Clostridium difficile-associated diarrhea in dialysis patients

BACKGROUND: Dialysis patients have impaired host defense mechanisms and frequently require antibiotics for various infective complications. In this study, we investigated whether dialysis patients have greater risk for Clostridium difficile-associated diarrhea (CDAD). METHODS: During the 4-year study period (2004-2008), 85 patients with CDAD were identified based on a retrospective review of C difficile toxin assay or histology records. Nosocomial diarrheal patients without CDAD were considered as controls (n=403). We assessed the association between renal function and the prevalence and clinical outcomes of CDAD. RESULTS: There was a significant difference in the prevalence rate of chronic kidney disease (CKD) between CDAD and non-CDAD patients (P<0.001). Sixteen patients (18.8%) of the CDAD group were treated with dialysis, whereas 21 patients (5.2%) of the non-CDAD group were treated with dialysis. There was a significant association between renal function and CDAD in patients on dialysis [odds ratio (OR)=4.44, 95% confidence interval (CI) 2.19-8.99, P<0.001], but not in patients with CKD stage 3-5 (OR=1.10, 95% CI 0.63-1.92, P=0.73). In multivariate analysis, CKD stage 5D was an independent risk factor for the development of CDAD (OR=13.36, 95% CI 2.94-60.67, P=0.001). CONCLUSION: Our data indicate that dialysis patients might be at a greater risk of developing CDAD, which suggests that particular attention should be provided to CDAD when antibiotic treatment is administered to dialysis patients.

Clostridium difficile-associated diarrhea in dialysis patients

BACKGROUND: Dialysis patients have impaired host defense mechanisms and frequently require antibiotics for various infective complications. In this study, we investigated whether dialysis patients have greater risk for Clostridium difficile-associated diarrhea (CDAD). METHODS: During the 4-year study period (2004-2008), 85 patients with CDAD were identified based on a retrospective review of C difficile toxin assay or histology records. Nosocomial diarrheal patients without CDAD were considered as controls (n=403). We assessed the association between renal function and the prevalence and clinical outcomes of CDAD. RESULTS: There was a significant difference in the prevalence rate of chronic kidney disease (CKD) between CDAD and non-CDAD patients (P<0.001). Sixteen patients (18.8%) of the CDAD group were treated with dialysis, whereas 21 patients (5.2%) of the non-CDAD group were treated with dialysis. There was a significant association between renal function and CDAD in patients on dialysis [odds ratio (OR)=4.44, 95% confidence interval (CI) 2.19-8.99, P<0.001], but not in patients with CKD stage 3-5 (OR=1.10, 95% CI 0.63-1.92, P=0.73). In multivariate analysis, CKD stage 5D was an independent risk factor for the development of CDAD (OR=13.36, 95% CI 2.94-60.67, P=0.001). CONCLUSION: Our data indicate that dialysis patients might be at a greater risk of developing CDAD, which suggests that particular attention should be provided to CDAD when antibiotic treatment is administered to dialysis patients.

A case of aortic thromboembolism and fresh nephrotic syndrome / 대한내과학회지

Nephrotic syndrome has frequently been associated with complications of thrombosis. Hypercoagulability is known as the principal contributing factor in the pathophysiologic mechanism, but the precise mechanism is unclear. Venous thrombosis is frequently recognized, but arterial thrombosis is rare, especially in the abdominal aorta. Most cases of arterial thrombosis present with acute ischemic symptoms and develop into a relapsing phase of nephrotic syndrome. The mainstream treatment for all abdominal aortic thrombosis patients is an emergency thrombectomy and thrombolytic therapy. We report on a 63-year-old male patient who was referred for malignant hypertension. The patient had no symptoms of claudication or peripheral ischemia. We diagnosed nephrotic syndrome using the laboratory data and detected a thrombosis involving the abdominal aortic, left renal and both iliac arteries. Because the patient had a single functioning kidney, we did not perform a kidney biopsy. We consider that the hypercoagulability state in nephrotic syndrome was caused by the abdominal aorta and peripheral arterial thrombosis. The patient's symptoms improved after anticoagulation and conservative therapy.

A Case of IgA Nephropathy Associated with Thin Basement Membrane Disease / 대한신장학회지

IgA nephropathy and thin basement membrane disease are common glomerular diseases in persistent microscopic hematuria with or without proteinuria. However, these two conditions cannot be easily distinguished on the biochemical or urinary findings alone. Therefore, renal biopsy is required for correct identification of the two conditions in most cases. Recently, it has been reported that thinning of glomerular basement membrane is accompanied with precipitation of electron dense deposits in some patients with IgA nephropathy. We report a case of IgA nephropathy associated with thin basement membrane disease in a 19-year-old male with microscopic hematuria and mild proteinuria. After 2 years' treatment with angiotensin II receptor blocker, the patient exhibited persistent microscopic hematuria but decreased proteinuria. Our finding concurs with the previous reports indicating that patients with both IgA nephropathy and thin basement membrane disease do not have different clinical features compared to those with IgA nephropathy alone. In addition, clinical outcome does not appear to be affected by thin basement membrane disease when these two conditions are combined.

Effects of Keto Acids on Serum Albumin Level in Hemodialysis Patients with Hypoalbuminemia / 대한신장학회지

PURPOSE: Malnutrition is a strong predictor of increased morbidity and mortality in patients on maintenance dialysis. Although a number of studies were performed to determine effective treatment, there is no proven medication for malnutrition. This study aimed to evaluate the effect of keto acids (ketosteril(R)) on serum albumin levels in hemodialysis patients with hypoalbuminemia. METHODS: Hemodialysis patients with hypoalbumineia (serum albumin < or = 3.8 g/dL) were enrolled. Exclusion criteria were previous supplementation of keto acids before the initiation of dialysis, acute infection, liver cirrhosis, malignancy and persistent hypercalcemia. Patients were treated with ketosteril for 6 months and serum albumin levels were compared to age- and gender-matched hemodialysis patients. RESULTS: There were no significant differences in the baseline serum albumin levels between ketosteril group (n=19) and the control group (n=19). After 6 months, the mean (+/-SD) serum albumin level in the ketosteril group rose from 3.46+/-0.40 g/dL to 3.66+/-0.37 g/dL (p=0.01), but not the control group. However, the difference between the two groups was not significant (p=0.06). Multivariate analysis showed that the ketosteril supplementation (p=0.03) and the baseline serum albumin level (< or = 3.4 g/dL, p=0.04) were predictors of increased serum albumin. There was no severe hypercalcemia during the study period. CONCLUSION: There was an improvement of serum albumin levels in hemodialysis patients with hypoalbuminemia after the supplementation of keto acids.

A Case of Familial Juvenile Hyperuricemic Nephropathy with Novel Uromodulin Gene Mutation, a Novel Heterozygous Missense Mutation in Korea

Familial Juvenile hyperuricemic nephropathy (FJHN, OMIM #162000) is a rare autosomal dominant disorder characterized by hyperuricemia with renal uric acid under-excretion, gout and chronic kidney disease. In most but not all families with FJHN, genetic studies have revealed mutations in the uromodulin (UMOD) gene located on chromosome 16p11-p13. We here described a novel heterozygous missense mutation (c.1382C>A causing p.Ala461Glu) in an affected 16-year-old male with hyperuricemia, gout and chronic kidney disease. His father was also affected and the UMOD mutation was found to segregate with the disease. There has been only one case report of Korean family with FJHN, which has not been diagnosed by genetic study. This is the first report of genetically diagnosed FJHN in Korea.

A case of severe metabolic acidosis after orthotopic neobladder replacement / 대한내과학회지

Following a radical cystectomy to treat bladder cancer, the ureters can be implanted in a short loop of ileum, which serves as an orthotopic bladder replacement. However, several investigators have reported the frequent development of a normal anion gap metabolic acidosis and electrolyte disturbance in these patients. The colon segments secrete sodium and bicarbonate ions and reabsorb ammonium, hydrogen, and chloride ions when exposed to urine, causing metabolic acidosis. In most cases, the acid-base disorder is not very troublesome. The metabolic acidosis can usually be corrected by administering sodium bicarbonate. We experienced a case of severe metabolic acidosis associated with urinary diversion that improved with continuous renal replacement therapy (CRRT).

Recovery from crescentic glomerulonephritis with bacterial endocarditis with antibiotics alone / 대한내과학회지

A 59-year-old woman presented to our hospital with fever, petechiae, pyuria, gross hematuria, and rapidly progressive glomerulonephritis (GN). She had a history of urinary tract infection. A renal biopsy specimen revealed crescentic GN and an echocardiogram showed a vegetation 3.15x1.73 cm in size on the mitral valve and severe mitral valve regurgitation. Blood cultures grew Enterococcus faecalis. Treatment with antibiotics alone resulted in clinical improvement of the renal function and resolution of the fever. Three months after hospitalization, the echocardiogram showed mild mitral valve regurgitation. This case suggests that crescentic glomerulonephritis associated with even a huge vegetation of infectious endocarditis can be treated with antibiotics alone and result in stable renal function.

Methylprednisolone Pulse Therapy in Adult-Onset Minimal Change Nephrotic Syndrome / 대한신장학회지

PURPOSE: The incidence of complete remission is lower and the relapse is more frequent in adult-onset minimal change nephrotic syndrome (MCNS) are observed especially when compared with those in children. This study was designed to examine the effect of methylprednisolone pulse therapy in adultonset MCNS comparing to oral steroid as an initial therapeutic modality. METHODS: We have retrospectively reviewed the clinical data of 25 adult-onset MCNS patients. Twelve patients were treated with three intravenous pulses of methylprednisolone (1 g daily) followed by oral prednisolone 1 mg/kg daily for 4-8 weeks and also by low doses of oral prednisolone for 4-6 months (MP group) Thirteen patients were initially treated with oral prednisolone 1 mg/kg daily for 4-8 weeks and then with low doses of oral prednisolone (PD group). RESULTS: The response to therapy was similar between MP and PD group, with a complete remission obtained in 83.3% and 84.6%, respectively. No statistically significant difference between the two groups was observed in the rate of response at 8 weeks (58.3% versus 69.2%). The mean time to response was not different between MP group (37.9+/-28.0 days) and PD group (45.5+/-40.2 days). No difference was recognized between the two groups with respect to relapse rate. CONCLUSION: These data suggest that a short course of methylprednisolone pulse therapy followed by oral prednisolone is not superior to oral prednisolone therapy as an initial therapeutic modality in adult-onset MCNS.

A Case of Pulmonary Thromboembolism in a Patient with Hyperhomocysteinemia / 결핵및호흡기질환

Hyperhomocysteinemia is an independent risk factor for cardiovascular, cerebrovascular and peripheral vascular diseases that are complicated by atherosclerosis and a thromboembolism. An increased level of plasma homocysteine develops from a genetic defect in the of enzyme for the homocysteine metabolism or a vitamin deficiency. Hyperhomocysteinemia has direct toxic effect on the vascular endothelium and causes damages to the antithrombotic action of vascular endothelial cells. Most cases of hyperhomocysteinemia are asymptomatic, but cardiopulmonary or cerebrovascular incidents developin rare cases. In the case of a thromboembolism with an unknown cause, hyperhomocysteinemia should be considered in a differential diagnosis. The authors report a case of pulmonary thromboembolism in a patient with hyperhomocysteinemia with a review of the relevant literature.

A case of recurrent flash pulmonary edema after renal artery bypass graft in renal artery stenosis / 대한내과학회지

Renal artery stenosis is a rare cause of acute pulmonary edema. So-called flash pulmonary edema is associated with bilateral renal artery stenosis or stenosis in a single functioning kidney. Flash pulmonary edema has been recognized as an absolute indication for vascular intervention. A 33-year old man was admitted with acute shortness of breath. Renal angiography showed occlusion of the right renal artery. He underwent a right renal artery bypass graft. However, after the renal artery bypass graft, episodes of pulmonary edema recurred. A renal angiography showed complete obstruction of the right renal artery and bypass graft. The left renal angiography showed an intact renal artery and decreased kidney size.

An Adult with Aplastic Crisis induced by Human Parvovirus B19 as an Initial Presentation of Hereditary Spherocytosis

The association between aplastic crisis and human parvovirus (HPV) B19 infection is well described in patients with sickle cell anemia. This association has also been described, although much less frequently, in patients with hereditary spherocytosis (HS). However, most cases of aplastic crises in patients with HS and induced by HPV B19 have been reported in children or adolescents. In this paper, we describe an aplastic crisis induced by HPV B19 in an adult with HS. A 34-year-old female presented with presyncope, febrile sensation, and myalgia. The complete blood counts showed severe anemia. The peripheral blood smear revealed spherocytosis with reticulocytopenia and pancytopenia. The direct Coombs' test was negative; the osmotic fragility test was positive. In the bone marrow aspirates, a few giant pronormoblasts with deep blue cytoplasm, pseudopods, and intracellular inclusion bodies were observed. The patient was given eight units of packed red blood cells. HPV B19 infection was proven by the presence of IgM antibodies to HPV B19 and the detection of viral DNA using the PCR technique. To the best of our knowledge, this is the first report in Korea that describes an adult with aplastic crisis presenting initially with HS.