A Case of Diabetic Ketoacidosis with Refractory Metabolic Acidosis Successfully Treated with Continuous Hemodiafiltration

Diabetic ketoacidosis (DKA) is a complex medical disorder characterized by abnormalities in electrolyte, acid-base, and volume status. Metabolic acidosis in mild and moderate DKA is corrected with insulin therapy. Bicarbonate therapy may be indicated in cases of severe metabolic acidosis, however the use of bicarbonate in severe DKA is controversial due to a lack of prospective randomized studies. Renal replacement therapy can be used for correction of systemic acidemia. Continuous renal replacement therapy (CRRT) is used in patients who are too hemodynamically unstable to tolerate conventional hemodialysis, but has also been used in treatment of patients with severe DKA. CRRT has never been used previously in DKA patients with refractory metabolic acidosis in Korea. Here, we describe the successful treatment of a DKA patient with refractory metabolic acidosis with CRRT.

A case of peritoneal dialysis-associated peritonitis by Rothia mucilaginosa

Rothia muciliaginosa (R. mucilaginosa) is a facultative, Gram-positive coccus that is considered to be part of the normal flora of the mouth and respiratory tract. There are sporadic reports of the organism causing endocarditis in patients with heart valve abnormalities, as well as meningitis, septicemia, and pneumonia associated with intravenous drug abuse. However, it is an unusual pathogen in cases of peritoneal dialysis (PD)-associated peritonitis. Although R. mucilaginosa is generally susceptible to penicillin, ampicillin, cefotaxime, imipenem, rifampicin, and glycopeptides, there are no guidelines for the treatment of PD-associated peritonitis. Herein, we report a case of PD-associated peritonitis due to R. mucilaginosa that was resolved with intraperitoneal antibiotic treatment.

Two Successfully Treated Cases of Pulmonary Fibrosis Due to Paraquat Poisoning

Paraquat poisoning can cause severe multiple organ failure involving the kidneys, liver, lungs, adrenals, and central nervous system. The toxic effect of paraquat on the lung manifests as pulmonary edema, hypoxia, respiratory failure, and pulmonary fibrosis. However, optimal guidelines for treatment of lung fibrosis following paraquat ingestion are not available. We experienced two cases, a 45-year-old Korean male and a 66-year-old Korean male, who visited the emergency center because of paraquat poisoning. They initially received methylprednisolone pulse therapy and cyclophosphamide. Then they experienced pulmonary fibrosis approximately 10 days after admission during renal recovery. Although steroid pulse therapy with cyclophosphamide was reported to reduce mortality due to paraquat poisoning, the side effects of cyclophosphamide treatment were concerning in our patients, who had already received cyclophosphamide. Therefore, we decided to repeat steroid pulse therapy without cyclophosphamide. Fortunately, pulmonary fibrosis in these two patients resolved after repeated steroid pulse therapy. Thus, steroid pulse therapy alone could benefit patients with lung fibrosis, who have already received steroid and cyclophosphamide treatment. Herein, we report on two cases of pulmonary fibrosis due to paraquat poisoning that were treated successfully with repeated steroid pulse therapy.

The Experience and Management of Two Cases of Metformin-associated Lactic Acidosis

Metformin, a dimethylbiguanide, is an oral antihyperglycemic drug used in treatment of type 2 diabetes mellitus. It has been reported that metformin may be associated with lactic acidosis in patients with clinical conditions such as renal failure and heart failure. Metformin-associated lactic acidosis (MALA) is a rare, but serious complication with a mortality rate of approximately 30~50%. Therefore, an aggressive treatment strategy including hemodialysis is recommended for these patients. Although continuous renal replacement therapy (CRRT) has been administered in hemodynamically unstable patients with MALA, there are few case reports describing the use of CRRT as a therapeutic modality in Korea. Here, we describe the case histories of two MALA patients who underwent treatment with CRRT.

Risk Factors and Reversibility of Renal Failure in Patients with Newly Diagnosed Multiple Myeloma / 대한내과학회지

BACKGROUND/AIMS: Multiple myeloma (MM) is frequently accompanied by renal insufficiency, which has been regarded as a poor prognostic factor for MM. It is known that the incidence and characteristics of MM in Asia differ from those in Western countries. The aim of this study was to evaluate risk factors for renal impairment and to investigate reversible factors for renal failure in patients with MM. METHODS: Patients newly diagnosed with MM from 2005 to 2008 were included. We investigated factors associated with renal insufficiency and those related to recovery from renal dysfunction after 12 weeks of treatment of MM. RESULTS: Renal failure was recognized in 86 (39%) of 221 patients at diagnosis. In the binary logistic regression analysis, low hemoglobin (odds ratio [OR], 0.813; p = 0.02), high beta2microglobulin (OR, 1.006; p < 0.01), and use of angiotensin-converting enzyme inhibitors (ACEi) (OR, 2.783; p < 0.04) at initial presentation were independent risk factors for renal failure in patients with multiple myeloma. After 12 weeks of treatment, 25 of 86 (29%) patients with renal failure had recovered renal function. Good response to chemotherapy (OR, 6.044; p < 0.01) and higher eGFR (OR, 1.084; p < 0.01) were associated with renal function recovery. CONCLUSIONS: Levels of hemoglobin and beta2microglobulin, and use of ACEi were independent risk factors for the development of renal failure in MM patients. The response to chemotherapy and eGFR at diagnosis significantly influenced recovery of renal function.

Risk Factors and Reversibility of Renal Failure in Patients with Newly Diagnosed Multiple Myeloma / 대한내과학회지

BACKGROUND/AIMS: Multiple myeloma (MM) is frequently accompanied by renal insufficiency, which has been regarded as a poor prognostic factor for MM. It is known that the incidence and characteristics of MM in Asia differ from those in Western countries. The aim of this study was to evaluate risk factors for renal impairment and to investigate reversible factors for renal failure in patients with MM. METHODS: Patients newly diagnosed with MM from 2005 to 2008 were included. We investigated factors associated with renal insufficiency and those related to recovery from renal dysfunction after 12 weeks of treatment of MM. RESULTS: Renal failure was recognized in 86 (39%) of 221 patients at diagnosis. In the binary logistic regression analysis, low hemoglobin (odds ratio [OR], 0.813; p = 0.02), high beta2microglobulin (OR, 1.006; p < 0.01), and use of angiotensin-converting enzyme inhibitors (ACEi) (OR, 2.783; p < 0.04) at initial presentation were independent risk factors for renal failure in patients with multiple myeloma. After 12 weeks of treatment, 25 of 86 (29%) patients with renal failure had recovered renal function. Good response to chemotherapy (OR, 6.044; p < 0.01) and higher eGFR (OR, 1.084; p < 0.01) were associated with renal function recovery. CONCLUSIONS: Levels of hemoglobin and beta2microglobulin, and use of ACEi were independent risk factors for the development of renal failure in MM patients. The response to chemotherapy and eGFR at diagnosis significantly influenced recovery of renal function.

A Case of Infective Endocarditis in an End-Stage Renal Disease Patient Caused by Candida famata / 대한내과학회지

Infective endocarditis is rare in end-stage renal disease (ESRD) patients, who have a poorer prognosis than the general population. Candida endocarditis is rare and has a poor prognosis among causes of infective endocarditis. A 45-year-old male was admitted with sepsis combined with a hematoma on his right back. Candida famata was cultured in his blood. We treated him with antifungal agents. Echocardiography was performed to identify vegetations and diagnose endocarditis. In this case, surgical therapy was impossible because the patient's condition had deteriorated. We also administered antibiotics because methicillin-resistant Staphylococcus aureus was cultured from his sputum and a perianal abscess. The symptoms did not improve despite the ongoing treatment. Metabolic acidosis, hypotension, and a decreased state of consciousness developed and he died. We report a rare case of Candida endocarditis in an ESRD patient on hemodialysis.

Idiopathic retroperitoneal fibrosis associated with Hashimoto's thyroiditis in a patient with a single functioning kidney

Retroperitoneal fibrosis (RPF) is a rare disease characterized by the presence of fibroinflammatory tissue around the abdominal aorta and ureteral entrapment in most cases. Idiopathic RPF is frequently reported in association with autoimmune diseases; however, there have been few reports of idiopathic RPF associated with Hashimoto's thyroiditis. Here, we report a case of idiopathic RPF with Hashimoto's thyroiditis in a patient with a single functioning kidney, which was successfully treated by corticosteroid therapy and transient intraureteral stent insertion with a double-J catheter.

A Case of Vancomycin Resistant Enterococcal Urinary Tract Infection and Pseudomembranous Colitis Co-Infection / 대한신장학회지

Infections are the second leading cause of mortality among patients with end-stage renal disease (ESRD). Recently, colonization or infection with vancomycin-resistant enterococci (VRE) is increasing in prevalence at many institutions and is often reported in dialysis patients. Enterococci are generally considered to be of low pathogenicity but may cause urinary tract infection, bacteremia, endocarditis or meningitis in debilitated patients. Three cases of VRE peritonitis in patients on CAPD were reported, but there was no report of VRE urinary tract infection (UTI) in hemodialysis patients in Korea. We present a case of VRE UTI with pseudomembranous colitis (PMC) in an ESRD patient with anal VRE colonization. The VRE UTI was treated successfully with linezolid.

A Case of Severe Acute Renal Failure Due to Sodium Bromate Intoxication / 대한신장학회지

Bromate is an oxidizing agent used as a permanent wave neutralizer. Accidental or deliberate ingestion of bromate has rarely been reported, but is potentially severe. We report a 36-year-old female hairdresser, who was admitted due to nausea and vomiting after ingestion of sodium bromate. The patient was successfully treated with hemodialysis therapy and renal function recovered without any complication. The clinicians must remember that early therapeutic measures, including hemodialysis, should be taken as soon as possible to prevent irreversible hearing loss and renal failure.

A Case of Adult Minimal Change Nephrotic Syndrome Associated with Thin Basement Membrane Nephropathy / 대한신장학회지

Thin basement membrane nephropathy (TBMN) is characterized by persistent hematuria, mild proteinuria, normal renal function and family history of hematuria. Many studies report that TBMN commonly occurs together with other glomerular diseases such as minimal change nephrotic syndrome, membranous nephropathy, IgA nephropathy and focal segmental glomerulosclerosis. Especially, the case of TBMN with minimal change nephrotic syndrome has been rare. We report a case of adult minimal change nephrotic syndrome with TBMN in a 44-year-old female with general edema and microscopic hematuria. On renal biopsy, electron microscopic examination demonstrated diffuse thinning of glomerular basement membrane with the thickness less than 250nm and diffuse foot process effacement. Treatment with corticosteroid resulted in complete remission of proteinuria.

Two Cases of Oropharyngeal Edema Caused by a Bee Sting / 대한소화기내시경학회지

Hymenoptera stings can result in local and systematic symptoms due to their toxic and allergic contents. Although serious sequela are rare, the occurrence of an anaphylactic reaction is considered to be very dangerous and can potentially cause death. Oropharyngeal stings, though infrequent, can cause local edema and airway obstruction due to an anaphylactic reaction and requires immediate epinephrine, antihistamine, steroid treatment and close observation over several days. Careful observation of the oropharyngeal and laryngopharyngeal area using upper gastrointestinal endoscopy is highly recommended, especially for detection of possible edematous swelling in the arytenoid cartilage area. Here we report two cases of patients complaining pain due to edematous swelling in the arytenoid cartilage area caused by hymenoptera stings after accidentally drinking water with a bee in it.

A Case of Systemic Lupus Erythematosus Involving the Kidneys in a Patient with IgA Nephropathy / 대한류마티스학회지

Renal involvement in systemic lupus erythematosus (SLE) is a typical manifestation of the disease. The occurrence of non-lupus nephritis, especially IgA nephropathy (IgAN), in patients with SLE has rarely been reported. We describe the case of a 21-year-old woman who was diagnosed with IgAN and subacute necrotizing lymphadenitis, and her renal lesion biopsy was typical of lupus nephritis (ISN/RPS Class III). Although IgAN and lupus nephritis share some common physiopathological characteristics, their laboratory, histopathologic findings, and the extra-renal clinical manifestations are different and support a different pathogenesis. Our case highlights the importance of a renal biopsy in patients with lupus and urinary alterations despite underlying IgAN. A correct diagnosis would permit the most appropriate immunosuppressive treatments to be considered.