Spontaneous Splenic Rupture in a Peritoneal Dialysis Patient / 대한내과학회지

Atraumatic splenic rupture (ASR) in a patient undergoing peritoneal dialysis (PD) is uncommon, but can be life-threatening. According to recent systematic reviews, the major causes of ASR are 1) neoplastic (30.3%), 2) infectious (27.3%), 3) non-infectious inflammatory (20.0%), 4) iatrogenic (9.2%), 5) mechanical (6.8%), and 6) idiopathic (6.4%). It is diagnosed by imaging studies, most commonly ultrasonography and computed tomography (CT). Due to its rarity, the early diagnosis of ASR is difficult, and no standard treatment has been described. Here, we report a case of idiopathic ASR in a patient undergoing PD. The diagnosis was established by abdominal CT scan, and splenectomy was performed. Thus, hemoperitoneum in a PD patient should raise suspicion of ASR. Early diagnosis and appropriate treatment will lead to a better outcome.

Spontaneous Splenic Rupture in a Peritoneal Dialysis Patient / 대한내과학회지

Atraumatic splenic rupture (ASR) in a patient undergoing peritoneal dialysis (PD) is uncommon, but can be life-threatening. According to recent systematic reviews, the major causes of ASR are 1) neoplastic (30.3%), 2) infectious (27.3%), 3) non-infectious inflammatory (20.0%), 4) iatrogenic (9.2%), 5) mechanical (6.8%), and 6) idiopathic (6.4%). It is diagnosed by imaging studies, most commonly ultrasonography and computed tomography (CT). Due to its rarity, the early diagnosis of ASR is difficult, and no standard treatment has been described. Here, we report a case of idiopathic ASR in a patient undergoing PD. The diagnosis was established by abdominal CT scan, and splenectomy was performed. Thus, hemoperitoneum in a PD patient should raise suspicion of ASR. Early diagnosis and appropriate treatment will lead to a better outcome.

A Case of Peritoneal Dialysis-related Peritonitis Caused by Aeromonas Hydrophila in the Patient Receiving Automated Peritoneal Dialysis

Peritoneal dialysis (PD)-related peritonitis is a major cause of injury and technique failure in patients undergoing PD. Aeromonas hydrophila is ubiquitous in the environment, and is a Gram-negative rod associated with infections in fish and amphibians in most cases; however, it can also cause opportunistic infections in immunocompromised patients. We report a case of A. hydrophila peritonitis in a 56-year-old male on automated PD. Peritonitis may have been caused by contamination of the Set Plus, a component of the automated peritoneal dialysis device. Although Set Plus is disposable, the patient reused the product by cleansing with tap water. He was successfully treated with intraperitoneally-administered ceftazidime and has been well without recurrence for more than 2 years.

Use of dapagliflozin in patients with advanced diabetic kidney disease

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are effective for overweight diabetic patients through the induction of glucosuria. However, SGLT2 inhibitors are not recommended for patients with advanced chronic kidney disease (CKD) because they may aggravate renal function and thus become less effective in controlling blood glucose in this patient population. We suggest that adequate hydration would be helpful to prevent the side effects of SGLT2 inhibitors in diabetic patients with advanced CKD. In this study, we review five cases of SGLT2 inhibitor therapy, specifically with dapagliflozin, for the treatment of diabetes mellitus in patients with advanced CKD. The patients experienced dramatic weight reduction, improved glucose control, and further benefits without aggravation of renal function.

Diagnostic accuracy of urine dipstick for proteinuria in older outpatients

BACKGROUND: The urine dipstick is widely used as an initial screening tool for the evaluation of proteinuria; however, its diagnostic accuracy has not yet been sufficiently evaluated. Therefore, we evaluated its diagnostic accuracy using spot urine albumin/creatinine ratio (ACR) and total protein/creatinine ratio (PCR) in proteinuria. METHODS: Using PCR > or = 0.2g/g or > or = 0.5g/g and ACR > or = 300mg/g or > or = 30mg/g as the reference standard, we calculated the diagnostic accuracy profile: sensitivity, specificity, positive and negative predictive value, and the area under the curve (AUC) of the receiver operating characteristic curve. RESULTS: PCR and ACR were available for 10,348 and 3,873 instances of dipstick testing. The proportions with PCR > or = 0.2g/g, > or = 0.5g/g and ACR > or = 300mg/g, > or = 30mg/g were 38.2%, 24.6% and 8.9%, 31.7%, respectively. The AUCs for PCR > or = 0.2g/g, > or = 0.5g/g, and ACR > or = 300mg/g were 0.935 (trace: closest to ideal point), 0.968 (1+), and 0.983 (1+), respectively. Both sensitivity and specificity were > 80% except for PCR > or = 0.5g/g with trace cutoff. For the reference standard of ACR > or = 30mg/g, the AUC was 0.797 (trace) and the sensitivity was 63.5%. CONCLUSION: Urine dipstick test can be used for screening in older outpatients with ACR > or = 300mg/g or PCR as the reference standard for proteinuria. However, we cannot recommend the test as a screening tool with ACR > or = 30mg/g as the reference owing to its low sensitivity.

A Case of Lymphedema Associated with Psoriasis / 대한내과학회지

Lymphedema is a rare but known complication of psoriatic arthritis and other inflammatory arthritides. Only a few cases associated with psoriatic arthritis have been reported, but none showed psoriasis was the sole factor. The precise etiology is, as yet, unknown, but many different mechanisms are likely to cause lymphedema in psoriatic arthritis, such as lymphatic vascular damage and perilymphatic accumulation of inflammatory material. Various immunosuppressive drugs have been assessed in treating this condition. Here, we report the case of an 85-year-old man with psoriasis presenting with a rare complication of bilateral lymphedema in the lower extremities. Lymphedema as well as psoriasis improved with cyclosporine.

Clinical Significance of Subjective Foamy Urine / 전남의대학술지

Foamy urine is widely regarded as a sign of proteinuria. However, there is no objective definition of foamy urine and there are no reports on the proportion of involved patients who have overt proteinuria or microalbuminuria. We performed this study to investigate this proportion and to identify possible risk factors for these two conditions. We reviewed all new outpatients from 1 November 2011 to 30 April 2012 and identified patients complaining of foamy urine. Their demographic data and medical records were examined. In particular, we tabulated the patients' spot urinary protein to creatinine ratio, spot urinary microalbumin to creatinine ratio (ACR), blood urea nitrogen (BUN), and serum levels of creatinine (Cr), uric acid, calcium, phosphate, and glucose. In addition, we calculated estimated glomerular filtration rates (eGFRs) by using the CKD-EPI equation. We also performed risk factor analysis with the Chi-squared test and by logistic regression. Seventy-two patients (6.3% of total new outpatients) complained of foamy urine; of these, there were 59 males with a median age of 65.5 years (range, 36-87 years). Of the 72 patients, 16 (22.2%) had overt proteinuria. We found that diabetes, poor renal function (high Cr, BUN, low eGFR), increased serum phosphate, and increased serum glucose were associated with overt proteinuria. Multiple logistic regression analysis showed that serum Cr and serum phosphate were associated with overt proteinuria. The ACR was available for 38 patients, and in this subgroup, 12 (31.6%) showed microalbuminuria or overt proteinuria. In this subgroup, a high serum Cr was the only statistically significant risk factor. Among patients who complained of foamy urine, approximately 20% had overt proteinuria, and increased serum Cr and phosphate were statistically significant risk factors.

Clinical Significance of Subjective Foamy Urine / 전남의대학술지

Foamy urine is widely regarded as a sign of proteinuria. However, there is no objective definition of foamy urine and there are no reports on the proportion of involved patients who have overt proteinuria or microalbuminuria. We performed this study to investigate this proportion and to identify possible risk factors for these two conditions. We reviewed all new outpatients from 1 November 2011 to 30 April 2012 and identified patients complaining of foamy urine. Their demographic data and medical records were examined. In particular, we tabulated the patients' spot urinary protein to creatinine ratio, spot urinary microalbumin to creatinine ratio (ACR), blood urea nitrogen (BUN), and serum levels of creatinine (Cr), uric acid, calcium, phosphate, and glucose. In addition, we calculated estimated glomerular filtration rates (eGFRs) by using the CKD-EPI equation. We also performed risk factor analysis with the Chi-squared test and by logistic regression. Seventy-two patients (6.3% of total new outpatients) complained of foamy urine; of these, there were 59 males with a median age of 65.5 years (range, 36-87 years). Of the 72 patients, 16 (22.2%) had overt proteinuria. We found that diabetes, poor renal function (high Cr, BUN, low eGFR), increased serum phosphate, and increased serum glucose were associated with overt proteinuria. Multiple logistic regression analysis showed that serum Cr and serum phosphate were associated with overt proteinuria. The ACR was available for 38 patients, and in this subgroup, 12 (31.6%) showed microalbuminuria or overt proteinuria. In this subgroup, a high serum Cr was the only statistically significant risk factor. Among patients who complained of foamy urine, approximately 20% had overt proteinuria, and increased serum Cr and phosphate were statistically significant risk factors.

Idiopathic Unilateral Retroperitoneal Fibrosis Diagnosed in a Patient with Normal Renal Function and Left Flank Pain / 대한신장학회지

Retroperitoneal fibrosis is a disease characterized by proliferation of fibro-inflammatory tissue, which mainly encloses the abdominal aorta, iliac arteries and (enlarges to the retroperitoneum to surrounds) ureters. Two leading pathogenesis are an exacerbated local inflammatory reaction to aortic atherosclerosis and a manifestation of systemic autoimmune disease. Because of insidious disease course, most cases are diagnosed late when bilateral urinary obstruction caused oliguria and symptoms related to uremia. In this case, the patient complained left flank pain which might have been caused by left ureter stone, but through abdominal CT scan, the patient was diagnosed as left unilateral retroperitoneal fibrosis. Abdominal CT scan showed encircling mass around abdominal aorta and left ureter with hydronephrosis. The patient had no underlying disease and didn't take any medication; she was diagnosed as idiopathic unilateral retroperitoneal fibrosis and started prednisolone, 40 mg daily. Three months have passed since the therapy was started; most fibrous tissue was disappeared, hydronephrosis was resolved and flank pain was relieved.

Concurrent IgA Nephropathy and Minimal Change Disease in a Patient with Polycythemia Vera: A Case Report / 대한신장학회지

Polycythemia vera is a hematopoietic stem cell disease, characterized by sustained and excessive proliferation of erythrocytic, granurocytic and megakaryocytic cells in the bone marrow resulting in pancytosis in peripheral blood. There have been a few reports of glomerulonephritis with polycythemia vera, most of which were IgA nephropathy. We report a case of a polycythemia vera associated with proteinuria. We confirmed the polycythemia vera according to World Health Organization criteria. Renal pathology showed IgA nephropathy and minimal change disease. Periodic phlebotomy was done and hydroxyurea was administered without specific managements for renal disease. After 3-month treatment, hemoglobin level decreased and proteinurea disappeared.

A Case of Vanishing Bile Duct Syndrome Associated with Hypersensitivity to Allopurinol / 대한간학회지

Allopurinol is frequently used for the treatment of hyperuricemia and gout. Sometimes, a life-threatening reaction develops, as is illustrated by the following case report. We describe a 60-year-old male patient who was treated with allopurinol because of asymptomatic hyperuricemia, and he was presented with fever, skin rash, eosinophilia, worsening renal function and vanishing bile duct syndrome. In this report, we discussed vanishing bile duct syndrome as a serious side effect of allopurinol, and we briefly reviewed the etiology, prevention, and treatment modalities for vanishing bile duct syndrome.

A Case of Acute Staphylococcal aureus Esophagitis in Immunocompromised Patients / 감염

Bacterial esophagitis is an uncommon disease and has not been well characterized. Bacterial infection of the esophagus is usually presented as a superimposed infection upon a preexisting viral or fungal esophagitis and most patients are immunocompromised hosts. A 67-year-old man was admitted for retrosternal pain and hematemesis, who had a past history of long-standing diabetes mellitus and end stage renal disease, also had a history of steroid medication. Extensive esophageal ulcerations of the mucosa were visualized by endoscopy. Staphylococcus aureus grew in blood culture. After the 2 weeks of antibiotics treatment, he was successfully recovered without any sequelae. Due to its rarity, this case is herein reported with a review of the corresponding literature.

Evaluation of Risk Factor for Development of Proteinuria in Spinal Cord Injury / 대한신장학회잡지

BACKGROUND: Patients with spinal cord injury have a significant degree of morbidity and mortality caused by renal disease. Tubulointerstitial form of renal disease with minimal proteinuria predominate in this population. A retrospective study was performed to investigate the risk factors that may contribte to the development of proteinuria in patient with chronic spinal cord injury. METHODS: Between December 1999 and May 2000, 40 spinal cord injury patient in Korean Veterans Hospital were recurited retrospectively into the study. The information was gathered included medical record, laboratory data, and radiological study. RESULTS: Proteinuric subjects were older, had a longer duration of injury, had undergone a greater number of decubitus ulcer procedures and hydronephrosis. CONCLUSION: Proteinuria in the patients with spinal cord injury was related to the increase of the therapy for the decubitus ulceration, hydronephrosis, and the duration of the spinal cord injury, and it developed significantly more in paraplegia patients than in quadriplegia patients, which might be due to the more duration of the spinal cord injury in paraplegia patients. Therapeutic efforts directed toward preserving renal function should focus on avoidance of hydronephrosis, and decubitus ulceration.

A Case of Urinothorax in Autosomal Dominant Polycystic Kidney Disease Hemodialyzed / 대한신장학회잡지

Urinothorax is rare cause of pleural effusion. Urinothorax should be considered when pleural effusion occurs in patients with urinary tract obstruction accompanied by retroperitoneal urinoma. It has been reported in patients with trauma, malignancy, kidney biopsy and renal transplantation. Most cases are diagnosed retrospectively by promt resolution of symptoms after relief of urinary obstruction. But diagnosis can be made based on clinical suspicion, radiological findings and biochemical analysis of the effusion and most important finding is the pleural level of creatinine is higher than the serum level. We experienced right pleural effusion in autosomal dominant polycystic kidney disease hemodialyzed. The patient had right urinoma in the retroperitoneal space before pleural effusion developed. After 3month, he complained acute dyspnea. There was no effect in resolving effusion by lowering dry weight. We thought alternative diagnostic possibility, urinothorax and checked the pleural fluid to serum creatinine ratio. Finally concluded that pleural effusion was urinothorax secondary to remnant left polycystic kidney rupture and tried left nephrectomy. The patient showed reduction of pleural effusion. It is important to alert physician to this condition and to avoid the other invasive diagnostic study.

A Case of Subclavian Vein Obstruction in a Patient with Hemodialysis / 대한신장학회잡지

Subclavian and internal jugular vein catheters are widely employed for temporary hemodialysis access. Placement of subclavian venous catheter has many complications such as pneumothorax and hemothorax, etc. Incidence of subclavian vein obstruction due to thrombosis is probably greater than is commonly appreciated. Subclavian vein obstruction may cause no specific complaints, but thrombosis in the presence of an arteriovenous fistula may produce severe symptoms such as massive edema and pain. This is report of one patient, who developed massive edema of upper extremity and in whom proximal subclavian vein occlusion developed after previous percutaneous dialysis catheter. Right internal jugular vein to axillary vein bypass with 8mm PTFE provided prompt and effective venous outflow, with complete resolution of venous engorgement of the affected limb and preservation of the dialysis fistula.

A Case of Perigraft Seroma in Chronic Hemodialysis Patient / 대한신장학회잡지

Perigraft seroma is uncommon complication of polytetrafluoroethylene(PTFE) grafts applied as an arteriovenous shunt for hemodialysis. It is a collection of clear, sterile fluid confined to nonsecretory fibrous pseudomembrane, most commonly localized around the middle and distal portion of graft. The possible etiologic factors of perigraft seroma include poor graft incorporation, mechanical graft damage caused by alcohol and povidone-iodine, intraoperative streching of the graft, variations in quality control at the time of manufacture and contributing factors such as anemia and coagulopathy in uremia. The best strategy for management of perigraft seroma is not clear. spiration or drainage alone is not effective, and some authors advocate graft removal. We report a case of perigraft seroma around arterial end of PTFE graft along with a brief review of the literatures.