Dialysis-related Amyloidosis Presenting as a Fever of Unknown Origin: Symptoms and Management

A 74-year-old woman with a 34-year history of hemodialysis presented with an intermittent fever, which later coincided with recurrent bilateral shoulder and hip joint pain. Imaging studies suggested amyloid arthropathy, which was histologically confirmed by a synovial biopsy. Increasing β2-microglobulin clearance during dialysis alone attenuated the intermittent fever and joint pain, but the symptoms did not disappear until the administration of prednisolone 10 mg/day. Reported cases of dialysis-related amyloidosis with a fever imply that changing to blood purification methods with high β2-microglobulin clearance is crucial for controlling the condition long-term, whereas concurrent use of anti-inflammatory agents promptly alleviates the symptoms.

Assessment of feline hospitalization environment using a one-way mirror

A separate, cat-specific hospitalization room away from dogs is recommended to reduce stress in cats; however, this can be difficult for some hospitals to provide. In such cases, measures are undertaken to reduce the cat's stress by providing a place to hide. However, inability to observe the cat's condition may be an obstacle to providing veterinary care. The use of a one-way mirror to create a sheltered environment while allowing observation of the cats was assessed. Five healthy cats were assessed using the Cat Stress Score (CSS) while in a cage with either a transparent panel or a one-way mirror. No significant differences in the CSS between the transparent panel and one-way mirror were observed. Variations in the CSS scores depended on the cat's personality, with friendlier and more sociable cats showing a lower CSS with the one-way mirror. A one-way mirror may be useful to reduce stress in hospitalized cats.

Transcranial Doppler Echography Measurement in Hemodialysis Patients: The Potential Role of Angiotensin II Receptor Blockades on Cerebrovascular Circulation

Background: Although hemodialysis (HD) patients have an elevated risk of strokes, there are few reports about transcranial doppler (TCD) echography measurements. It is well-known that angiotensin II receptor blockades (ARBs) protect against cardiovascular complications. In this study, we measured intracranial artery (ICA) velocity using TCD echography and studied the associated factors with its velocity in HD patients by a comparison with or without ARBs. Methods: We conducted a cross-sectional study in a single hospital. We included 61 patients who had measurable ICA velocity by TCD echography. Among them, the ARB usage group consisted of 22 subjects, whilst the non-ARB usage group consisted of 39 subjects. Results: Patients in the ARB (+) and ARB (-) groups did not show any difference in basic characteristics. ICA blood flow velocity in all intracranial arteries tended to show greater values in the ARB group than those in the non-ARB group. Particularly, blood velocity in the middle cerebral artery (MCA) (maximal flow velocity) statistically increased in the ARB group, respectively. In a univariate analysis, MCA maximum velocity was significantly associated with ARB usage (p = 0.011) and low hematocrit levels (p = 0.045). The multivariate analysis chose only ARB usage as an independent factor associated with left MCA maximum velocity (p = 0.022). Conclusions: We showed that dialysis patients with ARBs have significantly higher ICA blood velocity. ARBs might have a potential benefit for maintaining ICA blood flow in HD patients.

Relationship between Lower Extremity Peripheral Arterial Disease and Mild Cognitive Impairment in Hemodialysis Patients

Background: The link between arterial stiffness and mild cognitive impairment (MCI) in patients on hemodialysis (HD) has been receiving increased attention. The purpose of this study was to investigate the relationship between cognitive function and ankle brachial index (ABI) and toe brachial index (TBI) values in patients on hemodialysis. Of the 100 participants (mean age: 67.9 years; average history of hemodialysis: 7.3 years). Of these, 46.0% had MCI. The MoCA-J scores were significantly higher in the ABI ≥ 1.06 group. However, the MoCA-J scores divided into the two groups according to the TBI cutoff value were not significantly different. In a multiple regression model with the MoCA-J scores as the objective variable, the ABI was a significantly associated factor. This study indicates that a low ABI might be associated with MCI.

Impact of Arterial Calcification of the Lower Limbs on Long-Term Clinical Outcomes in Patients on Hemodialysis

Lower limbs' arterial calcification is significantly associated with the clinical severity of lower extremity artery disease (LEAD) in patients undergoing hemodialysis (HD). However, the association between arterial calcification of the lower limbs and long-term clinical outcomes in patients on HD has not been elucidated. Calcification scores of the superficial femoral artery (SFACS) and below-knee arteries (BKACS) were quantitatively evaluated in 97 HD patients who were followed for 10 years. Clinical outcomes, including all-cause and cardiovascular mortality, cardiovascular events, and limb amputation were evaluated. Risk factors for clinical outcomes were evaluated using univariate and multivariate Cox proportional hazard analyses. Furthermore, SFACS and BKACS were divided into three groups (low, middle, and high), and their associations with clinical outcomes were evaluated using Kaplan-Meier analysis. SFACS, BKACS, C-reactive protein, serum albumin, age, diabetes, presence of ischemic heart disease, and critical limb-threatening ischemia were significantly associated with 3-year and 10-year clinical outcomes in the univariate analysis. Multivariate analysis showed that SFACS was an independent factor associated with 10-year cardiovascular events and limb amputations. Kaplan-Meier life table analysis showed that higher SFACS and BKACS levels were significantly associated with cardiovascular events and mortality. In conclusion, long-term clinical outcomes and the risk factors in patients undergoing HD were evaluated. Arterial calcification of the lower limbs was strongly associated with 10-year cardiovascular events and mortality in patients undergoing HD.

Association between zinc deficiency and aorta stiffness in non-diabetic hemodialysis patients

OBJECTIVES

Zinc deficiency (Zn < 60 μg/dL) is known to play an important role for vascular calcification. However, little data is available regarding the association between zinc deficiency and aorta stiffness in dialysis patients. Thus, we studied the relationship between zinc deficiency and aorta stiffness in non-diabetic hemodialysis (HD) patients.

METHODS

Of 150 patients receiving maintenance HD at our hospital, we included 79 non-diabetic HD patients (age: 70±11 years, 49 men) after excluding 71 diabetic HD patients. Zinc deficiency was defined as Zn <60 μg/dL during pre-HD blood sampling. The association between zinc deficiency and aorta stiffness was analyzed. Aorta stiffness was evaluated as brachial-ankle pulse wave velocity (baPWV). Other surrogate markers for cardiovascular complications were also measured.

RESULTS

The zinc deficiency group (ZD group) included 45 patients (57.0%). Compared to the zinc non-deficiency group (ZND group), patients with ZD group were significantly older, higher levels of CRP and hypoalbuminemia. Moreover, they had significantly higher levels of baPWV, and lower levels of ankle-brachial pressure index (ABI) (p<0.05). After adjusting for hypoalbuminemia, and CRP, multivariate analysis showed that age and zinc level were independent predictors of baPWV.

CONCLUSION

The study suggested that zinc deficiency may be an independent risk factor for aorta stiffness, even after adjusting for malnutrition and inflammation.

Impact of Contrast-Induced Nephropathy on Long-Term Renal Function after Coronary Angiography and Contrast-Enhanced Computed Tomography

BACKGROUND

It remains unclear whether contrast-induced nephropathy (CIN) has a prognostic impact on subsequent renal dysfunction and whether deteriorating renal function is a risk factor for CIN. This study aimed to evaluate the occurrence of CIN in patients with pre-existing renal dysfunction and investigate the long-term effects of worsening renal function after coronary angiography or contrast-enhanced computed tomography (CT). The prognostic factors of worsening renal dysfunction were also analyzed.

METHODS

This was a prospective cohort study of patients at risk for CIN, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² on coronary angiography or eGFR <45 mL/min/1.73 m² on contrast-enhanced CT. Serum creatinine levels and the 2-year prognosis were evaluated. CIN was defined as an increase in serum creatinine level by more than 0.5 mg/dL or a 25% increase from the previous value within 72 hours after contrast administration. The primary endpoint was the proportion of patients who had serum Cr doubling or induction of dialysis within 2 years according to CIN occurrence.

RESULTS

Of the 410 patients, 19 patients developed CIN (8/142 patients on coronary angiography and 11/268 patients on contrast-enhanced CT), and 38 patients had worsened renal function (21/142 patients on coronary angiography and 17/268 patients on contrast-enhanced CT). CIN was not associated with worsening renal function at 2 years. Analysis by renal function at the time of coronary angiography or contrast-enhanced CT (i.e., eGFR ≥30 ml/min/1.73 m² and eGFR ≤1.73 m²) found no between-group difference in the occurrence of CIN.

CONCLUSIONS

CIN is not a prognostic risk factor for the long-term of chronic kidney disease after coronary angiography or contrast-enhanced CT. Pre-existing renal dysfunction is also not a risk factor for CIN, even if the eGFR is <30 ml/min/1.73 m².

Acquired aplastic anemia complicated with anti-glomerular basement membrane disease successfully treated with immunosuppressive therapy: a case report

BACKGROUND

Aplastic anemia (AA) is a rare but fatal disorder characterized by pancytopenia due to bone marrow hypoplasia. Anti-glomerular basement membrane disease (anti-GBM disease) is an immune complex small-vessel vasculitis that presents as rapidly progressive glomerulonephritis and/or pulmonary hemorrhage. Although both involve autoreactive T cells that are partially triggered by human leukocyte antigen (HLA)-DR15, there have been no reports of their co-existence and the treatment strategy is not well understood.

CASE PRESENTATION

A 67-year-old woman presented with fever, malaise, and acute kidney injury with proteinuria and hematuria requiring hemodialysis. She was diagnosed with anti-GBM antibody disease based on high serum anti-GBM antibody titer and crescentic glomerulonephritis on a renal biopsy. Pulse administration of methylprednisolone (MP), oral prednisolone (PSL), and plasmapheresis were performed. Only 2 weeks after the diagnosis of anti-GBM disease, the patient developed pancytopenia requiring frequent blood transfusions. The blood cell count did not recover even 1 month after discontinuing the drugs that could cause pancytopenia. Bone marrow examination showed hypocellularity without abnormal infiltrates or fibrosis, which led to the diagnosis of severe acquired AA. Further HLA phenotyping revealed that she had HLA-DR15. Increased dose of PSL with the secondary MP pulse and the addition of cyclosporine improved pancytopenia. Although she remained dialysis-dependent, anti-GBM disease and pancytopenia did not recur for more than 2 years.

CONCLUSIONS

We report the first case of acquired AA complicated with anti-GBM disease in an elderly woman with HLA-DR15, which was successfully treated with immunosuppressive therapy (IST). This report is valuable not only because it shows they may co-occur, but also because it provides a therapeutic option for this complex condition. It was also suggested that pancytopenia in patients with anti-GBM disease recalls serious hematologic diseases including AA that require immediate treatment based on bone marrow examination.

Recurrent hemorrhagic shock from hemorrhagic cystitis due to neurogenic bladder

INTRODUCTION

Hemorrhagic cystitis is characterized by gross hematuria, with hemorrhagic shock a rare complication. However, to our knowledge, its exact frequency has not been reported.

CASE PRESENTATION

We report a case of an 86-year-old woman who showed repeated hemorrhagic cystitis with massive bleeding and hemorrhagic shock. The hemorrhagic cystitis was supposedly caused by the administration of aspirin and a neurogenic bladder. A urethral catheter was indwelled and hemorrhagic cystitis subsequently ceased.

CONCLUSION

A review of patients with hemorrhagic cystitis at our hospital showed that only 3.3% experienced hemorrhagic shock. This case was even rarer because the patient experienced recurrent hemorrhagic shocks. A neurogenic bladder, which reduces the bladder's ability to function as a uroepithelial barrier against recurrent bacterial infections, caused the condition in this case. This report highlights how hemorrhagic cystitis can sometimes cause hemorrhagic shock.

MPO-ANCA-associated vasculitis after the Pfizer/BioNTech SARS-CoV-2 vaccination

Vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has demonstrated high efficacy at preventing coronavirus disease 2019 (COVID-19) and a favorable safety profile, however it has also been reported that COVID-19 vaccines may put increase of immune-mediated disease. We herein report a case of MPO-anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis following the mRNA vaccine BNT162b2 (Pfizer/BioNTech) for COVID-19. Although the causal relationship between vaccine and ANCA-associated vasculitis is uncertain, environmental and genetic factors may have set the stage for the development of vasculitis, and the vaccine may have triggered a domino effect.

Acute kidney injury successfully treated with autologous granulocyte colony-stimulating factor-mobilized peripheral blood CD34-positive cell transplantation: A first-in-human report

A 36-year-old man with severe acute kidney injury (AKI) was admitted to Shonan Kamakura General Hospital in Japan. He was diagnosed with refractory hypertension based on a severely elevated blood pressure of 224/116 mmHg and retinal, cardiac, and brain damage revealed by electrocardiogram, fundoscopy, and magnetic resonance imaging, respectively. Although hemodialysis was withdrawn following strict blood pressure control by an angiotensin receptor blocker, severe kidney insufficiency persisted. Therefore, we performed an autologous granulocyte colony-stimulating factor-mobilized peripheral blood CD34-positive cell transplantation. Collected CD34-positive cells were directly infused to both renal arteries. The patient's general condition was unremarkable after intervention, and the serum creatinine level gradually improved to 2.96 mg/dL 23 weeks after cell therapy. Although transient fever and thrombocytosis were observed after intervention, no major adverse events were observed. This patient is the first case in a phase I/II clinical trial of autologous granulocyte colony-stimulating factor-mobilized peripheral blood CD34-positive cell transplantation for severe AKI with a CD34-positive cell dose-escalating protocol (trial number jRCTb030190231).

Renal hemosiderosis presenting with acute kidney Injury and macroscopic hematuria in Immunoglobulin A nephropathy: a case report

Background

Macroscopic hematuria-associated acute kidney injury (AKI) is a well-known complication of immunoglobulin A (IgA) nephropathy. In such cases, intratubular obstruction by red blood cell (RBC) casts and acute tubular necrosis are mainly observed pathologically. Herein, we report the case of a patient with IgA nephropathy presenting with AKI following an episode of macrohematuria. The patient presented with severe renal tubular hemosiderosis and acute tubular necrosis and without any obvious obstructive RBC casts.

Case presentation

A 68-year-old woman, who was diagnosed with IgA nephropathy on renal biopsy 6 years ago, was admitted to our hospital after an episode of macroscopic glomerular hematuria and AKI following upper respiratory tract infection. Renal biopsy showed mesangial proliferation of the glomeruli, including crescent formation in 17 % of the glomeruli, and acute tubular necrosis without obvious hemorrhage or obstructive RBC casts. The application of Perls’ Prussian blue stain showed hemosiderin deposition in the renal proximal tubular cells. Immunofluorescence showed granular mesangial deposits of IgA and C3. Based on these findings, she was diagnosed with acute tubular necrosis with a concurrent IgA nephropathy flare-up. Moreover, direct tubular injury by heme and iron was considered to be the cause of AKI. She was treated with intravenous pulse methylprednisolone followed by oral prednisolone. Thereafter, the gross hematuria gradually faded, and her serum creatinine levels decreased.

Conclusions

IgA nephropathy presenting with acute kidney injury accompanied by macrohematuria may cause renal hemosiderosis and acute tubular necrosis without obstructive RBC casts. Hemosiderosis may be a useful indicator for determining the pathophysiology of macroscopic hematuria-associated AKI. However, renal hemosiderosis may remain undiagnosed. Thus, Perls’ Prussian blue iron staining should be more widely used in patients presenting with hematuria.

De novo ulcerative colitis after kidney transplantation treated with infliximab

Diarrhea is a common complication in kidney transplant recipients. Common causes of diarrhea include infection, side effect from medication, rejection, and malignancy. A less common but important cause of diarrhea is de novo inflammatory bowel disease (IBD). This is unexpected, as these patients are already immunosuppressed. Herein, we present the case of a 45-year-old man with end-stage kidney disease because of focal segmental glomerulosclerosis who underwent preemptive kidney transplantation, with his mother as donor. His immunosuppressive regimen included methylprednisolone, mycophenolate mofetil, and tacrolimus. He had no episodes of graft dysfunction, rejection, or infectious events. Two and a half years post-transplantation, he developed bloody diarrhea. After excluding infections, colonoscopy was performed and revealed edematous mucosa and erythema with pigmentation, which are typical findings in ulcerative colitis. Despite therapy with 5-aminosalicylate and granulocyte monocyte apheresis, he presented with massive bloody diarrhea. We initiated infliximab, an anti-tumor necrosis factor-α (TNF-α) agent. He responded very well and achieved remission within 6 months after initiation of infliximab, while administration of the other immunosuppressants was maintained. His course was uneventful and no complications developed. Management of immunosuppressants for de novo IBD after organ transplantation is complicated, because treatment of IBD, graft function protection, and prevention of infection must be considered. Therefore, cooperation between transplantation physicians and gastroenterologists is essential during therapy.

Angiectasia of the parietal pleura in a hemodialysis patient with central venous stenosis and bloody pleural effusion: a case report

Pleural effusion in hospitalized patients with long-term hemodialysis (HD) has been frequently reported. The most common causes of unilateral pleural effusions include hypervolemia, parapneumonic, uremic effusion, and malignancy. In contrast, central venous stenosis (CVS) has rarely been shown to result in pleural effusion. CVS is often diagnosed by percutaneous angiography, yet there are no reports of cases where percutaneous angiography missed CVS and instead intrathoracic endoscopy was performed. Herein, we report a case of CVS with angiectasia of the parietal pleura detected on intrathoracic endoscopy. A 62-year-old man with HD presented with massive unilateral pleural effusion. Although the cause of pleural effusion was suspected to be CVS, percutaneous angiography did not show apparent stenosis, and as a result, other potential causes of bloody effusion were investigated. The intrapleural cavity was assessed using intrathoracic endoscopy, which revealed angiectasia and no malignancy. As these findings might be suggestive of congestive and dilated vessels with venous stenosis or occlusion, 3D-computed tomography (CT) scans were performed instead of percutaneous angiography to determine whether a stenosis or occlusion was present. Brachiocephalic vein stenosis was found near the aortic arch. CVS was treated through ligation of the arteriovenous fistula (AVF), resulting in a dramatic decrease in the left pleural effusion. This case would suggest that CVS should be suspected when angiectasia of the parietal pleura is observed in HD patients. In addition, the benefit of utilizing 3D-CT should be considered when HD patients present with a unilateral hemothorax on the same side as that of the AVF, particularly when on the left side.

Improvement of microcirculatory impairment in patients with predialysis chronic kidney disease after AST-120 administration

Background

Endothelial dysfunction starts at an earlier stage in patients with chronic kidney disease (CKD), and induces macro- and microcirculatory impairments. We evaluated whether uremic toxin-lowering therapy could improve endothelial function in patients with CKD.

Methods

We performed a prospective interventional trial with 30 predialysis non-diabetic CKD patients who were administered oral adsorbent AST-120 (6 g/day) for 12 months. Surrogate markers of endothelial function including flow-mediated dilation (FMD) and skin perfusion pressure (SPP) were serially evaluated along with serum indoxyl sulfate (IS) levels and renal function. Renal function was evaluated based on blood urea nitrogen, serum creatinine (sCr) levels, and estimated glomerular filtration ratio (eGFR).

Results

Monthly decline in renal function (slope of reciprocal sCr) after AST-120 administration did not change compared to that during the pre-treatment period. However, serum IS levels significantly decreased at 3 months after AST-120 administration (p < 0.01), and it was sustained during the period of AST-120 administration (p < 0.01). Although FMD did not improve, SPP was constantly elevated after AST-120 administration, and was significantly higher at 12 months compared with baseline value (69.7 ± 14.6 vs. 78.8 ± 18.9 mmHg, p < 0.05). A significant correlation between the change of IS and SPP from baseline values was shown at 6 months after AST-120 administration (r = − 0.558, p = 0.02).

Conclusion

Microcirculatory impairment was improved after AST-120 administration in patients with predialysis CKD.

Trial registration

UMIN, UMIN000013577. Registered on March 31, 2014,

P0742ASSOCIATION BETWEEN EOSINOPHILIA AND RENAL PROGNOSIS IN PATIENTS WITH CHOLESTEROL CRYSTAL EMBOLISM

Background and Aims

Approximately, 20%-70% of patients with cholesterol crystal embolism (CCE) have eosinophilia. However, it remains unknown how eosinophilia influences on renal prognosis in patients with CCE. In this study, we investigated an association between eosinophil count (Eo) and renal prognosis in CCE patients on steroid therapy.

Method

The present study is a single-center retrospective cohort study in patients with pathological proven CCE and Chronic kidney disease from April 2007 to May 2018. This study included the patients who are not treated with maintenance dialysis nor steroid, and moreover followed until November 2019. We analyzed the validity of eosinophil counts using receiver operating characteristic (ROC) curve analysis. In the statistical analysis, renal survival was calculated with the Kaplan– Meier method, and comparisons between higher and low Eo groups were made with the log-rank test.

Results

Thirty-two patients with pathological diagnosed CCE were enrolled and followed-up for 11.0 (4.7-43.6) months. There were significant differences in the white blood cell (p=0.03), hemoglobin (p=0.007), serum creatinine levels (p=0.03), phosphate (p=0.045), Calcium×Phosphate (p=0.03), and Eo (p=0.016) between the renal survival and renal death groups. Using the receiver operating characteristic curve analysis with Youden index, Eo of 810/µL showed the sensitivity and specificity 71% and 88% for detecting renal death, respectively (area under the carve; 0.789). Comparing the outcomes in patients having Eo ≥ and &lt;810/µL by using the log-rank test, there are significantly higher renal death rate in CCE patients with Eo ≥810/µL (p=0.004).

Conclusion

Higher eosinophilia was a prognostic risk factor for renal death in the patients with CCE.

Association of pre-operative chronic kidney disease and acute kidney injury with in-hospital outcomes of emergency colorectal surgery: a cohort study

BACKGROUND

Pre-operative kidney function is known to be associated with surgical outcomes. However, in emergency surgery, the pre-operative kidney function may reflect chronic kidney disease (CKD) or acute kidney injury (AKI). We examined the association of pre-operative CKD and/or AKI with in-hospital outcomes of emergency colorectal surgery.

METHODS

We conducted a retrospective cohort study including adult patients undergoing emergency colorectal surgery in 38 Japanese hospitals between 2010 and 2017. We classified patients into five groups according to the pre-operative status of CKD (defined as baseline estimated glomerular filtration rate < 60 mL/min/1.73 m2 or recorded diagnosis of CKD), AKI (defined as admission serum creatinine value/baseline serum creatinine value ≥ 1.5), and end-stage renal disease (ESRD): (i) CKD(-)AKI(-), (ii) CKD(-)AKI(+), (iii) CKD(+)AKI(-), (iv) CKD(+)AKI(+), and (v) ESRD groups. The primary outcome was in-hospital mortality, while secondary outcomes included use of vasoactive drugs, mechanical ventilation, blood transfusion, post-operative renal replacement therapy, and length of hospital stay. We compared these outcomes among the five groups, followed by a multivariable logistic regression analysis for in-hospital mortality.

RESULTS

We identified 3002 patients with emergency colorectal surgery (mean age 70.3 ± 15.4 years, male 54.5%). The in-hospital mortality was 8.6% (169/1963), 23.8% (129/541), 15.3% (52/340), 28.8% (17/59), and 32.3% (32/99) for CKD(-)AKI(-), CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD, respectively. Other outcomes such as blood transfusion and post-operative renal replacement therapy showed similar trends. Compared to the CKD(-)AKI(-) group, the adjusted odds ratio (95% confidence interval) for in-hospital mortality was 2.54 (1.90-3.40), 1.29 (0.90-1.85), 2.86 (1.54-5.32), and 2.76 (1.55-4.93) for CKD(-)AKI(+), CKD(+)AKI(-), CKD(+)AKI(+), and ESRD groups, respectively. Stratified by baseline eGFR (> 90, 60-89, 30-59, and < 30 mL/min/1.73 m2) and AKI status, the crude in-hospital mortality and adjusted odds ratio increased in patients with baseline eGFR < 30 mL/min/1.73 m2 among patients without AKI, while these were constantly high regardless of baseline eGFR among patients with AKI. Additional analysis restricting to 2162 patients receiving the surgery on the day of hospital admission showed similar results.

CONCLUSIONS

The differentiation of pre-operative CKD and AKI, especially the identification of AKI, is useful for risk stratification in patients undergoing emergency colorectal surgery.

Intradialytic hypotension is an important risk factor for critical limb ischemia in patients on hemodialysis

BACKGROUND

Critical limb ischemia (CLI) and intradialytic hypotension (IDH) are common complications in patients on hemodialysis (HD). However, limited data are available on whether IDH is related to CLI in these patients. The aim of this retrospective study was to evaluate whether IDH is a risk factor for CLI in HD patients.

METHODS

We examined the frequency of IDH in 147 patients who received HD between January 1 and June 30, 2012. Blood pressure was measured during HD every 30 min and IDH was defined as a ≥ 20 mmHg fall in systolic blood pressure compared to 30 min before and a nadir intradialytic systolic blood pressure < 90 mmHg. The primary study outcome was newly developed CLI requiring revascularization treatment or CLI-related death. We assessed the association of IDH with outcome using a multivariable subdistribution hazard model with adjustment for male, age, smoking and history of cardiovascular disease.

RESULTS

The median follow-up period was 24.5 months. Fifty patients (34%) had episodes of IDH in the study entry period. During follow-up, 14 patients received endovascular treatment and CLI-related death occurred in 1 patient. Factors associated with incident CLI in univariate analysis were age, smoking, diabetes mellitus, peripheral arterial disease, history of cardiovascular disease, and IDH. IDH was significantly associated with the outcome with the subdistribution hazard ratio of 3.13 [95% confidence interval, 1.05-9.37].

CONCLUSIONS

IDH was an independent risk factor for incident CLI in patients on HD.

Seasonality of acute kidney injury incidence and mortality among hospitalized patients

Background

Understanding disease seasonality is important for improving clinical practice, hospital resource utilization and community-based preventive care. However, no studies have investigated the seasonality of acute kidney injury (AKI).

Methods

In the Tokushukai Medical Database, which includes 38 Japanese community hospitals, we identified hospitalized patients with AKI based on the Kidney Disease: Improving Global Outcomes serum creatinine criteria from January 2012 to December 2014. We plotted the number and proportion of patients with AKI among hospitalized patients by month of hospital admission. Subgroup analyses were conducted by the admission diagnosis category, timing of AKI diagnosis and age. We also examined the association between month of hospital admission and AKI, adjusting for patient characteristics and AKI risk factors. Finally, we assessed seasonal variations in disease severity and 30-day mortality of patients with AKI.

Results

We identified 81 279 (14.6%) patients with AKI among 555 940 hospitalized patients. The proportion of patients with AKI was highest in January (16.7%) and lowest in June (13.4%). Subgroup analyses suggested that the seasonality of AKI incidence was driven by community-acquired AKI associated with the admission diagnosis of cardiovascular and pulmonary diseases among older patients. The adjusted odds ratio for AKI (January versus June) was 1.24 (95% confidence interval, 1.17-1.31). Patients with AKI showed a larger number of failing organs in winter, and their 30-day mortality was 16.4% in spring, 14.5% in summer, 15.6% in autumn and 18.4% in winter.

Conclusion

AKI is more common among hospitalized patients and patients with AKI are more severely ill in winter.

Remarkable Improvement of Cardiac Function After Pre-emptive Kidney Transplant in a Patient With Severe Mitral Regurgitation Accompanied by Low Cardiac Function: A Case Report

Patients with end-stage renal disease are at a high risk for cardiovascular diseases. It is controversial whether end-stage renal disease patients with low cardiac function can safely accept kidney transplant. Here, we present a 42-year-old kidney transplant recipient with severe mitral regurgitation accompanied by low cardiac function. He wanted to undergo a pre-emptive kidney transplant from his uncle. We decided to perform living kidney transplant prior to cardiac surgery. Despite adequate ultrafiltration and hemodiafiltration before operation, the patient's ejection fraction still remained 35% 1 day before transplant. He showed complete recovery of cardiac function in only 2 days after pre-emptive kidney transplant, although his body weight did not change before and after the operation. Early removal of the uremic toxin or inflammatory cytokines may play a role in rapid improvement of the cardiac function. Increase of vasoactive substances by improvement of kidney function may lead to reduction of afterload and amelioration of cardiac microcirculation. This report also suggests that optimal timing for operation might be important.

Autologous Granulocyte Colony-Stimulating Factor-Mobilized Peripheral Blood CD34 Positive Cell Transplantation for Hemodialysis Patients with Critical Limb Ischemia: A Prospective Phase II Clinical Trial

Critical limb ischemia (CLI) is a devastating disease in patients undergoing hemodialysis (HD). Based on the unsatisfactory results of autologous mononuclear cell transplantation for patients with CLI undergoing HD, we conducted a phase II clinical trial to evaluate the safety and efficacy of granulocyte colony‐stimulating factor (G‐CSF)‐mobilized peripheral blood‐derived autologous purified CD34 positive (CD34+) cell transplantation for CLI in patients undergoing HD. Six patients with CLI (two with Rutherford category 4 and four with Rutherford category 5) were enrolled. As for primary endpoint, there were no major adverse events related to this therapy. As for efficacy, the amputation‐free survival rate was 100% at 1 year after cell therapy. Both rest pain scale and ulcer size were significantly improved as early as 4 weeks after therapy compared with baseline (p < .01), and three out of five ulcers completely healed within 12 weeks after cell transplantation. Clinical severity, including Fontaine scale and Rutherford category, significantly improved at 24 weeks after cell transplantation (p < .05), and further improved at 52 weeks (p < .01) compared with baseline. The improvement rate from CLI stage to non‐CLI stage was 83.3% at 52 weeks. Toe skin perfusion pressure and absolute claudication distance were also significantly improved. In conclusion, G‐CSF‐mobilized peripheral blood CD34+ cell transplantation was safe, feasible, and effective for patients with CLI undergoing HD. stem cells translational medicine2018;7:774–782

Human Peripheral Blood Mononuclear Cells Incubated in Vasculogenic Conditioning Medium Dramatically Improve Ischemia/Reperfusion Acute Kidney Injury in Mice

Acute kidney injury (AKI) is a major clinical problem that still has no established treatment. We investigated the efficacy of cultured human peripheral blood mononuclear cells (PBMNCs) for AKI. Ischemia/reperfusion injury (IRI) was used to induce AKI in male nonobese diabetic (NOD/severe combined immunodeficiency) mice aged 7 to 8 wk. PBMNCs were isolated from healthy volunteers and were subjected to quality and quantity controlled (QQc) culture for 7 d in medium containing stem cell factor, thrombopoietin, Flt-3 ligand, vascular endothelial growth factor, and interleukin 6. IRI-induced mice were divided into 3 groups and administered (1) 1 × 10⁶ PBMNCs after QQc culture (QQc PBMNCs group), (2) 1 × 10⁶ PBMNCs without QQc culture (non-QQc PBMNCs group), or (3) vehicle without PBMNCs (IRI control group). PBMNCs were injected via the tail vein 24 h after induction of IRI, followed by assessment of renal function, histological changes, and homing of injected cells. Blood urea nitrogen and serum creatinine (Cr) 72 h after induction of IRI in the QQc PBMNCs group dramatically improved compared with those in the IRI control and the non-QQc PBMNCs groups, accompanied by the improvement of tubular damages. Interstitial fibrosis 14 d after induction of IRI was also significantly improved in the QQc PBMNCs group compared with the other groups. The renoprotective effect noted in the QQc PBMNCs group was accompanied by reduction of peritubular capillary loss. The change of PBMNCs’ population (increase of CD34+ cells, CD133+ cells, and CD206+ cells) and increased endothelial progenitor cell colony-forming potential by QQc culture might be one of the beneficial mechanisms for restoring AKI. In conclusion, an injection of human QQc PBMNCs 24 h after induction of IRI dramatically improved AKI in mice.

Influence of various carbohydrate sources on postprandial glucose, insulin and NEFA concentrations in obese cats

Carbohydrate is an important source of energy, which can significantly affect postprandial blood glucose and insulin levels in cats. In healthy animals, this is not a big concern; however, in obese and diabetic animals, this is an important detail. In the present study, the impact of four different carbohydrate sources (glucose, maltose, corn starch, and trehalose) on short-term post-prandial serum glucose, insulin, and non-esterified fatty acid (NEFA) concentrations was investigated with four obese cats. Each of the carbohydrate sources was added to a commercial wet food diet for feeding the animals. A significant difference was observed in postprandial glucose, insulin, and NEFA area under the curve (AUC) values between each carbohydrate source in obese cats. Furthermore, glucose and maltose induced the highest postprandial glucose and insulin AUC values, whereas trehalose induced the lowest postprandial glucose and insulin AUC value amongst all carbohydrate sources, respectively, in obese cats. However, trehalose has a higher risk of inducing side effects, such as diarrhea, as compared to other carbohydrate sources. As such, different carbohydrate sources appear to have a very significant impact on post-prandial glycemia and subsequent insulin requirement levels in obese cats. These results might be useful when selecting a prescription diet for obese or diabetic cats. In addition, maltose appears to be capable of inducing experimentally evoked postprandial hyperglycemia in obese cats, which may serve as a good tool for use to check the impact and effectiveness of newly developed oral hypoglycemic drugs or supplements for cats in future experiments.

The canine prostate cancer cell line CHP-1 shows over-expression of the co-chaperone small glutamine-rich tetratricopeptide repeat-containing protein α

Although androgen therapy resistance and poor clinical outcomes are seen in most canine prostate cancer cases, there are only a few tools for analysing canine prostate cancer by using a cell biological approach. Therefore, to evaluate androgen-independent neoplastic cell growth, a new canine prostate cancer cell line (CHP-1) was established in this study. CHP-1 over-expressed the co-chaperone small glutamine-rich tetratricopeptide repeat-containing protein α (SGTA), which is over-expressed in human androgen-independent prostate cancer. The CHP-1 xenograft also showed SGTA over-expression. Although CHP-1 shows poor androgen receptor (AR) signalling upon dihydrotestosterone stimulation, forced expression of AR enabled evaluation of AR signalling. Taken together, these results suggest that CHP-1 will be a useful model for investigating the pathogenesis of androgen-dependent and androgen-independent canine prostate cancer.

Cerebral blood flow in patients with peritoneal dialysis by an easy Z-score imaging system for brain perfusion single-photon emission tomography

Cognitive impairment has long been recognized as a complication of chronic kidney disease. However, there is little information available regarding regional cerebral blood flow (rCBF) in patients with peritoneal dialysis (PD). Therefore, we evaluated rCBF using brain single photon emission computed tomography (SPECT). We conducted a cross-sectional study in our hospital. Eighteen consecutive PD patients who could visit the hospital by themselves without any history of stroke were examined by Technetium-99 m-labeled ethylcrysteinate dimer brain SPECT. An easy Z-score imaging system (eZIS) was used to compare rCBF in PD patients with those in age-matched healthy controls. We also evaluated cognitive dysfunction with the mini-mental state examination (MMSE) questionnaire. Only one patient showed an MMSE score of 18 points, and the remaining 14 patients were considered as normal (MMSE ≥ 27), and three patients were considered to have mild cognitive impairment (24 ≤ MMSE ≤ 26). In all patients, rCBF in the posterior cingulated gyri, precunei, and parietal cortices was significantly decreased. The ratio of the reduction of rCBF in each region relative to that of rCBF across the whole brain correlated positively with the PD duration (r = 0.559; P < 0.05). The serum β2-microglobulin level was significantly higher in patients who had a higher ratio of rCBF reduction compared with those with lower ratios. In conclusion, all PD patients in the present study had decreased rCBF irrespective of MMSE scores.

All-optical control and visualization of ultrafast two-dimensional atomic motions in a single crystal of bismuth

In a bulk solid, optical control of atomic motion provides a better understanding of its physical properties and functionalities. Such studies would benefit from active control and visualization of atomic motions in arbitrary directions, yet, so far, mostly only one-dimensional control has been shown. Here we demonstrate a novel method to optically control and visualize two-dimensional atomic motions in a bulk solid. We use a femtosecond laser pulse to coherently superpose two orthogonal atomic motions in crystalline bismuth. The relative amplitudes of those two motions are manipulated by modulating the intensity profile of the laser pulse, and these controlled motions are quantitatively visualized by density functional theory calculations. Our control-visualization scheme is based on the simple, robust and universal concept that in any physical system, two-dimensional particle motion is decomposed into two orthogonal one-dimensional motions, and thus it is applicable to a variety of condensed matter systems.

Controlling the motion of atoms in solids with light allows for a deeper understanding of their fundamental properties, yet most studies only deal with one spatial dimension. Katsuki et al. extend this approach to two-dimensional control and use it to visualize atomic motion in bismuth.

Fat mass, and not diet, has a large effect on postprandial leptin but not on adiponectin concentrations in cats

Leptin and adiponectin play important roles in carbohydrate and lipid metabolism in different species. Information is limited on the effects of diet, weight gain, and fat mass on their concentrations in cats. This study compared fasting and postprandial blood leptin and total adiponectin concentrations before and after 8 wk of ad libitum feeding to promote weight gain in adult cats (n = 32) fed either a low-carbohydrate, high-protein (23% and 47% ME) or a high-carbohydrate, low-protein (51% and 21% ME) diet. There were significant effects of total, abdominal, and nonabdominal fat mass, but not diet or body weight, on mean 24-h and peak leptin (P < 0.01); observed increases in mean and peak leptin were greatest for abdominal fat mass (50% and 56% increase for every extra 100 g, respectively). After weight gain, postprandial leptin concentration increased markedly relative to when cats were lean, and the duration of the increase was longer after a mean weight gain of 37% with the low-carbohydrate, high-protein diet group compared with 17% with the high-carbohydrate, low-protein group (P ≤ 0.01). Adiponectin was lower than fasting at some time points during the postprandial period in both groups (P ≤ 0.05). For both fasting and mean 24-h adiponectin, there was no significant diet effect (P ≥ 0.19) or changes in weight gain relative to when cats were lean (P ≥ 0.29). In conclusion, fat mass, and not diet, has a large effect on postprandial leptin but not adiponectin concentrations in cats.

Aliskiren, a direct renin inhibitor, improves vascular endothelial function in patients on hemodialysis independent of antihypertensive effect ∼ a pilot study∼

AIMS

Aliskiren inhibits the first step in the renin-angiotensin system (RAS) and recently has been shown to modulate vascular diseases via RAS-dependent and independent pathways. This study aimed to determine the effect of aliskiren-associated direct renin inhibition on endothelial function in patients on hemodialysis via flow-mediated dilatation (FMD) and platelet-derived microparticles (PDMP), as biomarkers of atherosclerosis.

METHODS

A 12-week prospective study was performed with 24 patients on hemodialysis who were administered 150 mg orally aliskiren once daily for 12 weeks.

RESULTS

No significant difference were observed between pre-dialysis, home, and weekly averaged blood pressure at baseline and at 12 weeks (151.5 ± 8.5/80.9 ± 12.9 mmHg vs 150.3 ± 15.3/78.9 ± 21.2 mmHg, 151.4 ± 9.7/82.3 ± 14.7 mmHg vs 151.2 ± 17.7/81.4 ± 10.6 mmHg, and 156.0 ± 18.3/81.9 ± 9.4 mmHg vs 152.5 ± 18.9/81.7 ± 12.3 mmHg, respectively). FMD significantly increased from 2.54% ± 1.45% at baseline to 3.11% ± 1.37% at 12 weeks (P = 0.0267), and PDMP significantly decreased from 13.9 ± 5.8 U/mL at baseline to 10.9 ± 4.5 U/mL at 12 weeks (P = 0.0002).

CONCLUSION

Aliskiren improved vascular endothelial function and platelet-endothelium activation in patients on hemodialysis independent of antihypertensive effect.

Characterization of the use of liraglutide for glycemic control in healthy and Type 1 diabetes mellitus suffering dogs

Glucagon-like peptide 1 (GLP-1) is a glucose-lowering, intestinal-derived factor with multiple physiological effects, making it attractive for diabetes therapy. However, the therapeutic potential of endogenous GLP-1 is limited, because of rapid inactivation by dipeptidyl peptidase-4. Recently, enhanced incretin preparations, such as liraglutide, have emerged, which are more resistant to degradation and longer lasting. Liraglutide is a long-acting acylated human GLP-1 receptor agonist, with a 97% amino acid sequence identity to endogenous human GLP-1, and 100% amino acid sequence homology with canine GLP-1. Since liraglutide has yet to be examined for use in dogs, and the incretin effect has been reported to exist in dogs, we sought to initially characterize liraglutide's ability for glycemic control in healthy dogs, under an oral glucose tolerance test (OGTT) environment initially. This was followed up a more realistic scenario involving food with insulin injection +/- liraglutide injection resulting in a glucose curve based study involving dogs suffering from Type 1 diabetes mellitus (T1DM). Overall, liraglutide had a stabilizing effect on glucose levels, maintaining circulating levels between 77.0 and 137.0mg/ml throughout the OGTT test period, resulting in a significant reduction of 13.8% in glucose AUC0-120 min (total area under the curve for 0-120 min) as compared to baseline control in healthy dogs (n=5). Interestingly, the liraglutide associated reduction in circulating glucose was not accompanied by any significant increase in insulin. Moreover, T1DM dogs (n=4) responded favorably to liraglutide treatment, which lead to a significant reduction of 46.0% in glucose AUC0-12h (total area under the curve for 0-12h), and a significant reduction of 66.5% in serum glucose as compared to baseline controls (insulin treatment only). Therefore, liraglutide's prandial glucagon suppressive ability appears to play a key role in its glucose-lowering capability, and offers great potential for use with dogs suffering from T1DM.

Lanthanum carbonate delays progression of coronary artery calcification compared with calcium-based phosphate binders in patients on hemodialysis: a pilot study

BACKGROUND AND OBJECTIVES

Coronary artery calcification (CAC) is associated with future cardiovascular events and/or death of patients on hemodialysis (HD). We investigated whether progression of CAC in patients on HD could be delayed by switching from a calcium (Ca)-based phosphate (Pi) binder to lanthanum carbonate.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

The CAC scores were evaluated at study enrollment and after 6 months in 52 patients on HD using calcium carbonate (CC) as a Pi binder. Patients were randomly divided into 2 groups assigned to receive either CC or lanthanum carbonate (LC), and the CAC scores were evaluated after a 6-month treatment period. Progression of CAC was assessed, as were serum levels of Ca, Pi, and intact parathyroid hormone (iPTH).

RESULTS

Forty-two patients completed the study (23 receiving CC and 19 receiving LC). In the 6 months prior to randomization, all patients were treated with CC. During this 6-month period, the CAC scores increased significantly in all 42 patients. Once randomized, there was significantly less progression in the group treated with LC than with CC. Changes in CAC scores from 6 to 12 months were significantly smaller in the LC group than the CC group (-288.9 ± 1176.4 vs 107.1 ± 559.6, P = .036), and percentage changes were also significantly different (-6.4% vs 41.2%, P = .024). Serum Ca, Pi, and iPTH levels were similar in both groups during the study period.

CONCLUSIONS

This pilot study suggested that LC delayed progression of CAC in patients on HD compared with CC.

Sarpogrelate hydrochloride, a selective 5-HT(2A) receptor antagonist, improves skin perfusion pressure of the lower extremities in hemodialysis patients with peripheral arterial disease

BACKGROUND

Peripheral arterial disease (PAD) frequently occurs in patients on hemodialysis (HD); however, little is known about the effectiveness of drugs. We compare the effects of sarpogrelate and cilostazol in HD patients with PAD.

METHODS

We conducted a prospective, randomized, open-label, and multicenter trial for 24 weeks in HD patients with PAD. Thirty-five patients were divided into two groups: sarpogrelate (n = 17) and cilostazol (n = 18). We analyzed changes in skin perfusion pressure (SPP), levels of oxidative stress biomarkers, and adverse events.

RESULTS

At 24 weeks, SPP was increased in both groups (sarpogrelate, 43 ± 17 to 55 ± 15 mmHg; cilostazol, 49 ± 21 to 66 ± 29 mmHg; p < 0.05), and no difference was observed between the groups. Plasma pentosidine levels decreased in both groups (sarpogrelate, 0.65 ± 0.24 to 0.48 ± 0.12 mg/mL; cilostazol, 0.58 ± 0.22 to 0.47 ± 0.17 mg/mL; p < 0.05), and there were no differences between the groups. Serum malondialdehyde-modified low-density lipoprotein (MDA-LDL) levels significantly increased only in cilostazol group (p < 0.05). There were no clinically significant safety concerns linked to the both drugs. Although blood pressure did not differ in both groups, heart rate increased only in cilostazol group from 77 ± 13 to 83 ± 16 beats per minute (p < 0.05).

CONCLUSION

Sarpogrelate improves SPP in HD patients with PAD without increasing heart rate and serum MDA-LDL levels. We demonstrated that sarpogrelate is an effective and safe drug for the treatment of HD patients with PAD.