Lupus nephritis emerging during remission of minimal change disease.

INTRODUCTION: Rare cases of association between lupus nephritis (LN) and minimal changes nephrotic syndrome (MCNS) were described. Some authors suggest that this association, taking into account the low prevalence of both diseases, may not be a simple coincidence. Several pathophysiological hypotheses have been proposed to explain this association, including a potential central role of T lymphocytes. CASE REPORT: We describe the case of a 21 years-old female patient who initially presented with isolated nephrotic range proteinuria. She had no evidence of systemic involvement and Immunological tests were negative, including anti-neutrophil antibodies (ANA) and anti-double-stranded DNA antibodies (Anti-dsDNA). Renal biopsy showed normal glomeruli under light microscopy and no significant deposits were found in immunofluorescence studies. She was diagnosed to have MCNS and responded to a short course of steroids. She remained in remission for three years, after which she presented again with nephrotic-range proteinuria accompanied by clinical signs of systemic involvement. During her second presentation, she fulfilled the diagnostic criteria of systemic lupus erythematosus (SLE) and another kidney biopsy showed class-V lupus nephritis. She was treated with pulse steroids followed by oral prednisolone and mycophenolate mofetil, with good clinical response. CONCLUSION: This case indicates that relapses of MCNS should be carefully investigated in the right setting to avoid missing a systemic disease such as SLE.

Acute tubulo-interstitial nephritis with positive anti-neutrophil cytoplasmic antibodies.

INTRODUCTION: Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis involving the kidney usually comprises pauci-immune, necrotizing glomerulonephritis with crescents. Mononuclear tubulo-interstitial infiltrates are common in ANCA associated vasculitis, but these have usually been described in conjunction with glomerulitis. Acute tubulo-interstitial nephritis (ATIN) is a common cause of acute kidney injury that is most frequently induced by drugs or infections. Idiopathic ATIN has rarely been reported in association with the presence of a positive ANCA. These two entities seem to share a common immunological basis. CASE REPORT: We report a 75 years-old male patient who presented with acute kidney injury and his serum tested positive for p-ANCA by indirect immunofluoresence with a titer of 1/320. Testing by ELISA demonstrated anti-myeloperoxidase (MPO) specificity with a level of 28.8 IU/mL. His kidney biopsy showed features of ATIN with no glomerular involvement. Treatment with corticosteroids led to improvement of his kidney function and serology for ANCA became negative. In this case report ATIN seems to be associated with ANCA positivity, in the absence of other obvious causes for the acute tubulo-interstitial insult. CONCLUSION: ATIN can be associated with positive ANCA without features of renal-limited vasculitis or systemic vasculitis. This can occur in the absence of drug exposure. The outcome in our case was favorable with corticosteroid therapy.

Applying sodium profile with or without ultrafiltration profile failed to show beneficial effects on the incidence of intradialytic hypotension in susceptible hemodilaysis patients.

INTRODUCTION: Intra-dialytic hypotension (IDH) is a common complication during hemodialysis (HD) treatment. Previous studies have reported that modulating dialysate sodium concentration combined or not with modulation of ultrafiltration (UF) rate may reduce the incidence of IDH. The aim of the present study was to evaluate the effect of sodium and UF profiles on the occurrence of intra-dialytic complications and dialysis quality. METHODS: From a total of 64 patients, we selected 18 patients who suffered from recurrent IDH. Every patient received ten HD sessions utilizing each of the following treatments: (1) CONTROL: constant sodium concentration and UF rates. (2) Sodium and UF profiles: a linearly decreasing sodium concentration combined with a linearly decreasing UF rate. (3) Sodium profile: decreasing sodium concentration with constant UF rate. RESULTS: Fourteen patients completed the study protocol. The incidence of IDH, mean inter-dialytic weight gain and the delivered dialysis dose were not different between the three treatments. However, symptomatic episodes of IDH were more commonand pre-dialysis systolic blood pressure was higher during the second and third treatment modalities compared to controls. Isolated sodium profile was associated with more malaise and less achievement of target session duration compared to the other two treatments. Isolated sodium profile was associated with less achievement of target UF while combined sodium and UF profiles were associated with more achievement of target UF compared to controls. CONCLUSION: Our results indicate that sodium profile with or without UF profile does not have a beneficial effect on the incidence of IDH, achievement of target session duration or the delivered dialysis dose. Keywords : Sodium Profile; Ultrafiltration; Intradialytic Complications.