The significance of atypical morphology in the changes of spectrum of postinfectious glomerulonephritis.

BACKGROUND: The characteristics of post infectious glomerulonephritis (PIGN) now differ from what were described decades ago. After encountering several patients of PIGN with atypical morphology, we conducted this retrospective study to determine the significance in the changes of clinicopathological spectrum of the disease. METHODS: Between July 2000 and February 2009, 21 cases of PIGN were identified at a medical center in Taiwan. The patients' records were reviewed with respect to clinical presentation, microbiology, serology, morphology of renal biopsy, and clinical course. RESULTS: The mean age was 60.4 years. All patients developed acute renal failure and the majority (66.7%) required dialysis support. Hypocomplementemia was present in 61.9% of patients. The most frequently identified infectious agent was Staphylococcus (57.1%). Histological characteristics showed two distinct patterns of PIGN. One was diffuse endocapillary proliferation typical of PIGN (61.9%) and the other was atypical pattern of focal mesangial proliferation (38.1%). In comparison, glomerular neutrophil infiltration was more commonly present in typical pattern (p = 0.018). Glomerular IgA dominant or co-dominant deposition was more frequently seen in atypical pattern (p = 0.032). However, there were no statistically significant differences in the clinical presentation and outcome between the two groups. Our data also showed that the percentage of patients with atypical morphology PIGN significantly increased over time. CONCLUSIONS: Atypical pattern of focal mesangial proliferative glomerulonephritis may represent a resolution stage of PIGN. The nature of subclinical infection with a more protracted course may contribute to the increasing recognition of this resolving PIGN at the time of renal biopsy. Another possible explanation is that the atypical morphology may be a peculiar pattern of poststaphylococcal glomerulonephritis which was increasingly identified in PIGN over the past 10 years.

Tubulointerstitial nephritis and uveitis with Fanconi syndrome in a patient with ankylosing spondylitis.

We report a 40-year-old man with ankylosing spondylitis who was referred to our hospital because of a 2-month history of general fatigue, anorexia, and weight loss. Laboratory findings showed anemia and renal dysfunction. Fanconi syndrome was suggested by multiple proximal tubular defects including renal glucosuria, hyperuricosuria, hyperphosphaturia, proximal renal tubular acidosis, and kaliuresis leading to hypokalemia. Renal biopsy showed acute tubulointerstitial nephritis. Furthermore, bilateral uveitis was diagnosed by an ophthalmologist. The patient was treated with systemic corticosteroids. The renal and proximal tubular function returned to normal and uveitis disappeared by 4 weeks after commencement of corticosteroid treatment. To our knowledge, tubulointerstitial nephritis and uveitis has rarely been associated with Fanconi syndrome and had not been reported in ankylosing spondylitis.

Crescentic glomerulonephritis associated with miliary tuberculosis.

We report a 70-year-old man who presented with cervical lymphadenopathy, hypercalcemia, and acute renal failure. Lymph node biopsy revealed caseating granulomas. Renal biopsy showed immune complex-mediated diffuse proliferative glomerulonephritis with crescentic formation. Ultrastructural features of the glomerular disease were compatible with the description in infectious glomerulonephritis. Disseminated tuberculosis was diagnosed when sputum, urine, and bone marrow cultures confirmed the presence of Mycobacterium tuberculosis. Successful treatment with antituberculous agents accompanied by recovery of renal function. As far as we know, the association of tuberculosis with glomerulonephritis appears to be exceedingly rare. In addition to describing this case, we also review cases of tuberculosis-associated glomerulonephritis retrieved from the literature.

Mesenteric panniculitis: an unusual cause of dyspepsia in a hemodialysis patient.

Many patients with chronic renal failure have dyspeptic symptoms. However, mesenteric panniculitis as a cause of dyspepsia has not been described in this patient group. We report a 78-year-old hemodialysis patient who was admitted because of intractable dyspepsia. Investigations with ultrasonography, endoscopy and barium studies were all inconclusive. Computed tomography of the abdomen demonstrated a large encapsuled soft-tissue mass in the root of mesentery. Percutaneous biopsy confirmed the diagnosis of mesenteric panniculitis. Percutaneous drainage was performed when liquefaction of the mesenteric mass lesion was noted on follow-up computed tomography 1 month later. Improvement of gastrointestinal symptoms occurred soon after drainage of the fluid component of the mesenteric mass. Microbiologic and cytologic studies of the drainage specimens were negative. Follow-up computed tomography 3 months later showed reduction in the size of the mesenteric mass.

An unusual case of xanthogranulomatous pyelonephritis in a leukemia patient.

We report a 65-year-old woman with leukemia who presented with urinary tract infection, splenic abscess, and a renal mass. Both urine and pus culture of the splenic abscess yielded Klebsiella pneumoniae. The differential diagnosis of the renal mass by radiological findings included unliquefied renal abscess, xanthogranulomatous pyelonephritis, and renal cell carcinoma. Percutaneous biopsy of the renal mass confirmed the diagnosis of xanthogranulomatous pyelonephritis. Because of high surgical risk, the patient received medical treatment with prolonged antibiotic therapy. With antibiotic therapy only, not only the splenic abscess was cured but also follow-up ultrasonography showed progressive resolution of the renal mass. The occurrence of xanthogranulomatous pyelonephritis has rarely been reported in the absence of urinary tract obstruction or nephrolithiasis. Furthermore, this is the first report of xanthogranulomatous pyelonephritis occurring in patients with leukemia and concurrent with splenic abscess. In addition to describing this unusual case, we provide a short review of xanthogranulomatous pyelonephritis successfully treated with antibiotics only.

Remission of nephrotic membranous glomerulonephritis after high-dose trimethoprim-sulfamethoxazole treatment for pneumocystis jiroveci pneumonia.

We report an unusual case of nephrotic syndrome due to membranous glomerulonephritis that responded to high-dose trimethoprim-sulfamethoxazole (TMP-SMX) treatment. A 52-year-old man presented with nephrotic syndrome and was diagnosed to have idiopathic membranous glomerulonephritis. At the time of diagnosis, his serum creatinine level was 1.2 mg/dl and daily urine protein excretion was 7.45 g. The patient was initially treated with angiotensin-converting enzyme inhibitor and diuretics. After a 6-month period, the patient remained symptomatic. Therefore, immunosuppressive therapy with a 6-month course of alternating corticosteroids with cyclophosphamide was commenced. Unfortunately, as a sequel of the immunocompromised state, the patient acquired severe pneumonia due to Pneumocystis jiroveci infection when he was on the fourth month of immunosuppressive therapy. At this time, he still had nephrotic range proteinuria and hypoalbuminemia. Because of the risk of aggravating infection, immunosuppressive agents were discontinued. A 14-day course of intravenous high-dose TMP-SMX therapy was given for the treatment of Pneumocystis jiroveci pneumonia. With this medication, not only the pneumonia was cured, but also a sustained remission of the nephrotic syndrome occurred. This case suggests a possible therapeutic role of high-dose TMP-SMX in membranous glomerulonephritis. We will discuss the possible mechanism.

Focal segmental glomerulosclerosis in association with Cushing's disease.

Focal segmental glomerulosclerosis (FSGS) may be idiopathic or secondary to a variety of causes. Clinical distinction between primary and secondary forms of FSGS has crucial therapeutic consequences. Whereas the former may respond to immunosuppressive therapy, treatment of secondary forms of FSGS must aim to resolve the underlying diseases. Although the combination of nephrotic syndrome and Cushing's syndrome has been described anecdotally, the causal relationship between these two diseases remains controversial. We report herein a 37-year-old man who presented with lower extremity pitting edema. Heavy proteinuria and mild renal insufficiency prompted to perform a kidney biopsy and the specimen showed FSGS. On the other hand, admission physical examination was notable for a Cushingoid appearance. After endocrinological investigations, the patient was diagnosed as having Cushing's disease caused by pituitary adrenocorticotropic hormone-producing microadenoma. Immunosuppressive therapy for the treatment of FSGS was not carried out and we treated his Cushing's disease with transsphenoidal resection of the pituitary microadenoma. Surprisingly, resolution of heavy proteinuria occurred when the patient's physical features characteristic of Cushing's disease were gradually resolved 3 months later. This case suggests a possible association of Cushing's disease with FSGS.

Xanthogranulomatous pyelonephritis complicated by emphysematous pyelonephritis in a hemodialysis patient.

Xanthogranulomatous pyelonephritis and emphysematous pyelonephritis are two uncommon variants of pyelonephritis. The combined occurrence is very rare and has not been described in dialysis patients. We report a 78-year-old woman with end-stage renal disease receiving chronic hemodialysis who presented with a one-week history of vague abdominal pain. During the previous 4 months, she had experienced four episodes of urinary tract infection presenting with fever and pyuria which were improved by antibiotic therapy. The urine cultures yielded Klebsiella pneumoniae at all events. Abdominal computed tomography showed the right kidney replaced by multiple hypodense masses. A kidney biopsy demonstrated characteristic pictures of xanthogranulomatous pyelonephritis. Subsequent computed tomography showed gas bubbles formation in the right renal masses suggestive of emphysematous pyelonephritis. Because the patient refused surgical nephrectomy, percutaneous needle aspiration with prolonged antibiotic treatment was done. Follow-up computed tomography demonstrated dramatic regression of the renal mass. This case suggests that xanthogranulomatous pyelonephritis can be complicated by emphysematous pyelonephritis. Furthermore, the unique features in end-stage renal disease patients make the diagnosis of xanthogranulomatous pyelonephritis more difficult.

Minimal change nephrotic syndrome in association with strongyloidiasis.

Although parasitic infections have been known to be associated with immune complex-mediated glomerular lesions, strongyloidiasis-related glomerulopathy has not been well documented. We report a patient with delayed-recognized disseminated strongyloidiasis who developed nephrotic syndrome 3 months after the beginning of the manifestations related to strongyloidiasis. A kidney biopsy showed minimal change disease. We treated strongyloidiasis and hesitated to give steroid therapy for the treatment of minimal change nephrotic syndrome (MCNS) because of the risk of aggravation of Strongyloides stercoralis infection. Surprisingly, resolution of heavy proteinuria occurred after anthelmintic therapy with ivermectin. This case suggests a possible causal relationship between S. stercoralis infection and MCNS. In addition, a review of another 4 cases previously reported in the literature demonstrates the importance of detecting underlying S. stercoralis infection in patients with nephrotic syndrome since steroid therapy can cause hyperinfection or disseminated strongyloidiasis, and which may lead to fatal outcome.

Outpatient versus inpatient renal biopsy: a retrospective study.

OBJECTIVE AND METHODS: There is a growing interest in the safety and efficacy of percutaneous kidney biopsy for outpatients in Taiwan. We conducted a retrospective study for patients receiving the biopsy in 2002 and 2003. Complication and mortality associated with the biopsy were compared between 147 inpatients and 183 outpatients who had been judged to need no hospitalization. All biopsies were performed using the ultrasound guidance and an automated spring-loaded biopsy device. RESULTS: There were no death and no significant difference in complication rates between the two groups. No delayed gross hematuria, delayed pain, fever or biopsy site bleeding developed in outpatients, who were followed-up by telephone contacts for 1 - 5 days after they had been discharged. Both outpatients and inpatients with hematoma were younger than those without (p < 0.05). Template bleeding time was longer for inpatients with hematuria compared with inpatients without (12.0 vs. 5.8 minutes in average, p = 0.036), but not for outpatients (4.5 vs. 6.0 minutes in average, p = 0.282). There were moderate differences in platelet count between outpatients with hematuria and those without (p = 0.057), and in serum creatinine between inpatients with hematuria and those without (p = 0.069). CONCLUSION: The outpatient renal biopsy appears to be equally as safe and efficient as the inpatient biopsy. However, we suggest checking template bleeding time and platelet count before biopsy for patients with clinical bleeding tendency, such as patients with a serum creatinine level over 4 mg/dl (approaching CKD stages IV, V) due to a higher risk of prolonged bleeding time. Outpatient biopsy with a 6-hour inpatient observation can be considered as a medically adequate procedure.

Rescue treatment for cyclosporine-associated hemolytic-uremic syndrome with intravenous immunoglobulin.

Hemolytic-uremic syndrome (HUS) is a rare complication occurring in solid-organ and bone marrow transplant recipients treated with calcineurin inhibitors cyclosporine or tacrolimus. We report here about a 30-year-old female cadaveric renal transplant recipient receiving cyclosporine who developed HUS in the early post-transplant period. Renal allograft biopsy specimens showed the characteristic features of thrombotic microangiopathy and acute cyclosporine nephrotoxicity. Cyclosporine was discontinued and the patient was switched to tacrolimus in conjunction with plasma exchange. Unfortunately, plasma exchange was interrupted by bleeding complication resulting from placement of double-lumen catheter. Intravenous immunoglobulin (IVIG) was then administrated as an alternative therapy. Hematological resolution occurred promptly and renal function recovered uneventfully. Our presenting case suggests the beneficial effect of IVIG on cyclosporine-associated HUS.

Antibiotic lock technique reduces the incidence of temporary catheter-related infections.

BACKGROUND: In the hemodialytic population, infections are the second leading cause of death; access infections account for a large proportion of this mortality. The antibiotic lock technique has been applied to infected tunneled catheters as rescue or prophylaxis medication to reduce infection rates. In addition, application of topical antibiotic ointments to tunneled and non-tunneled catheters also prevents exit site infections. METHODS: 17 patients with 25 catheters participated in our study from March 2004 - February 2005. The catheter lock comprised of mixed cefazolin (5 mg/dl) with heparin (2,500 IU/ml) and mupirocin was topically applied to the area (2 x 2 cm) surrounding the catheter exit site. RESULTS: The catheter infection rate was reduced from 12.7 times/1,000 catheter days to 5.02 times/1,000 catheter days in patients with jugular vein catheters. The total catheter-related infection rate was 14.9 times/1,000 catheter days in the control group and 4.1 times/1,000 catheter days in the study group. The reduction in catheter infections was more evident in a subgroup of non-diabetic patients, and in those with femoral catheters. CONCLUSION: The use of antibiotic lock and topical antibiotics significantly reduces the incidence of temporary catheter-related infections, especially in non-diabetic patients and in those with femoral catheters.

Microscopic polyangiitis atypically presenting with tubulointerstitial nephritis.

A 65-year-old woman was admitted with a 4-week history of non-specific constitutional symptoms. Microscopic hematuria, proteinuria and mild renal insufficiency together with the presence of serum antineutrophil cytoplasmic antibodies prompted to perform a renal biopsy. The specimen showed tubulointerstitial nephritis without glomerular change. However, she developed purpura on lower limbs and hemoptysis, along with diffuse pulmonary infiltrates on chest radiograph, 2 weeks after admission. Skin and lung biopsies demonstrated leukocytoclastic vasculitis and diffuse alveolar hemorrhage, respectively. Microscopic polyangiitis was diagnosed based on clinical and pathological criteria. Clinical improvement occurred after intensive immunosuppressive therapy was given. This case illustrates an unusual renal presentation of tubulointerstitial nephritis in microscopic polyangiitis. The possible pathogenetic mechanism will be discussed.

Crescentic glomerulonephritis associated with rifampicin in a patient co-infected with tuberculosis and human immunodeficiency virus.

A 73-year-old man presented with acute renal failure after 3-month standard antituberculosis therapy with rifampicin for pulmonary tuberculosis. Previously undiagnosed human immunodeficiency virus (HIV) infection was found at the same time. A kidney biopsy showed crescentic glomerulonephritis and tubulointerstitial nephritis. Furthermore, endothelial tubuloreticular inclusions were seen on electron microscopy. Rifampicin was stopped because it was considered as the most possible cause responsible for the rapidly progressive glomerulonephritis (RPGN). Immunosuppressive therapy was not carried out because of the risk of aggravation of underlying infectious diseases including tuberculosis and HIV. Fortunately, renal function recovered 1 month after discontinuation of rifampicin. This case presented a clinical challenge in the differential diagnosis of the cause for RPGN in such a complex condition and the therapeutic dilemma regarding the use of immunosuppressive drugs.

Remission of hepatitis B virus-associated membranoproliferative glomerulonephritis in a cirrhotic patient after lamivudine therapy.

We describe a 39-year-old man with hepatitis B virus-(HBV) related chronic hepatitis who presented with nephrotic syndrome and decompensated cirrhosis. A kidney biopsy revealed membranoproliferative glomerulonephritis (MPGN) which was thought to be related to the HBV infection. Because interferon-alpha therapy was generally not recommended in patients with advanced liver disease, we chose lamivudine as an alternate treatment for the HBV-associated glomerulonephritis (GN). After 3-month treatment with oral lamivudine, resolution of the renal disease dramatically occurred together with improvement in liver function. To our knowledge, this is the first case of HBV-associated MPGN successfully treated with oral lamivudine therapy. The possible role of lamivudine in the treatment of HBV-associated GN is discussed.

Inappropriate antidiuresis associated with pituitary adenoma--mechanisms not involving inappropriate secretion of vasopressin.

We report an unusual case of inappropriate antidiuresis with undetectable vasopressin in an elderly man presenting with confusion due to severe hyponatremia. Further investigations led to the diagnosis of non-functional pituitary macroadenoma. The patient had normal thyroid and adrenal function. The abnormal water balance resolved promptly after transsphenoidal removal of the tumor, confirmed by a repeat water loading test. We conclude that inappropriate antidiuresis in the absence of excess vasopressin secretion may implicate mass effect from an underlying pituitary tumor.

Development of reliability - based design criteria for buildings under seismic load

Designs of buildings and structures for seismic loads are traditionally based on experience of the performance of structures in past earthquakes. Althugh the large uncertainty in the earthquqke loadings has long been recognized by engineers, it has not been fully accounted for in the code procedures other than in the selection of a design earthquake. Since the design earthquake is used in conjuntion with a series of factors to account for effects of structural period, site soil condition, inelastic, behavior, importance of the structures, etc., the reliability and safety of the final design remains unknow and undefined. The recent sentiment of the research community and design professionals is that there is a need for development of design procedures based on consideration of the physics of the problem and explicit treatment of the uncertainties. Such procedures may be used as the basis for development of next generation of buildings codes (AU)