Kidney-limited thrombotic microangiopathy in patients with SLE treated with romiplostim.

We present the case of a 19 year-old Caucasian female with history of systemic lupus erythematosus (SLE) and normal baseline kidney function who developed severe acute renal failure following treatment of thrombocytopenia with the thrombopoietic agent romiplostim. Percutaneous kidney biopsy revealed thrombotic microangiopathy (TMA) without immune complex lupus glomerulonephritis. We discuss pathogenesis and differential diagnosis of TMA in patients with SLE and raise concerns regarding the use of thrombopoietic agents in such patients. Based on favorable long-term outcome in our case aggressive treatment and in particular prolonged use of plasma exchange in these patients are advocated.

Acute renal artery and vein thrombosis after renal transplant, associated with a short partial thromboplastin time and factor V Leiden mutation.

Renal graft thrombosis is a rare but devastating complication of renal transplantation. It accounts for one-third to one-half of early graft losses. We report a patient with acute renal artery and vein thrombosis associated with abnormally short activated partial thromboplastin time (aPTT) and factor V Leiden mutation. Vascular thrombosis developed on the ninth post-transplant day and led to a graft loss. Before transplantation, the patient had three episodes of thrombosis of arteriovenous access for hemodialysis. Our case illustrates the importance of investigating pretransplant patients for hypercoagulable states, particularly those with short aPTT.

Destabilization of natriuretic peptide C-receptor mRNA by phorbol myristate acetate.

Natriuretic peptide C receptor (NPR-C) expression in rat mesangial cells is downregulated by platelet-derived growth factor (PDGF) and the protein kinase C agonist phorbol myristate acetate (PMA). This study shows that PDGF and PMA diminish NPR-C mRNA abundance and that PMA does so by accelerating the degradation of the transcript. Exposure to PMA (0.1 microM) decreased mesangial cell NPR-C mRNA levels by more than 50% within 3 h and 125I-atrial natriuretic peptide binding by approximately 50% within 6 h. Disappearance of NPR-C transcripts after PMA treatment was more than twice as rapid as that seen after inhibition of RNA transcription with actinomycin D. Treatment with PDGF A/B (10 ng/ml) also produced downregulation of NPR-C mRNA, but the rate of transcript disappearance was similar to that seen after actinomycin D. Coincubation with actinomycin D inhibited the rapid disappearance of NPR-C mRNA with PMA. NPR-C mRNA levels increased four- to eightfold within 6 h after treatment with the protein synthesis inhibitor cycloheximide, but simultaneous treatment with PMA or PDGF still decreased the level of NPR-C mRNA despite the presence of cycloheximide. These results indicate that NPR-C expression is rapidly regulated by changes in the rate of catabolism of its mRNA through a protein kinase C-activated mechanism that depends on transcription. Treatment with cycloheximide induces NPR-C mRNA, but downregulation of this mRNA by either PDGF or PMA does not depend on synthesis of new protein.

Calciphylaxis in chronic renal failure.

Calciphylaxis is a rare and life-threatening complication that is estimated to occur in 1% of patients with ESRD each year. Typically, extensive microvascular calcification and occlusion/thrombosis leads to violaceous skin lesions, which progress to nonhealing ulcers and sepsis. Secondary infection of skin lesions is common, often leading to sepsis and death. The lower extremities are predominantly involved (roughly 90% of patients). Patients with skin involvement over the trunk or proximal extremities have a poorer prognosis. Although most calciphylaxis patients have abnormalities of the calcium:phosphate axis or elevated levels of parathyroid hormone, these abnormalities do not appear to be fundamental to the pathophysiology of the disorder, and the etiology of calciphylaxis remains unclear. Recently, functional protein C deficiency has been hypothesized to cause a hypercoagulable state that could induce thrombosis in small vessels, with resulting skin ischemia, necrosis, and gangrene. The lack of understanding of the pathophysiology of the disease results in treatments that are equally unsatisfactory. Patients who undergo parathyroidectomy have a tendency to improve, but the prognosis for the disease is poor and mortality remains high.