Dystrophic mineralization in uremic dogs: an update / Mineralização distrófica em cães urêmicos: uma atualização

Pathological mineralization is the abnormal deposition of minerals in body tissues, previously injured or not. In these lesions, in addition to calcium, other minerals can be found at lower concentrations. Classically, mineralization is divided into two types: dystrophic and metastatic. However, currently, there is no consensus among researchers on the type of mineralization that occurs in uremic dogs. The objective of this study was to elucidate the type of pathological mineralization that occurs in dogs with uremic syndrome through the correlation of biochemical examinations with gross and histopathological changes, given the existence of controversial information on this theme in the specialized literature. The Shapiro-Wilk, D'Agostino and Pearson tests were used to evaluate data normality distribution, and analysis of variance (ANOVA) was applied to compare the data between more than two groups. Additionally, the Dunnett's multiple comparison test was used in the comparison between the Control Group (CG) and the Experimental Groups (G1, G2, and G3). Serum levels of urea, creatinine, total and ionized calcium, phosphorus, calcium-phosphorus product (CPP), parathyroid hormone (PTH), and albumin of 40 azotemic dogs with chronic kidney disease (CKD) were evaluated. Dogs were categorized by degree of azotemia (mild, moderate, and severe). Ionized hypocalcemia was observed in 97.5% (39/40) of the dogs, and no animals presented ionized hypercalcemia. Hyperphosphatemia was frequent (62.5%), especially in dogs with severe azotemia. PTH concentration increased with progression of azotemia, and high PTH levels were verified in 100% of the dogs with severe azotemia. CPP >60mg2/dl2 was observed in 75% (30/40) of the dogs. Of the 29 dogs that died during the study period, 16 were necropsied. Soft tissue mineralization was observed in 93.7% (15/16) of these dogs at gross and histopathological evaluation (HE and Von Kossa), regardless of the degree of azotemia, in nine organs/tissues: kidneys (75%), lungs (50%), stomach (31.2%), heart (25%), larynx (25%), intercostal muscles (25%), aorta (6.2%), intestines (6.2%), and tongue (6.2%). In one animal, the serosa of all segments of the small intestine showed whitish, rough, irregular, multifocal plaques of varying sizes, confirmed by histopathology as dystrophic mineralization of the longitudinal outer muscular layer, which presented necrosis of coagulation and of the intestinal serosa. This intestinal lesion has not been described in dogs with uremic syndrome to date. In conclusion, the laboratory and histopathologic data previously described, especially regarding tissue and vascular mineralization, which occur in association with previous degenerative/necrotic lesions in the absence of hypercalcemia in dogs with CKD, assist with clarifying inconsistencies found in the existing literature. Therefore, conceptually, mineralization that occurs in uremic dogs should be considered dystrophic.(AU)

Mineralização patológica é a deposição anormal de minerais em tecidos previamente lesados ou não. Nessas lesões, além do cálcio, outros minerais podem ser encontrados em concentrações inferiores. Classicamente, as mineralizações são divididas em dois tipos: distrófica e metastática. Contudo, atualmente, ainda não há consenso entre os pesquisadores sobre o tipo de mineralização que ocorre em cães urêmicos. Objetivou-se com esse estudo elucidar o tipo de mineralização patológica que ocorre em cães com síndrome urêmica através da correlação de exames bioquímicos com alterações macroscópicas e histopatológicas, visto a existência de informações controversas na literatura especializada. Os dados obtidos foram submetidos ao teste de Shapiro-Wilk e teste de D'Agostino e Pearson para avaliação da normalidade da distribuição e para comparação de dados em mais de dois grupos foi utilizado o teste ANOVA. Adicionalmente, o teste de comparações múltiplas de Dunnett permitiu a comparação entre o grupo controle (GC) com os demais grupos (G1, G2 e G3). Foram avaliados os níveis séricos de ureia, creatinina, cálcio total e ionizado, fósforo, produto cálcio-fósforo (PCF), PTH e albumina de 40 cães azotêmicos com doença renal crônica (DRC). Os cães foram classificados quanto ao grau de azotemia (leve, moderada e severa). Verificou-se hipocalcemia ionizada em 97,5% (39/40) dos cães e, em nenhum animal houve hipercalcemia ionizada. Hiperfosfatemia foi frequente (62,5%), principalmente em cães com azotemia severa. A concentração do PTH aumentou conforme a progressão da azotemia, encontrando-se elevada em 100% dos cães com azotemia severa. Em 75% (30/40) dos cães o PCF foi superior a 60mg2/dl2. Durante o estudo, 29 cães morreram, sendo 16 desses necropsiados. Em 93,7% (15/16) desses cães observou-se mineralização de tecidos moles, durante a avaliação macroscópica e histopatológica (HE e Von Kossa), independentemente do grau de azotemia, em nove órgãos/tecidos: rins (75%), pulmões (50%), estômago (31,2%), coração (25%), laringe (25%), músculos intercostais (25%), aorta (6,2%), intestino (6,2%) e língua (6,2%). Adicionalmente, em um animal verificou-se na serosa de todos os segmentos do intestino delgado placas multifocais brancacentas, rugosas, irregulares de tamanhos variados, cuja histopatologia confirmou tratar-se de mineralização distrófica da camada longitudinal muscular externa que apresentava necrose de coagulação e da serosa intestinal. Essa lesão intestinal nunca havia sido descrita em cães com síndrome urêmica. Em suma, os dados laboratoriais e histopatológicos aqui descritos, sobretudo, no que se refere à mineralização tecidual e vascular, que ocorrem relacionadas a lesões degenerativo-necróticas prévias, na ausência de hipercalcemia, em cães com DRC, ajudam a esclarecer as incongruências existentes na literatura. Por conseguinte, conceitualmente, as mineralizações que ocorrem em cães urêmicos devem ser consideradas distróficas.(AU)

Protein-to-creatinine urinary in the early diagnosis of renal injury in canine pyometra / Relação proteína-creatinina-urinária no diagnóstico precoce de lesão renal em cadelas com piometra

Kidney disease that affects bitches with pyometra may lead patients to develop chronic renal failure even after pyometra treatment. Therefore, several studies have sought to clarify the gaps in the understanding of the pathogenesis of renal injury in pyometra. Identification of early detection markers for renal damage, which can predict and identify the prognosis of the disease, is very important. Proteinuria analysis can diagnose kidney damage, since proteins such as albumin are not filtered through the glomerulus and those that undergo glomerular filtration are almost completely reabsorbed by tubular cells. The objective of this study was to evaluate whether the urinary protein-to-creatinine ratio (UPC) can detect renal injury in bitches with pyometra before development of azotemia. For this, 44 bitches with pyometra were divided into two groups: bitches with azotemic piometra (A, n=15, creatinine >1.7) and bitches with non-azotemic pyometra (NA, n=29). The two groups were compared to the control group (CG, n=12), which had no signs of systemic disease. All animals underwent blood and urine tests. Leukocytosis was more evident in bitches in the A group than in the other groups. This shows that the inflammatory response may be associated with the pathogenesis of renal injury. The median UPC in bitches with pyometra was significantly higher than in the CG, with a median above the reference values. In conclusion, the UPC can be used in bitches with pyometra to detect renal damage before the development of azotemia. It has been suggested that the UPC of bitches with pyometra should be followed through during the postoperative period so that permanent renal lesions secondary to pyometra can be diagnosed and treated properly before the development of azotemia.(AU)

A doença renal que afeta cadelas com piometra pode levar a insuficiência renal crônica mesmo após o tratamento. Portanto, vários estudos procuraram esclarecer as lacunas na compreensão da patogênese da lesão renal na piometra. A identificação de marcadores de lesão renal precoce, que podem prever e identificar o prognóstico da doença é muito importante. A análise da proteinúria pode diagnosticar lesão renal, uma vez que proteínas como a albumina não são filtradas através do glomérulo e aquelas que sofrem filtração glomerular são quase completamente reabsorvidas pelas células tubulares. O objetivo deste estudo foi avaliar se a relação proteína-creatinina urinária (UPC) pode detectar lesão renal em cadelas com piometra antes do desenvolvimento de azotemia. Para isso, 44 cadelas com piometra foram divididas em dois grupos: cadelas com piometra azotêmica (A, n=15, creatinina >1,7) e cadelas com piometra não azotêmica (NA, n=29). Os dois grupos foram comparados ao grupo controle (CG, n=12), que não apresentaram sinais de doença sistêmica. Todos os animais foram submetidos a exames de sangue e urina. A leucocitose foi mais evidente nas cadelas do grupo A do que nos outros grupos. Isso mostra que a resposta inflamatória pode estar associada à patogênese da lesão renal. A mediana da UPC em cadelas com piometra foi significativamente maior que no CG, com uma mediana acima dos valores de referência. Em conclusão, a UPC pode ser usada em cadelas com piometra para detectar lesões renais antes do desenvolvimento de azotemia. Sugeriu-se que a UPC de cadelas com piometra deve ser acompanhada durante o pós-operatório, de modo que as lesões renais permanentes secundárias à piometra possam ser diagnosticadas e tratadas adequadamente antes do desenvolvimento de azotemia.(AU)

Clinical Significance of Urinary Neutrophil Gelatinase-associated Lipocalin Levels in Defining the Various Etiologies of Acute Kidney Injury in Liver Cirrhosis Patients / 대한소화기병학회잡지

BACKGROUND/AIMS: A diagnosis of hepatorenal syndrome (HRS) is based on a differential evaluation of acute kidney injury (AKI), which may aggravate the clinical course. This study assessed the clinical significance of the urinary neutrophil gelatinase-associated lipocalin (u-NGAL) levels in a differential diagnosis of AKI in patients with liver cirrhosis (LC). METHODS: Patients with LC who developed AKI were enrolled prospectively. Clinically, patients with AKI were classified into prerenal azotemia (PRA), HRS, and acute tubular necrosis (ATN) groups. RESULTS: Fifty-five patients (male, 74.5%) with LC who exhibited AKI upon admission were enrolled; 28, 9, and 18 patients were included in the PRA, HRS, and ATN groups, respectively. The baseline model for end-stage liver disease (MELD) scores was similar in the subgroups. The median event creatinine level, measured at the time of the AKI diagnosis, was similar in the HRS and ATN subgroups. On the other hand, the median event u-NGAL level differed significantly between the three subgroups (PRA, HRS, and ATN: 37 vs. 134 vs. 2,625 ng/mL, p=0.003). In particular, the median u-NGAL level of the HRS group was clearly different from those of the PRA (p<0.001) and ATN (p<0.001) groups. Multivariable analysis revealed the natural logarithm of the u-NGAL level (hazard ratio [HR] 1.77, p=0.031) and the MELD score (HR 1.17, p=0.027) to be independent prognostic factors for in-hospital mortality in patients with LC and AKI. CONCLUSIONS: The median u-NGAL level differentiated HRS from ATN and served as a clinical indicator of in-hospital mortality for patients with LC and AKI.

Clinical Significance of Urinary Neutrophil Gelatinase-associated Lipocalin Levels in Defining the Various Etiologies of Acute Kidney Injury in Liver Cirrhosis Patients / 대한소화기학회지

BACKGROUND/AIMS: A diagnosis of hepatorenal syndrome (HRS) is based on a differential evaluation of acute kidney injury (AKI), which may aggravate the clinical course. This study assessed the clinical significance of the urinary neutrophil gelatinase-associated lipocalin (u-NGAL) levels in a differential diagnosis of AKI in patients with liver cirrhosis (LC).METHODS: Patients with LC who developed AKI were enrolled prospectively. Clinically, patients with AKI were classified into prerenal azotemia (PRA), HRS, and acute tubular necrosis (ATN) groups.RESULTS: Fifty-five patients (male, 74.5%) with LC who exhibited AKI upon admission were enrolled; 28, 9, and 18 patients were included in the PRA, HRS, and ATN groups, respectively. The baseline model for end-stage liver disease (MELD) scores was similar in the subgroups. The median event creatinine level, measured at the time of the AKI diagnosis, was similar in the HRS and ATN subgroups. On the other hand, the median event u-NGAL level differed significantly between the three subgroups (PRA, HRS, and ATN: 37 vs. 134 vs. 2,625 ng/mL, p=0.003). In particular, the median u-NGAL level of the HRS group was clearly different from those of the PRA (p<0.001) and ATN (p<0.001) groups. Multivariable analysis revealed the natural logarithm of the u-NGAL level (hazard ratio [HR] 1.77, p=0.031) and the MELD score (HR 1.17, p=0.027) to be independent prognostic factors for in-hospital mortality in patients with LC and AKI.CONCLUSIONS: The median u-NGAL level differentiated HRS from ATN and served as a clinical indicator of in-hospital mortality for patients with LC and AKI.

Concurrent Anti-glomerular Basement Membrane Nephritis and IgA Nephropathy

Anti–glomerular basement membrane (GBM) nephritis is characterized by circulating anti-GBM antibodies and crescentic glomerulonephritis (GN) with deposition of IgG along the GBM. In a limited number of cases, glomerular immune complexes have been identified in anti-GBM nephritis. A 38-year-old female presented azotemia, hematuria, and proteinuria without any pulmonary symptoms. A renal biopsy showed crescentic GN with linear IgG deposition along the GBM and mesangial IgA deposition. The patient was diagnosed as concurrent anti-GBM nephritis and IgA nephropathy. Therapies with pulse methylprednisolone and cyclophosphamide administration were effective. Concurrent cases of both anti-GBM nephritis and IgA nephropathy are rare among cases of anti-GBM diseases with deposition of immune complexes. This rare case of concurrent anti-GBM nephritis and IgA nephropathy with literature review is noteworthy.

Bortezomib Treatment for Refractory Antibody-Mediated Rejection Superimposed with BK Virus-Associated Nephropathy during the Progression of Recurrent C3 Glomerulonephritis / 대한이식학회지

A 38-year-old man, who underwent a second kidney transplantation (KT), was admitted because of antibody-mediated rejection (AMR) complicated by BK virus-associated nephropathy (BKVAN). He was placed on hemodialysis at the age of 24 years because of membranoproliferative glomerulonephritis. At the age of 28 years, he underwent a living donor KT from his father; however, 1 year after the transplantation, he developed a recurrence of the primary glomerular disease, resulting in graft failure 2 years after the first KT. Ten years later, he received a deceased-donor kidney with a B-cell-positive-cross-match. He received 600 mg of rituximab before the KT with three cycles of plasmapheresis and immunoglobulin (0.5 g/kg) therapy after KT. During the follow-up, the first and second allograft biopsies at 4 and 10 months after KT revealed AMR with a recurrence of primary glomerular disease that was reclassified as C3 glomerulonephritis (C3GN). He received a steroid pulse, rituximab, plasmapheresis, and immunoglobulin therapies. The third allograft biopsy demonstrated that the BKVAN was complicated with AMR and C3GN. As the azotemia did not improve after repeated conventional therapies for AMR, one cycle of bortezomib (1.3 mg/m²×4 doses) was administered. The allograft function stabilized, and BK viremia became undetectable after 6 months. The present case suggests that bortezomib therapy may be applicable to patients with refractory AMR, even in cases complicated with BKVAN.

Increased nitric oxide plasma concentration in dogs with naturally acquired chronic renal disease / Aumento da concentração plasmática de óxido nítrico em cães com doença renal crônica naturalmente adquirida

This study aimed to determine the amount of plasma nitric oxide in clinically stable dogs at different stages of chronic kidney disease (CKD). Five groups of dogs were studied, aged from 4 to 18, comprising of a control group composed of healthy animals (control n=17), group CKD stage 1 (DRC-1, n=12), group CKD stage 2 (CKD-2, n=10) group, CKD stages 3 (CRD-3, n=13) and Group CKD stage 4 (DRC-4, n=10). Dogs with CKD were clinically stable and received no treatment. Two blood samples were collected at 24 hours intervals (repeated measures) to obtain serum and plasma. The serum creatinine values were used to classify dogs as CG, CKD-1, CKD-2, CKD-3 and CKD-4, and were (1.02±0.02mg/dL), (1.07±0.04mg/dL), (1.81±0.03mg/dL), (3.40±0.15mg/dL) and (6.00±0.20mg/dL) respectively. The determination of nitric oxide (NO) was performed by dosing nitrate/nitrite indirectly, and used for measurement of nitrate according to the NO/ozone chemiluminescence. The data were submitted to ANOVA for nonparametric analysis(Kruskal-Wallis) (P<0.05). The concentration of plasmatic NO did not differ significantly among GC (10.81±0.51µM), CKD-1 (15.49±1.97µM) and CKD-2 (19.83±3.31µM) groups. The plasma concentration of CKD-3 (17.02±1.73µM) and CKD-4 (83.56±13.63µM) was significantly higher compared with healthy dogs. In conclusion, the NO plasma concentration can increase in dogs with CKD and become significantly higher in stage 3 and 4 dogs.(AU)

A determinação de óxido nítrico no plasma em cães clinicamente estáveis em diferentes estágios da doença renal crônica (DRC) não foi estudada, constituindo este o objetivo do presente estudo. Foram estudados cinco grupos de cães, com idade variando entre quatro a 18 anos, compreendendo o grupo controle, composto por animais sadios (controle, n=17), grupo com DRC estágio 1 (DRC-1, n=12), grupo com DRC estágio 2 (DRC-2, n=10), grupo com DRC estágio 3 (DRC-3, n=13) e grupo com DRC estágio 4 (DRC-4, n=10). Os cães com DRC estavam com o quadro clínico estável e sem receber qualquer tipo de tratamento. Foram estudados cinco grupo de cães, com idade variando entre quatro a 18 anos, compreendendo o grupo controle, composto por animais sadios (controle, n=17), grupo com DRC estágio 1 (DRC-1, n=12), grupo com DRC estágio 2 (DRC-2, n=10), grupo com DRC estágio 3 (DRC-3, n=13) e grupo com DRC estágio 4 (DRC-4, n=10). Os animais sadios ou com DRC foram submetidos a duas coletas de sangue, com intervalo de 24 horas (amostras repetidas), para obtenção de soro e plasma. Os valores de creatinina sérica, que definiram a classificação dos pacientes do controle, DRC-1, DRC-2, DRC-3 e DRC-4, que foram 1,02±0,02mg/dL; 1,06±0,05mg/dL; 1,80±0,03mg/dL; 3,39±0,21mg/dL e 6,00±0,28mg/dL, respectivamente. A determinação plasmática indireta de óxido nítrico (NO) foi realizada por meio da dosagem de nitrato/nitrito, através da técnia de quimioluminescência NO / ozono. Os dados foram submetidos à ANOVA para análise não paramétrica (Kruskal-Wallis) (P <0,05). Os resultados das concentrações plasmáticas de NO não diferiram significativamente quando comparados os dados do controle (10,81±0,51µM), DRC-1 (15,49±1,97µM), DRC-2 (19,82±3,31µM). No entanto, o NO plasmático do grupo DRC-3 (17,01±1,73µM) e DRC-4 (83,55±13,63µM), foi significativamente maior, em relação às médias dos cães sadios. Concluímos que a concentração plasmática de NO pode aumentar em cães com DRC e torna-se significativamente mais elevada nos estágios 3 e 4 da doença.(AU)

Excess fluid volume: sociodemographic and clinical analysis in haemodialysis patients / Excesso de volume de líquidos: análise clínica e sociodemográfica em pacientes de hemodiálise / El exceso de volumen de líquido: el análisis sociodemográfico y clínico en pacientes en hemodiálisis

ABSTRACT Objective: To analyse the defining characteristics and related factors in the nursing diagnosis Excess fluid volume and its relationship to sociodemographic and clinical variables in haemodialysis patients. Method: Cross-sectional study, conducted using a form and physical examination, with a sample of 100 patients, between December 2012 and April 2013 at a university hospital and a dialysis clinic. Results: It was found 10 significant statistical associations between the defining characteristics/ related factors of Excess fluid volume and the sociodemographic and clinical variables. Conclusion: The defining characteristics and related factors of Excess fluid volume could be influenced by sociodemographic and clinical variables in haemodialysis clientele.

RESUMO Objetivo: analisar as características definidoras e fatores relacionados ao diagnóstico de enfermagem excesso de volume de líquidos e sua relação com variáveis clínicas e sociodemográficas em pacientes em hemodiálise. Método: estudo transversal, desenvolvido com a utilização de um formulário e exame físico, com uma amostra de 100 pacientes, entre dezembro 2012 e abril 2013 em um hospital universitário e uma clínica de diálise. Resultados: dez associações estatisticamente significantes foram encontradas entre as características definidoras/fatores relacionadas ao excesso de volume de líquidos e as variáveis clínicas e sociodemográficas. Conclusão: as características definidoras e fatores relacionados ao excesso de volume de líquidos podem ser influenciados por variáveis clínicas e sociodemográficas em pacientes em hemodiálise.

RESUMEN Objetivo: analizar las características definitorias y los factores relacionados con el diagnóstico enfermero de exceso de volumen líquido y su relación con variables sociodemográficas y clínicas en pacientes de hemodiálisis. Método: estudio transversal, realizado mediante un formulario y examen físico, con una muestra de 100 pacientes, entre diciembre de 2012 y abril de 2013 en un hospital universitario y una clínica de diálisis. Resultados: se encontraron 10 asociaciones estadísticamente significativas entre las características definitorias, factores relacionados de volumen de exceso de líquido y las variables sociodemográficas y clínicas. Conclusión: las características definitorias y los factores relacionados de exceso de volumen líquido podrían estar influenciados por variables sociodemográficas y clínicas en clientes de hemodiálisis.

C-ANCA-positive glomerulonephritis associated with subacute infective endocarditis caused by Bartonella infection / 영남의대학술지

Glomerulonephritis (GN) is sometimes associated with infective endocarditis (IE). Bartonella endocarditis is difficult to diagnose because it is rare and cannot be detected by blood culture. This is the first report of cytoplasmic anti-neutrophil cytoplasmic antibody-positive subacute endocarditis-associated GN caused by Bartonella infection in South Korea. A 67-year-old man was hospitalized due to azotemia. He complained of weight loss and anorexia for 6 months. A diagnosis of IE was made based upon echocardiographic detection of vegetations on the mitral and aortic valves and a Bartonella antibody titer of 1:2,048. Renal histology identified focal crescentic GN. Azotemia and proteinuria improved after doxycycline and rifampin treatment combining with steroid therapy.

A Case of Severe Hypercalcemia Causing Acute Kidney Injury: An Unusual Presentation of Acute Lymphoblastic Leukemia

Severe hypercalcemia is rarely encountered in children, even though serum calcium concentrations above 15-16 mg/dL could be life-threatening. We present a patient having severe hypercalcemia and azotemia. A 14-year-old boy with no significant past medical history was referred to our hospital with hypercalcemia and azotemia. Laboratory and imaging studies excluded hyperparathyroidism and solid tumor. Other laboratory findings including a peripheral blood profile were unremarkable. His hypercalcemia was not improved with massive hydration, diuretics, or even hemodialysis, but noticeably reversed with administration of calcitonin. A bone marrow biopsy performed to rule out the possibility of hematological malignancy revealed acute lymphoblastic leukemia. His hypercalcemia and azotemia resolved shortly after initiation of induction chemotherapy. Results in this patient indicate that a hematological malignancy could present with severe hypercalcemia even though blast cells have not appeared in the peripheral blood. Therefore, extensive evaluation to determine the cause of hypercalcemia is necessary. Additionally, appropriate treatment, viz., hydration or administration of calcitonin is important to prevent complications of severe hypercalcemia, including renal failure and nephrocalcinosis.

Usefulness of Blood Cultures and Radiologic Imaging Studies in the Management of Patients with Community-Acquired Acute Pyelonephritis

BACKGROUND: The objective of this study was to examine the usefulness of blood cultures and radiologic imaging studies for developing therapeutic strategies in community-acquired acute pyelonephritis (CA-APN) patients. MATERIALS AND METHODS: We prospectively collected the clinical data of CA-APN patients who visited 11 hospitals from March 2010 to February 2011. RESULTS: Positive urine and blood cultures were obtained in 69.3% (568/820) and 42.7% (277/648), respectively, of a total of 827 CA-APN patients. Blood culture identified the urinary pathogen in 60 of 645 (9.3%) patients for whom both urine and blood cultures were performed; the organisms isolated from urine were inconsistent with those from blood in 11 and only blood cultures were positive in 49 patients. Final clinical failure was more common in the bacteremic patients than the non-bacteremic ones (8.0% vs. 2.7%, P = 0.003), as was hospital mortality (3.6% vs. 0.3%, P = 0.003). Likewise, durations of hospitalization and fever were significantly longer. Bacteremia was independent risk factor for mortality (OR 9.290, 1.145-75.392, P = 0.037). With regard to radiologic studies, the detection rate of APN was 84.4% (445/527) by abdominal computed tomography and 40% (72/180) by abdominal ultrasonography. Eighty-one of 683 patients (11.9%) were found to have renal abscess, perinephric abscess, urolithiasis, hydronephorosis/hydroureter or emphysematous cystitis, which could potentially impact on clinical management. Patients with Pitt score ≥ 1, flank pain or azotemia were significantly more likely to have such structural abnormalities. CONCLUSION: Blood cultures are clinically useful for diagnosis of CA-APN, and bacteremia is predictive factor for hospital mortality. Early radiologic imaging studies should be considered for CA-APN patients with Pitt scores ≥1, flank pain or azotemia.

Severe Fever with Thrombocytopenia Syndrome Presenting with Rhabdomyolysis

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging febrile illness. While many kinds of severe complications including acute renal failure have been reported, rhabdomyolysis is rarely reported in association with SFTS. A 54-year-old female farmer was admitted with fever and diffuse myalgia. Laboratory finding showed thrombocytopenia, leukopenia, azotemia, extremely elevated muscle enzyme levels and myoglobinuria. We describe a fatal case of rhabdomyolysis with acute renal failure complicated by SFTS.

Acute kidney injury caused by administration of zaltoprofen in a cat

A 5-year-old, 2.7 kg, spayed female Scottish Fold cat presented with hematemesis after administration of oral zaltoprofen, a non-steroidal anti-inflammatory drug, by the owner. Diagnostic imaging and blood analyses indicated development of acute kidney injury (AKI) resulting from zaltoprofen ingestion. To correct dehydration and anemic conditions, the cat received intravenous fluid therapy with whole blood transfusion and peroral N-acetylcysteine. Clinical signs resolved, but persistent azotemia was unresolved indicating that AKI could progress to chronic kidney disease. This case suggests that although zaltoprofen may have low adverse effects on humans, administration of zaltoprofen in cats can have serious adverse effects.

C-ANCA-positive glomerulonephritis associated with subacute infective endocarditis caused by Bartonella infection / 영남의대학술지

Glomerulonephritis (GN) is sometimes associated with infective endocarditis (IE). Bartonella endocarditis is difficult to diagnose because it is rare and cannot be detected by blood culture. This is the first report of cytoplasmic anti-neutrophil cytoplasmic antibody-positive subacute endocarditis-associated GN caused by Bartonella infection in South Korea. A 67-year-old man was hospitalized due to azotemia. He complained of weight loss and anorexia for 6 months. A diagnosis of IE was made based upon echocardiographic detection of vegetations on the mitral and aortic valves and a Bartonella antibody titer of 1:2,048. Renal histology identified focal crescentic GN. Azotemia and proteinuria improved after doxycycline and rifampin treatment combining with steroid therapy.

Analgesic efficacy of oral firocoxib in ovariohysterectomized cats

The postoperative analgesic effects of firocoxib in ovariohysterectomized cats were observed. Twenty-four cats were divided into 3 groups: control (no medicine), firocoxib-1 (1 mg/kg/day) and firocoxib-3 (3 mg/kg/day). Colorado pain scale scores (CPSS), composite pain scores (CPS), and buccal mucosal bleeding times (BMBT) were recorded in blinded fashion before induction and 2, 5, 8, 24, 30, and 48 h post-operation. The average CPSS (mean ± SEM) over 2 to 48 h post-operation in firocoxib-3 (0.4 ± 0.1) was significantly lower than that of the control (0.7 ± 0.2; p = 0.004), but that of firocoxib-1 (0.5 ± 0.2) was not different from that of the control (p = 0.40). The mean CPS of firocoxib-3 was significantly lower than that of the control at 24 h post-operation (p = 0.04); nonetheless, there was no significant difference in mean CPS between firocoxib-1 and control groups at all intervals. BMBT and body temperature were within normal limits in all groups. However, reversible azotemia was identified in two firocoxib-3 cats at 72 h post-operation. One firocoxib-3 cat vomited once at 48 h post-operation. In conclusion, firocoxib-3 is helpful for postoperative pain control in cats; however, gastrointestinal irritation and renal function side effects may occur.

Clinicopathological characteristics of extremely young Korean multiple myeloma patients: therapeutic implications

BACKGROUND/AIMS: Although multiple myeloma (MM) is typically a disease of the elderly, a certain subset of extremely young patients exists. It is necessary to establish clinicopathological characteristics for this population. METHODS: We reviewed the medical records of MM patients whose age was 40 years or younger at diagnosis. RESULTS: A total of 32 patients were analyzed (male to female ratio 19:13, median age 37 years). According to International Staging System, 29%, 48%, and 16% were in stage I, II, and III, respectively. Light chain myeloma accounted for 30%. Clinically significant anemia, hypercalcemia, azotemia, and hypoalbuminemia were present in 29%, 28%, 13%, and 28%, respectively. Three or more lytic bone lesions were detected in 45% of the patients, whereas 13% had no lytic bone lesions. Regarding treatment, 79% of patients received autologous hematopoietic stem cell transplantation. After a median follow-up duration of 64 months, the 1-, 3-, and 5-year overall survival (OS) rates were 84%, 62%, and 54%, respectively. The median OS was 61 months for the entire cohort. CONCLUSIONS: In our study, MM patients aged 40 years or younger at diagnosis showed no superior survival compared to those of the moderately elderly patients based on historical data.

Successful Peritoneal Dialysis in an Extremely Preterm Infant

Peritoneal dialysis can be considered renal supportive therapy, even in an extremely low birth weight infant with acute kidney injury not responding to general supportive measures. Although there have been several reports of successful peritoneal dialysis in extremely low birth weight infants, general practice guidelines and commercially available optimal peritoneal dialysis catheters have not been introduced. We report a successful case of peritoneal dialysis in an extremely low birth weight infant born at 25 weeks gestational age, with birth weight 790 g, with uncontrollable metabolic acidosis, hyperkalemia, progressive azotemia and continued anuria.

Staphylococcus-associated Glomerulonephritis / 대한내과학회지

A 64-year-old woman was admitted with vertebral osteomyelitis and polyarthritis (both knees and the right shoulder). She had had no health problems before these conditions developed. Joint culture grew methicillin-resistant Staphylococcus aureus. During hospitalization, hematuria, proteinuria, azotemia, and decreased C3 were reported. The renal biopsy showed mesangial proliferative glomerulonephritis with C3 and IgA co-dominant deposits on immunofluorescence staining. Following incision and drainage of the right shoulder and right knee, and intravenous vancomycin for 15 weeks, the C-reactive protein, proteinuria, hematuria, and C3 level all normalized. Here, we report a case of Staphylococcus-associated glomerulonephritis with a brief review of the literature.

Renal artery stenosis presenting with nephrotic-range proteinuria: a case report

Renal artery stenosis (RAS) is commonly presented with hypertension and chronic kidney disease. We report a rare case of RAS occurring in a 78-year-old man who presented with nephrotic-range proteinuria. Renal biopsy on the left side was performed, and results showed mesangiopathic glomerulonephritis, which was not compatible with the cause of nephrotic-range proteinuria. Proteinuria was decreased by angiotensin receptor blocker, but azotemia was aggravated. Therefore, angiotensin receptor blocker was discontinued inevitably and thorough evaluation for the possibility of RAS was performed. Computed tomography angiography revealed significant RAS on the left side and a renal artery stent was inserted. After stenting, aortic dissection developed and progressed despite tight control of blood pressure. After inserting another stent graft through the true lumen of the left renal artery, the patient's renal function and proteinuria improved markedly.

Características definidoras dos diagnósticos de enfermagem identificados nos indivíduos em hemodiálise / Defined characteristics of the nursing diagnosis identifield on individuals in hemodialysis

Diagnóstico de enfermagem consiste no julgamento clínico do enfermeiro diante das respostas do indivíduo, família ou comunidade a problemas de saúde reais ou potenciais. É composto por características definidoras que representam sinais e sintomas que indicam a presença do diagnóstico. Assim, objetivou-se identificar as características definidoras dos indivíduos com doença renal crônica em hemodiálise. Estudo transversal desenvolvido em uma unidade de diálise localizada em uma cidade do nordeste do Brasil. A amostra foi de 178 pacientes. A coleta de dados se deu por entrevista e exame físico, nos meses de outubro/2011 a fevereiro/2012. Os dados foram analisados de forma descritiva, onde foram identificadas a frequência absoluta, percentual, médias, desvio padrão e percentil de cada variável. Como resultados, identificou-se a presença de 37 características definidoras que determinaram 14 diagnósticos de enfermagem da NANDA Internacional. As características definidoras: Azotemia, Eletrólitos alterados e Ganho de peso em curto período foram as mais prevalentes. Essas estavam relacionadas ao diagnóstico Volume de líquidos excessivo. Conclui-se que as principais características definidoras identificadas na clientela estudada estavam relacionadas aos aspectos fisiológicos da doença renal crônica, entretanto destaca-se que existiram também características voltadas aos aspectos psicológico e social do paciente renal crônico em hemodiálise.

Nursing diagnosis is the clinical judgment of the nurse in the face of the individual, family or community problems or potential health responses. It consists of defining characteristics representing signs and symptoms that indicate the presence of diagnosis. Thus, this paper aims to identify the defining characteristics of individuals with chronic kidney disease on hemodialysis. Cross-sectional study conducted in a dialysis unit located in a city in northeastern Brazil. The sample consisted of 178 patients. Data collection occurred by interview and physical examination in October/2011 to February/2012. Data analyzed descriptively, where the absolute frequency, percentage, mean, standard deviation and percentile of each variable identified. As a result, we identified the presence of 37 defining characteristics that determined 14 nursing diagnoses from NANDA International. Defining characteristics: azotemia, altered electrolytes, and weight gain in a short period were the most prevalent. These related to the diagnosis of excessive fluid volume. It concluded that the main defining characteristics identified in clientele studied related to the physiological aspects of chronic kidney disease; however, it said that there were also features geared to psychological and social aspects of chronic renal patients on hemodialysis.