Cardiovascular Complication after Kidney Transplantation

Patient mortality after kidney transplantation continues to be a major clinical challenge, with approximately 1 in 5 recipients dying within 10 years of engraftment. Cardiovascular disease (CVD) is the most common cause of death after the 1-year posttransplant and it has been estimated that the risk of cardiovascular events is 50-fold higher than in the general population. Because of this, post transplant outcomes are substantially influenced by cardiovascular disease. The presence of both traditional and non-traditional risk factors contributes to this overwhelming burden of cardiovascular disease in patients with chronic kidney disease (CKD)

Thunderclap-like headache triggered by micturition and angina as an initial manifestation of bladder pheochromocytoma. A case report / Cefaleia trovoada-símile desencadeada pela micção e angina como manifestação inicial de feocromocitoma de bexiga. Um relato de caso

CONTEXT: Pheochromocytoma is a catecholamine-producing tumor characterized by hypertension, headache, tachycardia, excessive diaphoresis and angina. The thunderclap headache is so named because the pain strikes suddenly and severely. Although the symptoms of bladder pheochromocytoma are rather evident, the diagnosis of this rare neuroendocrine tumor can be missed. CASE REPORT: This study reports the case of a woman diagnosed with bladder pheochromocytoma who experienced thunderclap headache triggered by micturition and angina as an initial manifestation. CONCLUSION: This case study suggests that thunderclap headache and angina occurring concurrently with sudden blood pressure elevation during or immediately after micturition are important diagnostic clues for bladder pheochromocytoma. .

CONTEXTO: Feocromocitoma é um tumor produtor de catecolaminas, caracterizado por hipertensão, cefaleia, taquicardia, sudorese excessiva e angina. A dor de cabeça trovão é assim chamada porque a dor ataca de repente e intensamente. Embora os sintomas de feocromocitoma de bexiga sejam bastante evidentes, o diagnóstico deste tumor neuroendócrino raro pode ser perdido. RELATO DE CASO: Este estudo relata o caso de uma mulher diagnosticada com feocromocitoma na bexiga que sentiu a dor de cabeça trovão, desencadeada pela micção e angina como manifestação inicial. CONCLUSÃO: Este estudo de caso sugere que a dor de cabeça trovão e angina ocorrendo simultaneamente com a elevação da pressão de sangue repentina durante ou imediatamente após a micção são dicas importantes de diagnósticos de feocromocitoma na bexiga. .

Impact of Cancer on Survival of Patients with AKI on CRRT.

Background: Few studies have examined cancer patients with acute kidney injury (AKI) who require continuous renal replacement therapy (CRRT). The aim of this study was to compare the characteristics and outcomes of patients with and without cancer requiring CRRT for AKI in general intensive care units (ICUs). Methods: We studied a retrospective cohort study in an ICU. A total of 200 patients (without cancer 79%; with cancer 21%) were included over a 24 month period. Predictors of all-cause death were examined using Kaplan-Meier and Cox proportional hazards analyses in both treatment groups for statistical analysis. Results: The 1st contributing factors of AKI was cardiac dysfunction (40%) and 2nd factors was sepsis (38%). The cause of AKI was multifactorial in 78% of cancer patients and in 71% of patients without cancer. Hospital mortality rates were higher in patients with cancer (69%) than in patients without cancer (49.4 %) (P = 0.023). In multivariate analyses, older age, medical admission, poor chronic health status, comorbidities, ICU days until RRT start, number of associated organ dysfunctions, and diagnosis of cancer were associated with hospital mortality. The diagnosis of cancer was independently associated with mortality [odds ratio = 1.68 (95% confidence interval, 1.10–2.59), P = 0.017]. Conclusions: The presence of cancer may be independently associated with mortality in our study.

IgA Nephropathy may be a Disease Related to Crohn's Disease.

IgA nephropathy (IgAN) is the commonest form of glomerulonephritis worldwide and 15–30% of patients will ultimately develop end-stage renal failure. IgAN can be primary (in most cases) or secondary (associated with seronegative arthritis, cirrhosis, coeliac disease, vasculitis, HIV), but is rarely associated with Crohn’s disease (CD). We describe a case of 22 year-old man with CD associated with IgAN. After the patient underwent surgical resection of right colon due to suspected colon tumor, CD was diagnosed. 5 years after right hemicolectomy, microscopic hematuria was developed and a renal biopsy had revealed IgAN (type III). Patients with CD who present with hematuria more commonly have urological complications, but the possibility of renal parenchymal disease should also be considered.

Outcomes of Acute Kidney Injury Patients with and Without Cancer: A Single Center Study.

Background: Acute kidney injury (AKI) is a frequent complication in hospitalized patients. Incidence of AKI in hospitalized patients with cancer is increasing, but there have been few studies on AKI in patients with cancer. The purposes of this study were: 1. To evaluate and compare the characteristics and outcomes of cancer and non-cancer AKI patients; 2. To determine the impact of cancer diagnosis on hospital mortality of AKI patients; and 3. To compare outcome predictors between the two groups of AKI patients. Methods: We conducted a retrospective cohort study in a South Korean tertiary care hospital. A total of 2211 consecutive patients (without cancer 61.5%; with cancer 38.5%) were included over a 140-month period. Predictors of all-cause death were examined using the Kaplan-Meier method and the Cox proportional hazards model. Results: The main contributing factors of AKI were sepsis (31.1%) and ischemia (52.7%). AKI was multifactorial in 78% of patients with cancer and in 71% of patients without cancer. Hospital mortality rates were higher in patients with cancer (42.8%) than in patients without cancer (22.5%) (P = 0.014). In multivariate analyses, diabetes mellitus (DM) and cancer diagnosis were associated with hospital mortality. Cancer diagnosis was independently associated with mortality [odds ratio = 3.010 (95% confidence interval, 2.340-3.873), P = 0.001]. Kaplan-Meier analysis revealed that subjects with DM and cancer (n = 146) had lower survival rates than subjects with DM and without cancer (n = 687) (log rank test, P = 0.001). Conclusion: The presence of DM and cancer were independently associated with mortality in AKI patients both with and without cancer. Studies are warranted to determine whether proactive measures may limit AKI and improve outcomes.

Uremic Encephalopathy with Basal Ganglia Lesions in a Diabetic Predialysis Patient.

Syndromes associated with acute bilateral lesions of the basal ganglia in diabetic uremic patients are uncommon, and usually have reversible clinical and imaging findings. Such syndromes are seen almost exclusively in patients with diabetes mellitus and renal failure. Previously reported cases have described diabetic men with uremia on dialysis. Here, we report a case of uremic encephalopathy with lesions of the basal ganglia in a diabetic predialysis patient. A 44-year-old man with uremic encephalopathy presented with dysarthria, chorea, and right upper extremity paresthesia. Magnetic resonance imaging of the brain showed classic findings of hyper intensity in the bilateral basal ganglia. The patient had no family history of psychiatric or neurological disease. Laboratory findings revealed elevated levels of blood urea nitrogen, creatinine, and glucose. Haloperidol and ropinirole therapy was continued, resulting in significant improvement without dialysis. The patient recovered from his episode without apparent sequelae.

Survival by Time of Day of Hemodialysis in Korean Patients: A Single Center Study.

Background: Patients with end-stage renal disease (ESRD) typically undergo hemodialysis (HD) during the morning or afternoon, with time of treatment generally based on space availability or patient preference. No studies have investigated variation in patient survival as a function of the time of day of dialysis in Korean HD patients. We investigated the association of patient HD treatment shift with continued survival, controlling for well-established HD-related mortality risk factors. Method: A 10-year (from January 1, 2001 to December 31, 2010) follow-up retrospective cohort study was conducted among 120 ESRD patients who underwent HD at Kosin University Gospel Hospital either during a morning shift (n = 60) or an afternoon shift (n = 60). A variable comparison was conducted using a Chi-square test and t-test for categorical and continuous variables, respectively. Life table analysis was used to compare survival rates in the two treatment groups. Results: The mean survival rate of the morning-shift HD patients and afternoon-shift HD patients were not statistically different (mean survival, 61.1 months vs. 48.2 months; P = 0.139). The unadjusted 5-year survival rate for patients on morning shift hemodialysis was 87.3% versus 86.4% for patients on afternoon shift hemodialysis (P = 0.704 by Wilcoxon test). Conclusions: The survival rates of morning-shift HD patients and afternoon-shift HD patients were not different. Results from this cohort study may warrant prospective observational studies and randomized clinical trials in Korean HD patients for whom the time of day at which HD is administered is systemically varied.

Two Cases of Baclofen-Induced Encephalopathy in Hemodialysis and Peritoneal Dialysis Patients.

Hiccups are a spasmodic contraction of the diaphragm and usually transient phenomenon that affects nearly everyone. When hiccups develop, the patients are administrated antispastic agent, such as balcofen. Baclofen is widely used for the treatment of this spastic movement disorders. Also, baclofen is a gamma-aminobutyric acid (GABA) derivative that induces presynaptic motor neuron inhibition and produces a central antispastic response. Baclofen toxicity is rare and has been reported with intrathecal pump and orally administered baclofen, particularly in patients with poor renal function. Herein, we report two cases of encephalopathy in hemodialysis and peritoneal dialysis patients who received low doses of baclofen for persistent hiccups. We suggest that, in patients with chronic kidney disease (CKD), baclofen should be avoided or started at a low dose. If the renal insufficiency patient develops toxic baclofen-induced encephalopathy, hemodialysis may be the proper treatment to improve clinical symptoms.

A Case of the Syndrome of Acute Bilateral Basal Ganglia Lesions due to Hypoglycemia in Hemodialysis Patient.

Patients with chronic kidney disease may have neurological complications including uremic encephalopathy, stroke, neuropathy and myopathy. Rarely, acute movement disorder associated with bilateral basal ganglia lesion is seen in patients with end stage kidney disease. The hallmarks of this condition include reversible and uniform lesions of the basal ganglia on MRI which stand for decreased signal intensity on T1-weighted images and increased signal intensity on T2-weighted images, and the clinical presentation includes acute parkinsonism and/or involuntary movements. This syndrome has been reported mainly in Asian patients, typically in the setting of long-standing diabetes. We report a case of bilateral basal ganglia lesions in a patient with chronic renal failure, poorly controlled diabetes, and incidents of severe hypoglycemia. In our case, there was no evidence of acute metabolic disorders. Most reported patients with acute basal ganglia lesions in uremia also had diabetes and/or abnormal blood glucose levels. Our case had previously experienced occasional hypoglycemia before the onset of involuntary choreic movements. MRI of our patient showed acute bilateral basal ganglia lesion, corresponding to cytotoxic edema. This pattern was also observed in patients with hypoglycemic encephalopathy.

Toll-like Receptors.

Mammals sense pathogen invasion through pattern-recognition receptors (PRRs). A group of transmembrane proteins, Toll-like receptors (TLRs) are mainly expressed on antigen-presenting cells, such as macrophages or dendritic cells, and play critical roles as PRRs (1). TLR signaling activates antigen-presenting cells that provoke innate immunity and establish adaptive immunity. TLRs can be activated not only by invading pathogens but also by certain danger or stress-associated endogenous molecules leading to the induction of sterile inflammation. Activation of TLRs is a first line defense of the immune system, leading not only to the activation and recruitment of neutrophils and macrophages to sites of infection, but also to the enhancement of antimicrobial activity (2). Each TLR has common effects, such as inflammatory cytokine induction or upregulation of costimulatory molecule expression. However, TLRs also have specific functions, exemplified by type I IFN-inducing ability. These immunoadjuvant effects are critical in antimicrobial immunity and also involved in manifestations of autoimmunity (1). Therefore, understanding the molecular mechanisms of TLRs should facilitate the development of therapeutic solutions for allergy and autoimmune diseases.

A case of tacrolimus-induced supraventricular arrhythmia after kidney transplantation / Um caso de arritmia supraventricular induzida por tacrolimus, apos o transplante renal

CONTEXT Tacrolimus is a potent immunosuppressive drug often administered to transplant recipient patients and exhibits a variety of adverse cardiovascular effects. CASE REPORT We report a case of a 53-year-old Asian female who developed various arrhythmic phenomena including atrial premature complexes and supraventricular tachycardia after administration of tacrolimus. CONCLUSION Tacrolimus-associated arrhythmia after kidney transplantation may be life-threatening, and so patients undergoing this procedure should be carefully monitored. .

CONTEXTO Tacrolimus (tacrolimo) é uma potente droga imunossupressora frequentemente administrada a pacientes receptores de transplante e exibe uma variedade de efeitos cardiovasculares adversos. RELATO DE CASO Relatamos um caso de uma mulher asiática de 53 anos de idade que desenvolveu vários fenômenos de arritmias, incluindo complexos atriais prematuros e taquicardia supraventricular após a administração de tacrolimus. CONCLUSÃO Tacrolimus associado a arritmia após transplante de rim pode ser fatal, por isso, pacientes submetidos a esse procedimento devem ser cuidadosamente monitorados. .