underlying critical illness, pre-existing comorbid conditions, and commonly used and life-saving procedures and medications. Familiarity with the myriad neurologic complications that occur in the intensive care unit can facilitate their timely recognition and treatment. Additionally, awareness of treatment-related neurologic complications may inform decision-making, mitigate risk, and improve outcomes.
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Affiliation(s)
- Clio Rubinos
- Department of Neurology, Loyola University Chicago-Stritch School of Medicine, Maywood, IL, 60153, USA
| | - Sean Ruland
- Department of Neurology, Loyola University Chicago-Stritch School of Medicine, Maywood, IL, 60153, USA.
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11
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Nakanishi T, Watanabe M, Nakajima M, Nojiri N, Oda A, Ando Y. [Nephrotic syndrome might be an inhibitor of the endovascular recanalization in a patient with acute ischemic stroke]. Rinsho Shinkeigaku 2015; 55:18-22. [PMID: 25672860 DOI: 10.5692/clinicalneurol.55.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 65-year-old man with left hemiparesis was referred to our hospital by ambulance. Diffusion-weighted magnetic resonance imaging (DWI-MRI) showed a slight hyperintensity area in the right basal ganglion and deep white matter, and brain magnetic resonance angiography (MRA) revealed right middle cerebral artery (MCA) occlusion in the M1 proximal segment. Receiving intravenous rt-PA therapy, the patient showed no neurological improvement. Therefore emergency neuroendovascular revasculization was decided. After the first evacuation of the clot, the occlusion site was partly recanalyzed. However it was re-occluded after a few minutes. Then, mechanical disruption using balloon catheters were added for the occlusion site allowing it to be recanalyzed. After the acute ischemic stroke therapy, the patient was diagnosed as nephrotic syndrome, because his blood chemistry test indicated hypoproteinemia and urine examination showed proteinuria. Renal biopsy confirmed nephrotic syndrome due to AL amyloidosis. Nephrotic syndrome causes hypercoagulability and increases platelet aggregation. Thus we speculated that nephrotic syndrome inhibited the early recanalization in this patient.
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Affiliation(s)
- Toshihito Nakanishi
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University
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12
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Gigante A, Barbano B, Liberatori M, Sardo L, Gasperini ML, Rosato E, Cianci R, Amoroso A. Nephrotic syndrome and stroke. Int J Immunopathol Pharmacol 2014; 26:769-72. [PMID: 24067475 DOI: 10.1177/039463201302600322] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The hypercoagulability of patients with nephrotic syndrome could be an important trigger for arterial and venous thrombotic events. Arterial thromboses are less frequent than venous thromboses and the most common locations are femoral arteries. The association of stroke and nephrotic syndrome is extremely rare. Here we report the case of a patient with stroke as first manifestation of nephrotic syndrome. Ischemic stroke can be the first manifestation of nephrotic syndrome and should be considered as a possible complication of the syndrome, when the commonest causes of ischemic stroke are excluded and especially in presence of pre-existing glomerular disease.
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Affiliation(s)
- A Gigante
- Department of Clinical Medicine, Sapienza University of Rome, Italy
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13
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Sasaki Y, Raita Y, Uehara G, Higa Y, Miyasato H. Carotid thromboembolism associated with nephrotic syndrome treated with dabigatran. Case Rep Nephrol Dial 2014; 4:42-52. [PMID: 24803917 PMCID: PMC4000300 DOI: 10.1159/000362162] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Nephrotic syndrome (NS) may be complicated by thromboembolism, which occasionally manifests as stroke. Although the optimal, standardized approach to the prophylaxis and management of thromboembolic complications associated with NS has not been established, anticoagulation with heparin and subsequent warfarin is the de facto standard of treatment. Dabigatran, a novel direct thrombin inhibitor, has become a substitute for warfarin and heparin for many indications, including the prophylaxis of stroke associated with nonvalvular atrial fibrillation and postoperative thromboprophylaxis in orthopedic patients. We report a 35-year-old male with NS due to membranous nephropathy (MN) that presented with carotid thromboembolism. Because the patient developed drug-induced hepatitis due to warfarin, we attempted treatment with dabigatran and were successful in continuing the medication without any complications. We also reviewed the literature on stroke associated with NS. Twenty-one prior cases have been reported, and the review of these cases revealed some interesting points. The age of onset ranged from 19 to 59 years. Most of the reported cases sustained a stroke at earlier ages than patients with atherosclerosis and atrial fibrillation, which suggests that NS may independently predispose individuals to arterial and venous thromboses. MN was the most common underlying pathology. Given that a standardized approach to the prophylaxis and management of thrombotic complications associated with NS has not been established, our experience suggests that dabigatran is a valid new treatment option for thrombotic complications of NS.
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Affiliation(s)
- Yosuke Sasaki
- Department of Nephrology, Okinawa Chubu Hospital, Okinawa, Japan
| | - Yoshihiko Raita
- Department of Nephrology, Okinawa Chubu Hospital, Okinawa, Japan
| | - Genta Uehara
- Department of Nephrology, Okinawa Chubu Hospital, Okinawa, Japan
| | - Yasushi Higa
- Department of Nephrology, Okinawa Chubu Hospital, Okinawa, Japan
| | - Hitoshi Miyasato
- Department of Nephrology, Okinawa Chubu Hospital, Okinawa, Japan
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Abstract
Nephrotic syndrome refers to excessive proteinuria, with associated hypoalbuminemia, edema, and hyperlipidemia. A diverse spectrum of disorders has been associated with nephrotic syndrome and related neurologic complications, although the relative infrequency of these cases limits conclusive associations. Neurologic manifestations of nephrotic syndrome may result from hypoproteinemia, hypercoagulability, hyperlipidemia, hypertension, amyloid deposition, hormonal changes, or electrolyte disorders. Neurologic diagnosis hinges on prompt recognition of this syndrome and rational therapeutic strategies are aimed at the underlying systemic disorder.
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15
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Yeh SM, Lee JJ, Hung CC, Chen HC. Acute cerebral infarction in a patient with nodular glomerulopathy--atypical features and differential diagnosis. Kaohsiung J Med Sci 2011; 27:39-44. [PMID: 21329892 DOI: 10.1016/j.kjms.2010.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Accepted: 04/22/2010] [Indexed: 11/17/2022] Open
Abstract
Nodular glomerulopathy is a pattern of glomerular injury observed under light microscopy that could result from several diseases presented as nephrotic syndrome clinically. Compared with venous thrombosis, cerebral infarction resulting from arterial thrombosis is relatively rare in these patients. We report an interesting case of severe nephrotic syndrome complicated with acute cerebral infarction, and renal biopsy revealed nodular glomerulopathy under light microscopy. Immunofluorescent staining was positive for λ light chain (predominant) and κ light chain, mainly in mesangial areas, and electron microscopic study showed massive amorphous acellular deposits also in mesangial areas with some local extension to subendothelial space. Congo red stain gave negative results under polarized light. The case was concluded as an atypical presentation of light chain deposition disease both pathologically and clinically.
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Affiliation(s)
- Shih-Meng Yeh
- Division of Nephrology, Department of Internal Medicine, Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
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16
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Díez-Tejedor E, Fuentes B. Stroke related to systemic illness and complicated surgery. HANDBOOK OF CLINICAL NEUROLOGY 2009; 93:935-954. [PMID: 18804687 DOI: 10.1016/s0072-9752(08)93046-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Exuperio Díez-Tejedor
- Stroke Unit, Department of Neurology, La Paz University Hospital, Madrid autonomous university, Madrid, Spain.
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Podda GM, Lussana F, Moroni G, Faioni EM, Lombardi R, Fontana G, Ponticelli C, Maioli C, Cattaneo M. Abnormalities of homocysteine and B vitamins in the nephrotic syndrome. Thromb Res 2007; 120:647-52. [PMID: 17276499 DOI: 10.1016/j.thromres.2006.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2006] [Revised: 12/06/2006] [Accepted: 12/07/2006] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The nephrotic syndrome is associated with heightened risk for arterial and venous thrombosis. Multiple derangements of hemostasis and acquired risk factors such as hyperlipidemia and hypertension contribute to this risk. The prevalence in the nephrotic syndrome of high circulating levels of homocysteine and of low levels of the B vitamins that are involved in its metabolism, which may play a role in thrombosis, is not well defined. MATERIALS AND METHODS In 84 patients with nephrotic syndrome and 84 sex- and age-matched controls, hemostasis variables and the circulating levels of total homocysteine (tHcy), vitamin B(6), B(12) and folates were measured. RESULTS tHcy levels were higher, vitamin B(6) and vitamin B(12) levels were lower in nephrotic patients than in controls. The association of low vitamin B(6) levels with the nephrotic syndrome was independent of any other alteration associated with the disease. Eighty-two percent of patients with the nephrotic syndrome had vitamin B(6) levels falling in the lowest quartile of the normal distribution. Antithrombin deficiency, factor V Leiden, antiphospholipid antibodies, hypertension, dyslipidemia, were more frequent in patients with the nephrotic syndrome than in controls. CONCLUSIONS Patients with the nephrotic syndrome have multiple risk factors for thrombosis. We report that they frequently have low circulating levels of vitamin B(6), which associate with a heightened risk for venous and arterial thrombosis.
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Affiliation(s)
- Gian Marco Podda
- Centro Emofilia e Trombosi "Angelo Bianchi Bonomi", Dipartmento di Medicina Interna e Dermatologia, Fondazione I.R.C.C.S. Ospedale Maggiore, Mangiagalli e Regina Elena, Università di Milano, Italy
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Nandish SS, Khardori R, Elamin EM. Transient Ischemic Attack and Nephrotic Syndrome: Case Report and Review of Literature. Am J Med Sci 2006; 332:32-5. [PMID: 16845239 DOI: 10.1097/00000441-200607000-00006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thrombotic complications in patients with nephrotic syndrome are attributed to a hypercoagulable state. Venous thrombosis is common, but arterial thrombosis occurs less frequently in adult nephrotic patients. We report a case of recurrent transient ischemic attacks as an initial manifestation of nephrotic syndrome due to early-stage membranous glomerulonephritis, review the literature for similar cases, and briefly discuss this potentially life-threatening condition. We observed that transient ischemic attack or ischemic stroke could be the initial manifestation of nephrotic syndrome. Our observation may serve as reminder to consider nephrotic syndrome as a possible contributor when evaluating patients with transient ischemic attacks with no other discernable clues. A high index of suspicion alone avoids the unnecessary withholding of prophylaxis or treatment that can be life saving.
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Affiliation(s)
- Shailesh S Nandish
- Department of Medicine, Southern Illinois University School of Medicine, Springfield, Illinois 62794-9636, USA.
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Kotani K, Kawano M. A young female with marked hyperlipoprotein(a)emia associated with nephrotic syndrome and stroke. J Atheroscler Thromb 2006; 12:234. [PMID: 16148404 DOI: 10.5551/jat.12.234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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