Preexisting comorbidities are associated with the mortality rate as well as the predialysis adverse events in incident dialysis patients

Background@#Optimal estimated glomerular filtration rate (eGFR) to start maintenance dialysis is controversial. Observational studies have reported that initiation of dialysis at high eGFRs is associated with worse postdialysis survival. @*Methods@#We retrospectively investigated 1,038 incident dialysis patients who started maintenance dialysis during 2010-2015. Patients were assessed for comorbidities and adverse events during the transitional period of dialysis initiation. Patients were classified as planned dialysis (PD) vs. unplanned dialysis (UD) according to indications for dialysis initiation. @*Results@#UD group comprised 352 patients (33.9%). Mean eGFR at dialysis initiation was higher in UD patients than PD patients (7.9 ± 5.1 mL/min/1.73 m2 vs. 5.9 ± 3.4 mL/min/1.73 m2, p < 0.001). Mean Davies comorbidity index in the UD group was higher than in the PD group (1.3 ± 1.0 vs. 0.9 ± 1.0, p < 0.001). In multivariable Cox regression, patients with more comorbidities experienced more ischemic heart disease (hazard ratio [HR], 4.36; 95% confidence interval [CI], 1.71–11.14) in the medium-risk group and HR of 8.84 (95% CI, 3.06–25.55) in the high-risk group (vs. low-risk group, p < 0.001)) during the predialysis period. High-risk group had increased postdialysis mortality (HR, 2.48; 95% CI, 1.46–4.20; p = 0.001). Adjusted HR of mortality was higher in the medium-risk group of UD patients (HR, 1.72; 95% CI, 1.16–2.56; p = 0.007). @*Conclusion@#Patients with more comorbidities were at increased risk of predialysis ischemic heart disease and postdialysis mortality. UD patients in the medium-risk population had increased risk of postdialysis mortality. Dialysis start should be individualized by considering comorbidities.

Minimal Change Disease in a Patient with Multiple Endocrine Neoplasia Type 1 / 대한내과학회지

Multiple endocrine neoplasia type 1 (MEN 1) is an autosomal dominant disorder characterized by two or more tumors of the parathyroid gland, duodenum-pancreas, and anterior pituitary. Membranous nephropathy is the most common manifestation of paraneoplastic glomerulopathy. However, minimal change disease in patients with MEN 1 has yet to be reported. Here, we report a case of minimal change disease in a 59-year-old man with MEN 1, along with a review of the relevant literature.

Posterior Nutcracker Syndrome with Microscopic Hematuria / 대한내과학회지

Nutcracker syndrome (NCS) refers to left renal vein compression with impaired blood outflow. The etiology of NCS has been attributed to various anatomic anomalies. Posterior NCS is caused by compression of the retroaortic left renal vein between the aorta and spine. The classic symptoms of NCS include left flank pain with gross or microscopic hematuria. The frequency and severity of the syndrome vary from asymptomatic microhematuria to severe pelvic congestion. For this reason, diagnosis of NCS is difficult and often delayed. Here, we report a case of posterior NCS that was incidentally discovered.

Posterior Nutcracker Syndrome with Microscopic Hematuria / 대한내과학회지

Nutcracker syndrome (NCS) refers to left renal vein compression with impaired blood outflow. The etiology of NCS has been attributed to various anatomic anomalies. Posterior NCS is caused by compression of the retroaortic left renal vein between the aorta and spine. The classic symptoms of NCS include left flank pain with gross or microscopic hematuria. The frequency and severity of the syndrome vary from asymptomatic microhematuria to severe pelvic congestion. For this reason, diagnosis of NCS is difficult and often delayed. Here, we report a case of posterior NCS that was incidentally discovered.

Renal Failure with Branchio-Oto-Renal Syndrome / 대한내과학회지

Branchio-oto-renal (BOR) syndrome is a rare autosomal dominant disorder that is characterized by preauricular pits, branchial fistula, branchial cyst, hearing impairment, and kidney anomalies. Hearing impairment is the single most common feature of BOR syndrome, affecting 89% of patients. Preauricular pits (77%), kidney anomalies (66%), branchial fistula (63%), external auditory canal anomalies (41%) are also common. For most patients, BOR syndrome does not affect life expectancy. The major life-threatening feature of this condition is kidney dysfunction, which occurs with about 6% of kidney anomalies. Therefore, once BOR syndrome is recognized in a patient, careful evaluation to detect renal anomalies and treatment of any kidney involvement are necessary. No case reports of BOR syndrome involving adult-onset end-stage kidney disease have been published in the Korean medical literature. We report a case of end-stage kidney disease in a 19-year-old male patient with BOR syndrome, together with a review of the pertinent literature.

Effects of education on low-phosphate diet and phosphate binder intake to control serum phosphate among maintenance hemodialysis patients: A randomized controlled trial

BACKGROUND: For phosphate control, patient education is essential due to the limited clearance of phosphate by dialysis. However, well-designed randomized controlled trials about dietary and phosphate binder education have been scarce. METHODS: We enrolled maintenance hemodialysis patients and randomized them into an education group (n = 48) or a control group (n = 22). We assessed the patients’ drug compliance and their knowledge about the phosphate binder using a questionnaire. RESULTS: The primary goal was to increase the number of patients who reached a calcium-phosphorus product of lower than 55. In the education group, 36 (75.0%) patients achieved the primary goal, as compared with 16 (72.7%) in the control group (P = 0.430). The education increased the proportion of patients who properly took the phosphate binder (22.9% vs. 3.5%, P = 0.087), but not to statistical significance. Education did not affect the amount of dietary phosphate intake per body weight (education vs. control: −1.18 ± 3.54 vs. −0.88 ± 2.04 mg/kg, P = 0.851). However, the dietary phosphate-to-protein ratio tended to be lower in the education group (−0.64 ± 2.04 vs. 0.65 ± 3.55, P = 0.193). The education on phosphate restriction affected neither the Patient-Generated Subjective Global Assessment score (0.17 ± 4.58 vs. −0.86 ± 3.86, P = 0.363) nor the level of dietary protein intake (−0.03 ± 0.33 vs. −0.09 ± 0.18, P = 0.569). CONCLUSION: Education did not affect the calcium-phosphate product. Education on the proper timing of phosphate binder intake and the dietary phosphate-to-protein ratio showed marginal efficacy.

Clinical analysis of single filtration plasmapheresis using continuous renal replacement therapy machines in kidney transplantation

BACKGROUND: Plasmapheresis has become an essential element of kidney transplantation (KT). In the present study, we report clinical outcomes of filtration plasmapheresis using continuous renal replacement therapy machines with a single filter for the first time in Korea. METHODS: We retrospectively analyzed six patients who underwent filtration plasmapheresis for KT in our center; plasmapheresis was performed using the Plasmaflex (Baxter®) with a TPE 2000 filter set (Baxter®) in our hemodialysis unit. Five percent albumin was used as the replacement fluid, and intravenous immunoglobulin G was administered after each plasmapheresis session. The target preoperative ABO isoagglutinin titer was less than 1:8. RESULTS: Filtration plasmapheresis was performed in four patients for ABO-incompatible KT, one for antibody-mediated rejection after KT, and the last one for positive T cell crossmatch. Altogether, 46 sessions of plasmapheresis were performed. ABO isoagglutinin titers successfully declined to or below the target level in all patients, and all patients successfully received KT with no significant antibody titer rebound. Acute antibody-mediated rejection and positive T cell crossmatch were well treated with filtration plasmapheresis, and no patient required fresh frozen plasma infusion for coagulopathy. There were one episode of hypotension and three of hypocalcemia. No patients experienced bleeding, infection, or allergic reaction. CONCLUSION: Filtration plasmapheresis was effective and safe. Although our result is from a single center, our protocol appears to be promising.

Allogenic Peripheral Blood Stem Cell Transplant-Induced Membranous Glomerulonephropathy as Chronic Graft-Versus-Host Disease / 대한내과학회지

Heavy proteinuria in the nephrotic range is an uncommon, often unrecognized manifestation of graft-versus-host disease (GVHD) following hematopoietic stem cell transplantation. A few isolated case reports have been published in the Korean literature involving a small number of patients who developed membranous nephropathy as GVHD after peripheral blood stem cell transplantation (PBSCT). A 17-year-old female was diagnosed with non-Hodgkin's lymphoma. Following remission, she underwent allogeneic PBSCT. Shortly thereafter, she developed acute GVHD, which was managed by medical therapy with prednisolone and cyclosporine. Approximately 13 months following PBSCT, the patient developed proteinuria without peripheral edema. Pulsed steroid therapy was initiated three times, but her condition did not improve. Twenty months after PBSCT, she developed nephrotic range proteinuria. A renal biopsy was performed, and the diagnosis was histologically consistent with membranous nephropathy. Because the response to steroids was not satisfactory, the dose of cyclosporine was increased. Approximately 3 months after renal biopsy, the proteinuria disappeared. Given the recent increase in the incidence of GVHD-mediated renal disease, in particular, renal biopsy is indispensable to the diagnosis of nephropathy and to the prevention of disease progression.

Metformin induced acute pancreatitis and lactic acidosis in a patient on hemodialysis / 영남의대학술지

Metformin, commonly prescribed for type 2 diabetes, is considered safe with minimal side-effect. Acute pancreatitis is rare but potentially fatal adverse side-effect of metformin. We report a patient on hemodialysis with metformin-related acute pancreatitis and lactic acidosis. A 62-year-old woman with diabetic nephropathy and hypertension presented with nausea and vomiting for a few weeks, followed by epigastric pain. At home, the therapy of 500 mg/day metformin and 50 mg/day sitagliptin was continued, despite symptoms. Laboratory investigations showed metabolic acidosis with high levels of lactate, amylase at 520 U/L (range, 30-110 U/L), and lipase at 1,250 U/L (range, 23-300 U/L). Acute pancreatitis was confirmed by computed tomography. No recognized cause of acute pancreatitis was identified. Metformin was discontinued. Treatment with insulin and intravenous fluids resulted in normalized amylase, lipase, and lactate. When she was re-exposed to sitagliptin, no symptoms were reported.

Tumor necrosis factor α is a risk factor for infection in peritoneal dialysis patients

BACKGROUND/AIMS: It has been shown that circulating tumor necrosis factor α (TNF-α) is elevated in end stage renal disease patients; however, the relationship between TNF-α and the development of infection in these patients is unknown. In this study, we investigated the association of plasma TNF-α and interleukin 6 (IL-6) with infection in peritoneal dialysis (PD) patients. We also evaluated the association of their plasma levels with the production by peripheral blood mononuclear cells (PBMC), and with various clinical parameters. METHODS: We enrolled 32 patients on maintenance PD and 10 healthy controls. Plasma and PBMC were isolated from blood. PBMC were stimulated with lipopolysaccharide in vitro. RESULTS: Mean follow-up duration was 775 days. Six patients developed organ infections (five pneumonia and one liver abscess), and six patients developed PD peritonitis and eight developed exit site infection. Plasma TNF-α and IL-6 levels were significantly elevated in organ infections but not in peritonitis or in exit site infection. Plasma TNF-α was the only significant risk factor for organ infections and pneumonia in multivariate regression analysis. Patients with high plasma TNF-α levels showed a significantly greater cumulative hazard rate for organ infections compared to those with low TNF-α levels. Plasma TNF-α levels correlated with TNF-α production by PBMC and showed an inverse association with Kt/V. CONCLUSIONS: This is the first study showing that plasma TNF-α is a significant risk factor for infection in PD patients.

Comparison of estimated glomerular filtration rate equations at the time of hemodialysis initiation

BACKGROUND: Estimated glomerular filtration rate (eGFR) is one of the most important guidelines in deciding the optimal timing of dialysis initiation. In the present study, we calculated the eGFR at the time of hemodialysis (HD) initiation using 5 commonly used equations to relate them with clinical and laboratory characteristics of the patients and to evaluate which of these equations best define the eGFR at HD initiation. METHODS: We retrospectively analyzed 409 end-stage renal disease patients who were newly started on HD treatment in our institution. The eGFR was calculated using the Cockcroft-Gault equation, the Cockcroft-Gault equation corrected for body surface area, the Modification of Diet in Renal Disease (MDRD) equation, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, and the Nankivell equation. RESULTS: The mean eGFRs at HD start were significantly different across the equations. The mean eGFR was 7.8 mL/min for the corrected Cockcroft-Gault equation, 7.7 mL/min for the Cockcroft-Gault equation, 6.2 mL/min/1.73 m2 for the MDRD equation, and 5.6 mL/min/1.73 m2 for the CKD-EPI equation. The corrected Cockcroft-Gault, the MDRD, and the CKD-EPI equations were well correlated with all CKD-specific complications including hypertension, anemia, hyperkalemia, metabolic acidosis, hypocalcemia, hyperphosphatemia, and hyperparathyroidism. The mean eGFR calculated by the corrected Cockcroft-Gault equation showed the lowest coefficient of variation among all the equations. CONCLUSIONS: The eGFR at HD initiation are significantly different according to the used eGFR equations, and the corrected Cockcroft-Gault equation may be the best in defining the eGFR at HD initiation.

Severe but reversible acute kidney injury resulting from Amanita punctata poisoning

Mushroom-related poisoning can cause acute kidney injury. Here we report a case of acute kidney injury after ingestion of Amanita punctata, which is considered an edible mushroom. Gastrointestinal symptoms occurred within 24 hours from the mushroom intake and were followed by an asymptomatic period, acute kidney injury, and elevation of liver and pancreatic enzymes. Kidney function recovered with supportive care. Nephrotoxic mushroom poisoning should be considered as a cause of acute kidney injury.

Renal Artery Embolization in Patients with Polycystic Kidney Disease / 대한내과학회지

Polycystic kidney disease (PCKD) is the most common life-threatening genetic disease that causes kidney failure worldwide. Patients with autosomal dominant PCKD notice an increase in abdominal size as the kidney cysts grow and present with gastrointestinal and pulmonary symptoms. Surgical therapy, percutaneous drainage, sclerotherapy, cyst decompression, and laparoscopic fenestration have been used to treat the symptoms, but the results are often unsatisfactory. We recruited five patients with PCKD. Each patient complained of severe abdominal discomfort, and had a poor quality of life. In these patients, we performed renal artery embolization. After the procedure, all of the patients were discharged without severe complications. Follow-up abdominal computed tomography was performed 3-6 months after the procedure, and we were able to confirm a reduction in the size of both kidneys. In addition, the clinical symptoms improved in all five patients.

A Case of Sarcoidosis Associated with Renal Failure in a Kidney Transplant Patient / 대한내과학회지

Sarcoidosis, systemic inflammatory disease characterized by non-caseating granulomas, is rarely associated with renal failure in a kidney transplant. We report a 51-year-old woman with a kidney transplant who was diagnosed to have renal sarcoidosis. After 7 years of renal transplantation, the patient presented with relatively rapid deterioration of renal function and, subsequently, she underwent kidney transplant biopsy. Renal biopsy revealed interstitial nephritis with non-caseating granulomas compatible with granulomatous interstitial nephritis (GIN). She was also found to have granulomatous lymphadenitis and skin lesions. Diagnosis of sarcoidosis was made based on histopathologic findings, the high serum angiotensin converting enzyme level and exclusions of other causes of GIN including tuberculosis, ANCA associated glomerulonephritis and tubulointerstitial nephritis and uveitis syndrome. The patient was started on oral prednisolone, and subsequently her renal function improved.

Acute Renal Vein Thrombosis and Pulmonary Thromboembolism in a Patient with Rapid Weight Loss / 대한내과학회지

Renal vein thrombosis (RVT) is rare and primarily observed in children with severe dehydration or in adults in a hypercoagulable state. This diagnosis is rarely considered when it occurs in adults. We report a case of a young man who had weight loss of 8 kg in 2 weeks accompanied by dehydration with excessive exercise, and he developed a right RVT with a pulmonary thromboembolism. The man had a 3-year history of essential hypertension and was admitted to the hospital because of severe right-flank pain. A RVT and pulmonary thromboemboli were visualized by computed tomography. No abnormal results were observed on coagulation tests, and no evidence of malignancy was found. We concluded that the RVT and pulmonary thromboembolism were induced by dehydration. Even though the patient was an adult, rapid weight loss with dehydration may cause RVT and unusual thromboembolic events must be suspected to avoid a delay in the diagnosis.

Vancomycin Pharmacokinetics in Oliguric Patients Undergoing Continuous Venovenous Hemodialysis and Continuous Venovenous Hemodiafiltration / 대한신장학회지

PURPOSE: Critically ill patients receiving continuous renal replacement therapy are susceptible to infection with methicillin-resistant bacteria, which require treatment with vancomycin. However, there are limited reports regarding vancomycin pharmacokinetics in the continuous venovenous hemodialysis (CVVHD) and continuous venovenous hemodiafiltration (CVVHDF). We performed this study to investigate the pharmacokinetics of vancomycin in oliguric patients receiving CVVHD and CVVHDF. METHODS: Data at steady-state obtained as part of our routine drug monitoring of vancomycin therapy in critically ill adult oliguric patients undergoing CVVHD or CVVHDF, retrospectively. Data were available for 35 cases of 23 patients assessed for 2 years. We analyzed the pharmacokinetic parameters of these cases. RESULTS: 8 cases on CVVHD and 27 cases on CVVHDF were available. The mean intensity of CVVHD was 17.7+/-4.9 mL/hour/kg and that of CVVHDF was 32.1+/-3.9 mL/hour/kg (p=0.000). The mean clearance of vancomycin was 16.4+/-3.8 mL/min in the CVVHD group and 21.6+/-5.1 mL/min in the CVVHDF group (P=0.007). The elimination of vancomycin correlated with the intensity of CVVHD and CVVHDF (CVVHD; r2=0.745, p=0.012, CVVHDF; r2=0.452, p=0.000). CONCLUSION: CVVHD and CVVHDF are effective for vancomycin elimination and there is a strong dependency of the vancomycin removal on the intensity of continuous renal replacement therapy. Strategies for individualization of vancomycin therapy in patients receiving CVVHD and CVVHDF are proposed.

Improved Gastrointestinal Symptoms and Quality of Life after Conversion from Mycophenolate Mofetil to Enteric-Coated Mycophenolate Sodium in Renal Transplant Patients Receiving Tacrolimus

It is reported that a conversion from mycophenolate mofetil (MMF) to enteric-coated mycophenolate sodium (EC-MPS) relieves gastrointestinal (GI) symptom burden and improves health-related quality of life (HRQoL). However, it is unclear whether renal transplant recipients using tacrolimus receive the same benefit from the conversion. In this prospective, multi-center, open-label trial, patients were categorized into two groups by their GI symptom screening. Equimolar EC-MPS (n=175) was prescribed for patients with GI burdens; those with no complaints remained on MMF (n=83). Gastrointestinal Symptom Rating Scale (GSRS) and Gastrointestinal Quality of Life Index (GIQLI) were evaluated at baseline and after one month. Patients and physicians completed Overall Treatment Effect (OTE) at one month. EC-MPS-converted patients had worse GSRS and GIQLI scores at baseline than MMF-continued patients (all P<0.001). Significant improvements in GSRS and GIQLI scores were observed for EC-MPS-converted patients at one month, but MMF-continued patients showed worsened GSRS scores (all P<0.05). OTE scale indicated that EC-MPS patients improved in overall GI symptoms and HRQoL more than MMF patients did (P<0.001). In tacrolimus-treated renal transplant recipients with GI burdens, a conversion from MMF to EC-MPS improves GI-related symptoms and HRQoL.

Routine Perioperative Antibiotic Prophylaxis in Renal Transplantation: It Makes No Difference for Bacterial Infections / 대한이식학회지

BACKGROUND: Although it has been a popular practice to use preventative antibiotics for the kidney recipients, it could increase the cost, encourage the growth of resistant micro-organism and have adverse effects. There has been no reported concrete evidence about the benefits and risks of using peri-operative prophylactic antibiotics for an immunosuppressed population. Therefore, we retrospectively evaluated the differences in the incidences of bacterial infection and adverse events after transplant surgery according to using peri-operative prophylactic antibiotics. METHODS: We reviewed retrospectively 106 cases of renal transplantations (cadaver donor: 42 cases, living donor: 64 cases) that were performed at Ajou University Hospital, Korea from January, 2006 to December, 2008. We divided the cases into two groups: Group A (n=41; 38.7%) included the patients who did not receive prophylactic antibiotics and Group B (n= 65; 61.3%) included the patients who did receive prophylactic antibiotics. We analyzed the infectious complications that occurred within 1 month after renal transplantation. RESULTS: In Group A, most patients (62 cases, 95.3%) used a 1st generation cephalosporin. The incidence of wound infection after kidney transplant for the 65 patients who received prophylactic antibiotics was 1.5%, compared to 2.5% for the 41 patients who did not receive prophylactic antibiotics. CONCLUSIONS: This retrospective study could not demonstrate a statistically significant difference in the rates of infectious complications between the two groups, although renal transplantation is considered to be a clean-contaminated surgery. But in order to obtain a definite conclusion, we need a bigger cohort in a prospective study.

A Case of Acute Renal Failure Complicated by the Poisoning of Amanita virgineoides / 대한신장학회지

Mushroom poisonings are potentially fatal. Most fatalities are due to the amatoxin that causes fulminant hepatic failure and acute renal failure. We report a patient who developed acute renal failure after ingesting Amanita virgineoides, which required renal replacement therapy, despite recovery of liver injury. A kidney biopsy showed acute tubular necrosis. The patient was recovered with the supportive care and temporary hemodialysis.

A Commentary on the Staging of CKD Based on eGFR / 대한신장학회지

No abstract available.