Effects of percutaneous angioplasty on kidney function and blood pressure in patients with atherosclerotic renal artery stenosis

BACKGROUND: Previous randomized controlled trials of revascularization for atherosclerotic renal artery stenosis (ARAS) were not successful. We investigated the effects of percutaneous transluminal angioplasty with stent insertion (PTA/S) on kidney function and blood pressure (BP) control in patients with ARAS. METHODS: From 2000 to 2017, 47 subjects who underwent PTA/S for ARAS were identified. A high-risk group was defined, composed of patients having one or more of the following clinical presentations: pulmonary edema, refractory hypertension, and rapid deterioration of kidney function. Subjects who met the criteria of ‘kidney function improvement’ or ‘hypertension improvement’ after PTA/S were classified as responders. RESULTS: Twenty-one (44.7%) subjects were classified into the high-risk group. Two subjects (8.0%) in the low-risk group (n = 25) and 5 subjects (27.8%) in the high-risk group (n = 18) showed improvement in kidney function after PTA/S (P = 0.110). In patients with rapid decline of kidney function, estimated glomerular filtration rate improved from 28 (interquartile range [IQR], 10–45) mL/min/1.73 m² to 41 (IQR, 16–67) mL/min/1.73 m² at 4 months after PTA/S, although the difference was not significant (P = 0.084). Regarding BP control, 9 (36.0%) and 14 (77.8%) subjects showed improvement after PTA/S in the low- (n = 25) and high-risk (n = 18) groups, respectively (P = 0.007). In patients with refractory hypertension, the systolic BP dropped from 157 (IQR, 150–164) mmHg to 140 (IQR, 131–148) mmHg at 4 months after PTA/S (P = 0.005). Twenty-five subjects were defined as responders and comprised a significant proportion of the high-risk group (P = 0.004). CONCLUSION: PTA/S might improve BP control and kidney function in patients with ARAS presenting with high-risk clinical features. The optimal application of PTA/S should be based on individual assessment of the clinical significance of renal artery stenosis.

Development of Epidural and Paraspinal Abscesses after Insufficient Evaluation and Treatment of Acute Pyelonephritis Caused by Staphylococcus aureus / 가정의학회지

Diagnoses of pyelonephritis caused by Staphylococcus aureus should be accompanied by investigations of concomitant bladder obstruction and metastatic infections, especially to the spine or heart. Complicated pyelonephritis due to S. aureus requires more than 2 weeks of antibiotics, which is the typically recommended treatment duration for pyelonephritis. We describe a patient who was diagnosed with complicated epidural and paraspinal abscesses after insufficient evaluation and treatment of acute pyelonephritis due to S. aureus. A 62-year-old man with type 2 diabetes was admitted with fever, increased urinary frequency, and left flank pain. He was diagnosed with acute pyelonephritis caused by S. aureus. His fever and flank pain subsided after 3 days of intravenous antibiotics. Evaluation of bladder obstruction and metastatic infection were not performed, as he declined further evaluation. The patient was discharged with oral antibiotics and was requested to attend weekly appointments but was lost to follow-up. One month later, the patient presented at the outpatient clinic with similar symptoms. Computed tomography showed recurrent pyelonephritis and a distended bladder. His flank pain persisted despite administration of an opioid agent. Therefore, magnetic resonance imaging was performed, revealing epidural and paraspinal abscesses. Ultrasound-guided aspiration of the paraspinal muscle layer was performed, and blood and percutaneous aspirated fluid cultures revealed S. aureus growth. The pattern of antimicrobial sensitivity was identical to that at his first admission. Following more than 4 weeks of antibiotics, magnetic resonance imaging showed the abscesses had decreased in size. The patient was discharged without neurologic sequelae and was provided with oral antibiotics.

Severe Hyponatremia with Mental Change after Ingestion of Picosulfate Sodium/Magnesium Citrate for Bowel Preparation / 대한내과학회지

Picosulfate sodium/Magnesium citrate (PS/MC) is a common bowel cleansing agent for colonoscopy. It is equally effective and better tolerated by patients with regard to taste and volume than polyethylene glycol. However, because of its osmotically active characteristics, PS/MC can cause plasma volume depletion and electrolyte disturbances, such as hyponatremia. Here, we report a case of severe hyponatremia combined with loss of consciousness in a 59-year-old woman following ingestion of PS/MC as bowel preparation for a screening colonoscopy. Upon arrival, serum sodium level was 109 mEq/L and urine osmolality and sodium levels were 393 mOms/Kg and 99 mmol/L, respectively. She was euvolemic and showed normal kidney, thyroid, and adrenal function. Based on these findings, inappropriate anti-diuretic hormone syndrome (SIADH) was diagnosed. She was treated with 3% hypertonic saline and completely recovered without any neurologic sequelae. This case shows that SIADH can be caused by PS/MC (not accompanied by dehydration), even in patients without any underlying renal, heart, or liver diseases.

Crystalline podocytopathy and tubulopathy without overt glomerular proteinuria in a patient with multiple myeloma

Crystalline nephropathy is a rare yet well-known condition associated with multiple myeloma and other light chain–secreting disorders. Paraproteins that are resistant to proteolysis crystallize within proximal tubular cells and cause light-chain proximal tubulopathy, which presents clinically as Fanconi syndrome. Podocytes are rarely affected, and the crystalline inclusions within podocytes are typically precipitated, yielding significant glomerular proteinuria. Here we report a case of extensive crystalline inclusions primarily within podocytes and proximal tubules that presented only with Fanconi syndrome and renal insufficiency. Despite the presence of extensive crystalline inclusions in podocytes and diffuse foot process effacement, the patient had no clinical evidence suggestive of podocyte injury.

Measurement of antioxidant capacity using the biological antioxidant potential test and its role as a predictive marker of metabolic syndrome

BACKGROUND/AIMS: Oxidative stress increases the risk of cardiovascular complications of metabolic syndrome (MetS). This study was conducted to examine the difference in antioxidant capacity according to the presence of MetS, and to characterize the association between antioxidant capacity and MetS-related factors. METHODS: We used the biological antioxidant potential (BAP) test to estimate antioxidant capacity. The BAP test has recently been used as an indicator of antioxidant capacity. We measured BAP levels in 45 patients with MetS (mean age, 44.6 +/- 1.1 years) and 47 age- and sex-matched controls (mean age, 42.7 +/- 1.1 years). To evaluate the association between antioxidant capacity and MetS, adiponectin, high-sensitivity C-reactive protein (hs-CRP), interleukin-6, tumor necrosis factor-alpha, and homeostatic model assessment for insulin resistance (HOMA-IR), linear regression and logistic analyses were performed. RESULTS: The mean BAP of the MetS group (1,937.3 +/- 36.5 micromol/L) was significantly lower than that of the non-MetS group (2,101.7 +/- 29.5 micromol/L). Also, the mean BAP was low in persons having low high density lipoprotein and high triglyceride. Reduced antioxidant capacity was significantly associated with adiponectin, HOMA-IR and hs-CRP after adjusting for age and sex. The odds ratios for MetS with BAP, log adiponectin, log HOMA-IR, and log hs-CRP were 0.63 (95% confidence interval [CI], 0.49 to 0.82), 0.22 (0.10 to 0.51), 14.24 (4.35 to 46.58), and 1.93 (1.36 to 2.75), respectively. CONCLUSIONS: Persons with MetS showed reduced antioxidant capacity. We identified relationships between antioxidant capacity measured by BAP test and MetS, as well as MetS-related factors, such as insulin resistance, hs-CRP, and adiponectin.

Hyponatremia after Thyroid Hormone Withdrawal in a Patient with Papillary Thyroid Carcinoma

Hyponatremia is an electrolyte abnormality commonly found in clinical practice. It is important to diagnose the underlying etiology of the hyponatremia and correct it appropriately because severe hyponatremia can cause serious complications and substantially increase the risk of mortality. Although hypothyroidism is known to be a cause of hyponatremia, it is rare that hyponatremia occurs in relation to hypothyroidism induced by thyroid hormone withdrawal in patients with differentiated thyroid cancer. We report a case of a 76-year-old woman with papillary thyroid carcinoma presenting with severe hyponatremia related to hypothyroidism induced by thyroid hormone withdrawal for radio-active iodine whole-body scanning, who was treated by thyroid hormone replacement and hydration. Considering that the incidence of differentiated thyroid cancer is rapidly increasing, physicians should be aware that, although uncommon, hyponatremia can occur in patients undergoing radioiodine therapy or diagnostic testing.

Effect of Intravenous High-Dose Selenium Supplementation in Patients with Systemic Inflammatory Response Syndrome: A Pilot Study / 대한내과학회지

BACKGROUND/AIMS: Systemic inflammatory response syndrome (SIRS) can induce occurrence of oxidative stress. Several reports have evaluated selenium supplementation in SIRS patients with encouraging results. Therefore, we evaluated the effect of intravenous high-dose selenium supplementation in patients with SIRS. METHODS: Patients were randomly assigned to one of two groups: the selenium group (800 microg/day of selenoic acid by intravenous bolus injection for 7 days) or the placebo group. Physical and biochemical measurements were used to assay acute phase reactants, severity of illness index and serum selenium concentration. RESULTS: A total of 23 patients classified as mild-to-moderate severity of illness index were enrolled between March 2010 and October 2011. Serum selenium concentration increased in the selenium group after intervention, but there was no significant change in the placebo group. In the selenium group, the white blood cell (WBC) count, serum level of c-reactive protein (CRP), Acute Physiology and Chronic Health Evaluation II (APACHEII) score and Sequential Organ Failure Assessment (SOFA) score improved significantly by days 7 and 14 compared with day 0. In the placebo group, only the serum CRP level at day 14 and APACHE II score at days 7 and 14 improved significantly compared to day 0. CONCLUSIONS: Intravenous supplementation with high-dose selenium improved acute phase reactants and the severity of illness index in patients with SIRS. However, larger prospective clinical trials are required to determine the efficacy of selenium supplementation in SIRS patients.

Three-Week Dietary Intervention at Workplace Cafeteria - a Pilot Study

BACKGROUND: A healthy diet is important for the prevention and management of major chronic diseases including cancer, cardiovascular disease, diabetes, and obesity. However, the effect of dietary intervention-based education and consultation has not been satisfactory. This study sought to investigate the effects of a diet intervention supplying food directly to the workplace cafeteria. METHODS: Study subjects included 36 employees (23 men) staffed at two companies located in Seoul and Gyeonggi-do. Participants were supplied with liquid meals made mainly with fruits and vegetables for breakfast and dinner. Lunch was supplied as well and comprised of a balanced diet. Consumption of other foods, except water and provided snacks, were prohibited. The program also included light exercise, yoga, and mind-body control for 20 minutes, three times a week. Changes in anthropometric and metabolic parameters were evaluated. RESULTS: None of the subjects complained of serious adverse effects or dropped out of the program. Post-intervention mean body weight and body fat mass decreased significantly (-3.3 kg and -2.0 kg respectively, p<0.001 for both comparisons). There were additional reductions in systolic blood pressure (-6.7 mmHg, p<0.001), fasting glucose (-9.0 mg/dL, p<0.001), total cholesterol (-13.9 mg/dL, P=0.005), triglyceride (-44.0 mg/dL, p<0.001), and insulin (-2.4 uIU/mL, P=0.007). The satisfaction rate of the program was 88%. CONCLUSIONS: This study showed that a diet intervention supplying food directly to the workplace cafeteria could succeed in decreasing body weight and improving metabolic parameters, most likely due to high compliance.

A Case of Dengue Fever Complicated by Retinitis

Dengue fever is an acute febrile disease caused by the dengue virus. As the numbers of reported patients with dengue fever are increasing, rare complications associated with dengue fever, such as rhabodomyolysis or meningitis, are increasing in Korea. We describe the case of a Korean male presenting with fever, myalgia, nausea, diarrhea and blurred vision, who as a result of serologic test and fundoscopy, was diagnosed with dengue fever complicated by retinitis. He completely recovered with conservative care.