Peritoneal dialysis underscores its merits in portal hypertensionrelated and nephrogenic ascites.

In the Western world, peritoneal dialysis (PD) is less frequently applied as substitute therapy in end-stage renal disease (ESRD). In the Netherlands the use of PD has decreased from 30.3 to 13.5% due to several factors, but not due to lower PD-related outcome. The lower penetrance of PD diminishes experience with and exposure of young professionals to this treatment modality. This does not enhance a free and motivated choice among renal replacement therapies for patients who cannot be transplanted pre-emptively. To rejuvenate interest in PD and to underscore its merits, we would like to share the use of PD on two extraordinary occasions, where PD was the only way out. Ascites due to portal hypertension with profound gastrointestinal haemorrhage and nephrogenic ascites poses major management challenges in ESRD patients. In conclusion, PD came to the rescue and tremendously increased quality of life in the patients presented. To be readily available, a certain penetrance of and expertise in PD as renal replacement therapy is warranted.

Safety and long-term effects of renal denervation: Rationale and design of the Dutch registry.

BACKGROUND: Percutaneous renal denervation (RDN) has recently been introduced as a treatment for therapy-resistant hypertension. Also, it has been suggested that RDN may be beneficial for other conditions characterised by increased sympathetic nerve activity. There are still many uncertainties with regard to efficacy, safety, predictors for success and long-term effects. To answer these important questions, we initiated a Dutch RDN registry aiming to collect data from all RDN procedures performed in the Netherlands. METHODS: The Dutch RDN registry is an ongoing investigator-initiated, prospective, multicentre cohort study. Twenty-six Dutch hospitals agreed to participate in this registry. All patients who undergo RDN, regardless of the clinical indication or device that is used, will be included. Data are currently being collected on eligibility and screening, treatment and follow-up. RESULTS: Procedures have been performed since August 2010. At present, data from 306 patients have been entered into the database. The main indication for RDN was hypertension (n = 302, 99%). Patients had a mean office blood pressure of 177/100 (±29/16) mmHg with a median use of three (range 0-8) blood pressure lowering drugs. Mean 24-hour blood pressure before RDN was 157/93 (±18/13) mmHg. RDN was performed with different devices, with the Simplicity™ catheter currently used most frequently. CONCLUSION: Here we report on the rationale and design of the Dutch RDN registry. Enrolment in this investigator-initiated study is ongoing. We present baseline characteristics of the first 306 participants.

Vitamin K1 in oral solution or tablets: a crossover trial and two randomized controlled trials to compare effects.

BACKGROUND: Vitamin K1 (VK1) reverses the effects of vitamin K antagonists (VKAs). The literature shows that the bioavailability from solutions might be higher than that from tablets, possibly resulting in different effects. OBJECTIVES: To compare the bioavailability and effect on the International Normalized Ratio (INR) of 5-mg VK1 tablets and solution in three randomized clinical trials. METHODS AND RESULTS: The bioavailability was determined in a crossover trial with 25 healthy volunteers. VK1 plasma concentrations were assessed at 0, 2, 4, 5, 6, 8, 10 and 24 h, and the area under the curve was higher in the solution group than in the tablet group (mean difference 365 µg L(-1) h, 95% confidence interval [CI] 230-501, P < 0.0001). In the other two trials, the effects of both formulations on the INR were measured at 0, 24 and 48 h. In the second trial, on 72 patients on phenprocoumon with planned invasive procedures, both formulations were similarly effective, because all patients reached an INR of < 2.0, which was the primary endpoint. In the last trial, on 72 patients on phenprocoumon with an INR of 7.0-11.0, the INR decreased slightly more in the solution group (4.7, 95% CI 4.3-5.1) than in the tablet group (4.2, 95% CI 3.8-4.6). The solution group had a 3.3-fold increased likelihood (95% CI 0.7-15.1) of reaching an INR of < 2.0 at 48 h. Additionally, the increases in VK1 concentrations were similar (tablets, 3.2 µg L(-1) ; solution, 3.4 µg L(-1) ; P = 0.99) after 24 h. CONCLUSIONS: VK1 tablets are at least as clinically effective as the solution in countering VKAs.

Randomised trial of no hydration vs. sodium bicarbonate hydration in patients with chronic kidney disease undergoing acute computed tomography-pulmonary angiography.

BACKGROUND: Hydration to prevent contrast-induced acute kidney injury (CI-AKI) induces a diagnostic delay when performing computed tomography-pulmonary angiography (CTPA) in patients suspected of having acute pulmonary embolism. AIM: To analyze whether withholding hydration is non-inferior to sodium bicarbonate hydration before CTPA in patients with chronic kidney disease (CKD). METHODS: We performed an open-label multicenter randomized trial between 2009 and 2013. One hundred thirty-nine CKD patients were randomized, of whom 138 were included in the intention-to-treat population: 67 were randomized to withholding hydration and 71 were randomized to 1-h 250 mL 1.4% sodium bicarbonate hydration before CTPA. Primary outcome was the increase in serum creatinine 48-96 h after CTPA. Secondary outcomes were the incidence of CI-AKI (creatinine increase > 25%/> 0.5 mg dL(-1) ), recovery of renal function, and the need for dialysis within 2 months after CTPA. Withholding hydration was considered non-inferior if the mean relative creatinine increase was ≤ 15% compared with sodium bicarbonate. RESULTS: Mean relative creatinine increase was -0.14% (interquartile range -15.1% to 12.0%) for withholding hydration and -0.32% (interquartile range -9.7% to 10.1%) for sodium bicarbonate (mean difference 0.19%, 95% confidence interval -5.88% to 6.25%, P-value non-inferiority < 0.001). CI-AKI occurred in 11 patients (8.1%): 6 (9.2%) were randomized to withholding hydration and 5 (7.1%) to sodium bicarbonate (relative risk 1.29, 95% confidence interval 0.41-4.03). Renal function recovered in 80.0% of CI-AKI patients within each group (relative risk 1.00, 95% confidence interval 0.54-1.86). None of the CI-AKI patients developed a need for dialysis. CONCLUSION: Our results suggest that preventive hydration could be safely withheld in CKD patients undergoing CTPA for suspected acute pulmonary embolism. This will facilitate management of these patients and prevents delay in diagnosis as well as unnecessary start of anticoagulant treatment while receiving volume expansion.

Chronic kidney disease and implantable cardioverter defibrillator related complications: 16 years of experience.

INTRODUCTION: Implantable cardioverter defibrillator (ICD) implantation has become an accepted therapy for the prevention of sudden cardiac death. However, serious comorbidities such as chronic kidney disease (CKD) are influencing the beneficial effects of ICD therapy. In this study, the association between kidney function and the occurrence of ICD related complications was assessed. METHODS: All patients receiving an ICD or cardiac resynchronization therapy-defibrillator between 1996 and 2012 were included. Renal function was categorized as: glomerular filtration rate (GFR) >90, GFR 30-90 or GFR <30 mL/min/1.73 m(2) . Registered complications were pocket hematoma, pneumothorax, lead complications, and device infection. RESULTS: In 3,147 device recipients, 236 patients (7.5%) suffered from at least 1 complication. Patients with a GFR <30 (n = 110) had a higher event rate for hematoma, pneumothorax, and infection. These patients were older, had a higher incidence of hypertension, diabetes, and a lower body mass index (BMI; P < 0.05). After correcting for these risk factors, hematoma remained independently associated with a GFR <30 mL/min (OR 2.7, CI: 1.05-6.9, P = 0.04). Device infection, pneumothorax, and lead complications were not independently associated with a GFR <30 mL/min/1.73 m(2) . CONCLUSIONS: Patients with CKD suffered from more ICD related complications than patients without kidney disease. This was partially associated with kidney dysfunction itself as was the case with the occurrence of hematoma. However, the high burden of risk factors associated with device complications in patients with renal disease played an important role as well.

[Tubulo-interstitial nephritis in inflammatory bowel disease: extra-intestinal manifestation or drug toxicity?]. / Tubulo-interstitiële nefritis bij inflammatoire darmziekte: extra-intestinale manifestatie of geneesmiddeltoxiciteit?

Chronic inflammatory bowel disease (IBD) is seldom complicated by renal function disorder, but when this occurs the consequences are serious. In addition to the known effects of 5-aminosalicylates, there is also evidence that tubulo-interstitial nephritis (TIN) occurs as an extra-intestinal manifestation of IBD. A 27-year-old woman with colitis ulcerosa, developed end-stage renal insufficiency due to a mesalazine-induced TIN. She was treated by haemodialysis for two years before she underwent renal transplantation. Another patient, a 36-year-old man with Crohn's disease, developed extensive granulomatous nephritis with stable moderate renal function. After excluding other possible causes, we diagnosed an extra-intestinal manifestation of his Crohn's disease. There are no official guidelines on renal function monitoring in IBD patients, nor is there consensus in literature. We advise renal monitoring after three months of treatment with 5-aminosalicylates, followed by monitoring every year. Patients not receiving treatment should be monitored every year.

Aortic aneurysm and orchitis due to Wegener's granulomatosis.

We present a patient with Wegener's granulomatosis (WG) with involvement of the abdominal aorta, testis, peripheral nerve system, and skin. A 51-year-old man presented at our outpatient clinic with lower back pain. He had a history of smoking, hypertension, and an embryonal carcinoma of the left testis, treated 13 years ago with orchidectomy and chemotherapy. One month earlier, he underwent a partial orchidectomy of the right testis due to testicular swelling. Abdominal computed tomography showed a 3.8 cm wide aneurysm of the distal part of the aorta with inflammation. One week later he was admitted to the hospital with numbness of his hands and feet. Physical examination showed signs of peripheral microemboli. Serological laboratory tests revealed elevated antineutrophil cytoplasmic antibody titers with positive reactions against proteinase-3, indicating Wegener's disease. The chest X-ray was normal. Pathological examination of the right testis showed necrotizing vasculitis of a small artery. He was treated with cyclophosphamide and prednisolone. WG with extrapulmonary involvement occurs infrequently, and reports of manifestations of WG in aorta, testis, the peripheral nerve system, and skin are even more uncommon. Small- and medium-vessel vasculitis can precede large-vessel vasculitis or occur in the absence of small-vessel involvement. Therefore, WG should be included in the work-up of large-vessel vasculitis, which can give rise to periaortic inflammation.

Transfer of ureteral carcinoma in a transplanted kidney presenting by early stenosis of the proximal ureter.

A 71-yr-old male kidney transplant recipient suffered from delayed graft function. Eighty days after transplantation complete obstruction of the proximal ureter was observed, complicated by recurrent urinary tract infections. Two months later, the donor kidney was removed because of infectious complications and inadequate arterial perfusion. Histological examination of the removed graft showed signs of rejection as well as a low-grade papillary urothelial cell carcinoma of donor origin in the ureter. The remaining donor ureter was removed subsequently and showed no further signs of malignancy. Follow-up of the patient until 12 months after surgery did not reveal recurrence of the tumor. This case report is the first to describe accidental transfer of urothelial cell carcinoma in the ureter by transplantation, highlighting the possibility of malignancy when early stenosis is not related to the anastomosis. It again emphasizes the need for precise and cautious screening of organ donors, especially those of higher age.

[Spontaneous renal bleeding in haemodialysis patients]. / Spontane nierbloedingen bij hemodialysepatiënten.

In three women on chronic haemodialysis because of end-stage renal disease who were 40, 59, and 73 years of age respectively, spontaneous renal bleeding was diagnosed. The first two patients presented with acute flank pain and signs of sudden blood loss, the third one had chronic abdominal pain and anaemia. A CT scan demonstrated perirenal bleeding in all three patients and expansion into the retroperitoneal space in the first and third patient. In the latter two patients, acquired renal cysts had been visible during earlier abdominal ultrasound. None of the patients had severe hypertension, but all of them had received medication enhancing bleeding tendency, such as nadroparin, which was administered during haemodialysis. The first and the last patient were treated conservatively and survived. The second patient was haemodynamically unstable and underwent embolisation to stop the bleeding. She died in hospital after fifteen days due to the complications of a cardiac arrest. Abdominal CT or ultrasound is the technique of choice to evaluate patients with end-stage renal disease with loin pain or bleeding. Most of the time, conservative treatment suffices.

A pitfall in screening with decoy cells after simultaneous pancreas kidney transplantation.

In this report, we describe a bladder-drained simultaneous pancreas-kidney transplant (SPKT) recipient with a polyoma virus-associated nephropathy (PVAN) in whom the urine cytology failed to detect decoy cells despite repeated attempts. Several tests were performed to confirm our hypothesis that pancreatic enzymes can degrade decoy cells and granulocytes. This case illustrates an important pitfall in the urinary screening for PVAN with cytology and for urinary tract infections with urine sediment in bladder-drained SPKT recipients.

Simulating the effects of different spatio-temporal fire regimes on plant metapopulation persistence in a Mediterranean-type region.

Spatio-temporal fire regimes are likely to shift with changes in land use and climate. Such a shift in the disturbance regime has been proposed from recent reconstructions of the regional fire history in the Mediterranean-type woodlands and shrublands of Western Australia which suggest that fire was much more frequent before 1930 (local fire intervals of 3-5 years) than it is today (local fire intervals of 8-15 years).To investigate the potential biodiversity consequences of such changes in fire regime for fire-killed woody species, we developed a spatial model for the serotinous shrub Banksia hookeriana that grows on sand dunes of the Eneabba Plain, Western Australia. We sought to identify the envelope of fire regimes under which the spatially separated populations in this species are able to persist, and whether this encompasses the fire regimes proposed by recent fire-history reconstructions.We tested two fire frequency-size distribution scenarios: (1) a scenario where fire size depends on the spatial patch configuration; and (2) a scenario depending also on available fuel (time since last fire), which reduces fire size at short inter-fire intervals.In scenario 1, metapopulation persistence was only likely for mean ignition intervals at the landscape scale of 6 years. In scenario 2, persistence was likely for the whole range of fire interval distributions at the landscape scale suggested by the empirical data. However, persistence was almost impossible if the mean return fire interval at the local scale (i.e. for individual dunes) is < 8 years.Synthesis and applications. We have demonstrated that this plant metapopulation can potentially persist over a wide range of temporal fire regimes at the landscape scale, so long as there are buffering mechanisms at work (e.g. feedback between fire spread and vegetation age) which reduces the probability of large fires at short intervals. Our findings demonstrate that at least some parts of the landscape must burn substantially less frequently on average than suggested by the empirical fire reconstructions for the early and pre-European period if populations of fire-killed woody species such as B. hookeriana are to be conserved.

An approach to the patient with severe hypokalaemia: the potassium quiz.

The objective of this teaching session with Professor McCance is to develop an approach to the management of patients with a very low plasma potassium (K(+)) concentration (P(K)). The session begins with a quiz based on six recent medical consultations for a P(K) < 2 mmol/l. Professor McCance outlined how he would proceed with his diagnosis and therapy, using the synopsis that described each patient. This approach was then applied to a new patient, a 69-year-old woman who had a large volume of dependent oedema and developed a severe degree of weakness and hypokalaemia during more aggressive diuretic therapy that included a K(+)-sparing diuretic. The initial challenge for Professor McCance was to deduce why the K(+)-sparing diuretic was not effective in this patient. He also needed to explain why the P(K) was so low on admission.

Hb zoeterwoude [beta23(B5)Val-->Ala)]: a new beta-globin variant found in association with erythrocytosis.

We describe the characterization of a new hemoglobin (Hb) variant found in a 77-year-old Dutch woman, suspected of hypoxia-mediated erythrocytosis. The typical blood parameters (Hb 17.3 g/dL; PCV 0.525 L/L; RBC 5.82 x 10(12)/L) could not be explained by any of the pathological or physiological conditions causing erythrocytosis. The patient was preventively phlebotomized because of intermittent claudication and erythrocytosis. At the hematological and biochemical levels, no anemia or hemolysis were present and no abnormal Hb fractions were detectable on alkaline electrophoresis or high performance liquid chromatography (HPLC). Molecular analysis revealed intact alpha-globin genes and a heterozygosity for a GTT-->GCT transition at codon 23 of the beta-globin gene, causing a Val-->Ala amino acid substitution. The P50 measured in full blood indicated that this mutant has an elevated oxygen affinity. This is the fourth single nucleotide substitution at codon 23 of the beta gene and the second associated with erythrocytosis. Because the family was not available for investigation no information was obtained as to whether the mutation represents a de novo event or was inherited, and might be a more common cause of erythrocytosis in Dutch patients. Considering the relatively high frequency of beta-thalassemia (thal) in the large allochthonous population in The Netherlands, combinations of Hb Zoeterwoude and beta-thal traits may lead to hemizygosity, with severe hypoxia and erythrocytosis from a few months after birth.

[Shoshin beriberi provoked by the inhalation of salbutamol]. / Sjosjin-beriberi na inhalatie van salbutamol.

A 45-year-old male alcoholic with a deficient diet was given salbutamol for exertion-related dyspnoea. After inhalation, he presented with a severe dyspnoea, acrocyanosis, anuria and low blood pressure as well as a respiratory compensated lactate acidosis. Shoshin beriberi was suspected on clinical grounds. The low level of thiamine and the prompt recovery after thiamine repletion confirmed this diagnosis. Shoshin beriberi is an acute, cardiac form of beriberi, which can rapidly result in death due to cardiogenic shock and lactate acidosis. Adrenergic agents can cause a hyperdynamic circulation and thus aggravate the effects of a thiamine deficiency.

[Ototoxicity induced by clarithromycin]. / Door claritromycine geïnduceerde ototoxiciteit.

A 76-year-old man developed a progressive bilateral hearing loss 4 days after starting a high dose of clarithromycin for atypical pulmonary tuberculosis. When the clarithromycin was discontinued the hearing improved subjectively but it worsened again upon reexposure. Halving the dose resulted in both an objective and subjective improvement in hearing, yet the original level of hearing was only obtained once clarithromycin had been permanently withdrawn. It would seem that this adverse effect is dose dependent. This seems to be the first published case study that demonstrates ototoxicity as a result of clarithromycin use.