Conversion from acetate dialysate to citrate dialysate in a central delivery system for maintenance hemodialysis patients

BACKGROUND: The objective of this study was to compare the impact of citrate dialysate (CD) and standard acetate dialysate (AD) in hemodialysis by central delivery system (CDS) on heparin demand, and clinical parameters. METHODS: We retrospectively evaluated 75 patients on maintenance hemodialysis with CDS. Patients underwent hemodialysis with AD over a six-month period (AD period), followed by another six-month period using CD (CD period). Various parameters including mean heparin dosage, high sensitivity C-reactive protein (hsCRP), calcium-phosphate product (CaxP), intact parathyroid hormone (iPTH), and urea reduction ratio (URR) were collated at the end of each period. RESULTS: Patients were 60.5 ± 14.7 years old, of whom 62.7% were male. Patients required less heparin when receiving CD (AD period: 1,129 ± 1,033 IU/session vs. CD period: 787 ± 755 IU/session, P < 0.001). After the CD period (Δ(CD)), pre-dialysis total CO₂ increased to 1.21 ± 2.80 mmol/L, compared to −2.44 ± 2.96 mmol/L (P < 0.001) after the AD period (Δ(AD)). After the CD period, concentrations of iPTH (Δ(AD): 73.04 ± 216.34 pg/mL vs. Δ(CD): −106.66 ± 251.79 pg/mL, P < 0.001) and CaxP (Δ(AD): 4.32 ± 16.63 mg²/dL² vs. Δ(CD): −4.67 ± 15.27 mg²/dL², P = 0.015) decreased. While hsCRP levels decreased after the CD period (Δ(AD): 0.07 ± 4.09 mg/L vs. Δ(CD): −0.75 ± 4.56 mg/L, P = 0.705), the change was statistically insignificant. URR remained above clinical guideline of 65% after both periods (Δ(AD): 72.33 ± 6.92% vs. Δ(CD) period: 69.20 ± 4.49%, P = 0.046). CONCLUSION: Our study confirmed that the use of CD in CDS required lower heparin doses compared to the use of AD. The use of CD also provided a more stable acid-base status.

Update of aristolochic acid nephropathy in Korea

BACKGROUND/AIMS: The true incidence of aristolochic acid nephropathy (AAN) is thought to be underestimated because numerous ingredients known or suspected to contain aristolochic acid (AA) are used in traditional medicine in Korea. METHODS: We collected data on cases of AAN since 1996 via a database in Korea. We evaluated the year of AAN development, route to obtaining AA-containing herbal medicine, gender, reason for taking AA-containing herbal medicine, clinical manifestations, histological findings, phytochemical analysis, and prognosis of patients with AAN. RESULTS: Data on 16 cases of AAN were collected. Thirteen cases developed AAN before and three cases after the prohibition of AA-containing herbal medicine by the Korea Food and Drug Administration. Patients were prescribed AA-containing herbal medicine from oriental clinics or had purchased it from traditional markets. AAN was distributed in all age groups. Young females were most commonly exposed to AA-containing herbal medicine for slimming purposes and postpartum health promotion, while older adults took AA-containing compounds for the treatment of chronic diseases. The most common symptoms presented at hospitalization were nausea and vomiting, and acute kidney injury was accompanied by Fanconi syndrome in almost half of the patients. Phytochemical analysis of AA in herbal medicine was available in six cases. Progression to end stage renal disease (ESRD) was observed in seven patients (43.8%), and five patients (31.3%) had progressed to ESRD within 6 months of diagnosis. CONCLUSIONS: Our report shows that patients were still exposed to AA-containing herbal medicine and that there is a possibility of underdiagnosis of AAN in Korea. A stronger national supervision system of herbal ingredients and remedies in oriental medicine is needed to prevent AAN.

Contrast-free (Zero-contrast) TAVR for Severe Aortic Stenosis in Patient with Chronic Kidney Disease

Transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) is a minimally invasive interventional procedure that repairs a valve without removing the old, damaged valve. Instead, a replacement valve is wedged into the location of the native aortic valve. During TAVR, contrast is used for conventional aortic root angiography, positioning of the TAVR valve device, and assessing the peripheral vasculature. Therefore, contrast-induced acute kidney injury (AKI) is a major concern when performing TAVR and is associated with increased mortality in patients with impaired renal function. Although the exact mechanism of post-TAVR AKI is unknown and appears multifactorial, contrast medium has been reported as a major contributing factor. We report a case of zero-contrast TAVR for severe AS in a patient with chronic kidney disease (CKD). The procedure was successfully performed with only fluoroscopic and transesophageal echocardiography (TEE) guidance.

Syndrome of inappropriate antidiuretic hormone secretion associated with seronegative neuromyelitis optica spectrum disorder

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a potential cause of hyponatremia of the central nervous system (CNS). Although SIADH has been reported to be associated with many other central nervous disorders, its association with neuromyelitis optica (NMO) or NMO spectrum disorders are rare. NMO is a demyelinating disorder characterized by optic neuritis and transverse myelitis. Aquaporin-4 (AQP4), which is the target antigen for a NMO autoantibody, is the predominant CNS water channel. However, some NMO patients show seronegative AQP4 antibody results. The spectrum of NMO has been changed, and new findings about the disease have been reported. Here, we report a case of seronegative NMO spectrum disorder associated with SIADH.

Acute Phlegmonous Gastritis Developing after Endoscopic Submucosal Dissection That Was Successfully Treated by Antibiotics Alone / 대한내과학회지

Endoscopic submucosal dissection (ESD) is widely used to treat a variety of gastric lesions including early gastric cancer and gastric adenoma. Bleeding and perforation are the most common complications of ESD. However, a rare and fatal bacterial stomach infection, termed acute phlegmonous gastritis, can also develop after ESD. We treated a patient with a high fever who complained of severe abdominal pain after ESD. Abdominal computed tomography (CT) revealed a diffuse, submucosal, minimally attenuated lesion and mucosal irregularity. The clincial presentation and the CT findings were compatible with acute phlegmonous gastritis and the patient was successfully treated with antibiotics alone. The case is worth reporting because acute phlegmonous gastritis is a very rare complication of ESD.

Total Ankle Arthroplasty: An Imaging Overview

With advances in implant technology, total ankle arthroplasty (TAA) has become an increasingly popular alternative to arthrodesis for the management of end-stage ankle arthritis. However, reports in the literature do not focus on the imaging features of TAA. Through a literature review, we demonstrate basic design features of the current ankle arthroplasty system, and the normal and abnormal postoperative imaging features associated with such devices. Pre- and postoperative evaluations of ankle arthroplasty mainly include radiography; in addition, computed tomography and magnetic resonance imaging provide further characterization of imaging abnormalities. Familiarization with multimodal imaging features of frequent procedural complications at various postoperative intervals is important in radiological practice.

Elevated serum immunoglobulin E level as a marker for progression of immunoglobulin A nephropathy

BACKGROUND: Immunoglobulin E (IgE) has traditionally been associated with anaphylaxis and atopic disease. Previous studies reported that serum IgE levels are elevated in nephrotic syndrome and suggested IgE levels as a prognostic indicator in glomerular diseases. The aim of this study was to explore the association between serum IgE levels and renal outcome in patients with immunoglobulin A nephropathy (IgAN). METHODS: We included 117 patients with biopsy-proven IgAN. Renal progression was defined if a patient meets one of these criteria: (1) a negative value of delta estimated glomerular filtration rate (mL/min/1.73 m²/mo) or (2) a rise in serum creatinine to an absolute level of ≥ 1.3 mg/dL (male) or 1.2 mg/dL (female). We defined delta changes in serum creatinine, estimated glomerular filtration rate, and proteinuria as a difference of values during the follow-up period. RESULTS: A total of 117 patients with IgAN were included. The serum IgE level was significantly high in the renal progressive group compared with the nonprogressive group. Sex and history of gross hematuria were significantly different between the high-IgE group and the low-IgE group. Regression analysis showed that a male sex, initial proteinuria, and change of proteinuria were significantly associated with serum IgE levels. CONCLUSION: The serum IgE level is potentially associated with disease progression and pathogenesis of IgAN.

A case of Ramsay Hunt syndrome diagnosed after kidney transplantation

We report the first case of Ramsay Hunt syndrome (RHS) diagnosed after kidney transplantation in Korea. RHS is a disease caused by latent varicella-zoster characterized to involve geniculate ganglion of the seventh cranial nerve. Patients who have undergone kidney transplantation can be easily affected by viral infections because of their immune-compromised status. A 35-year-old man with hypertensive end-stage renal disease underwent kidney transplantation. Two months after surgery, the recipient was diagnosed with RHS and treated with antivirals and steroids. However, after using the antiviral agents for the recommended duration, facial paralysis occurred as a new presentation and he required further treatment. Otalgia and periauricular vesicles improved, but the facial palsy remained.

Comparison of Two Different Doses of Single Bolus Steroid Injection to Prevent Atrial Fibrillation Recurrence after Radiofrequency Catheter Ablation

PURPOSE: Steroids may play a role in preventing the early recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA). However, optimal doses and route of steroid delivery have not yet been determined. This study evaluated the effect of two different doses of a single bolus injection of steroids on AF recurrence after RFCA. MATERIALS AND METHODS: Of 448 consecutive AF patients who underwent RFCA, a single steroid bolus was injected into 291 patients. A low-dose steroid group (n=113) received 100 mg of hydrocortisone and a moderate-dose steroid group (n=174) received 125 mg of methylprednisolone. We used propensity-score matching to select patients as follows: control (n=95), low-dose (n=95), and moderate-dose steroid groups (n=97). RESULTS: Pericarditis developed in 1 (1.1%) control patient, 2 (2.1%) low-dose patients and 0 moderate-dose patients. Maximum body temperature and C-reactive protein were significantly decreased in the moderate-dose steroid group compared to the other groups (p<0.01). The number of patients of early AF recurrence (< or =3 months) did not differ among three groups. Early recurrence was 24 (25%) in the control, 24 (25%) in the low-dose and 25 (26%) in the medium-dose groups (p=0.99). Compared with control group, low-dose or moderate-dose steroid treatment did not effectively decrease mid-term (3-12 months) AF recurrence [22 (23%) vs. 23 (24%) vs. 18 (19%); p=0.12]. CONCLUSION: A single injection of moderate-dose steroid decreased inflammation. However, single bolus injections of low-dose or moderate-dose steroids were not effective in preventing immediate, early or midterm AF recurrence after RFCA.

Severe Hyponatremia Associated with the Use of Angiotensin II Receptor Blocker/thiazide Combinations

There are several widely used combinations of angiotensin II receptor blocker (ARB)/thiazide. The complimentary mechanism of action for such anti-hypertensive therapies is that, while ARB inhibits the vasoconstricting and aldosterone-secreting effects of angiotensin II, hydrochlorothiazide affects the renal tubular mechanisms of electrolyte reabsorption and increases excretion of sodium and chloride in the distal tubule, consequently promoting water excretion. In addition, hypokalemia, which may be triggered by a hydrochlorothiazide-induced increase in urinary potassium loss, is resisted by the use of ARB. Hence, the ARB/thiazide combination is safe in terms of potassium imbalance. For these reasons, fixed-dose ARB/thiazide combination anti-hypertensive drugs have been widely used for the treatment of hypertension. However, there have not been many studies done regarding cases where patients under such regimens showed severe hyponatremia, even when the amount of thiazide included was low. Here we report two cases in which severe hyponatremia occurred following treatment with the ARB/thiazide combinations. Upon discontinuation of the regimen, both patients showed recovery from hyponatremia.