The effects for inflammatory responses by CPP with different colloidal properties in hemodialysis patients.

Calciprotein particles (CPPs) are colloids composed of solid-phase calcium-phosphate and serum protein fetuin-A. CPPs form a polydispersed system with different particle size and density. CPPs with specific physical properties can induce calcification and innate immune responses in cultured cells. In hemodialysis patients, blood CPP levels were reported to correlate with vascular calcification and inflammation. However, little is known about relation between these disorders and physical properties of CPPs. Here, we show that the association between physical properties of plasma CPPs and serum levels of inflammatory cytokines/chemokines in 78 hemodialysis out-patients by cross-sectional study. Patients with cardiovascular disease (CVD) had significantly higher high density CPP (H-CPP) levels than patients without CVD but not low density CPP (L-CPP). Seven cytokines/chemokines (EGF, eotaxin, IL-8, IP-10, MCP-1, MIP-1, MIP-1ß and TNFα) were detectable in the serum samples from > 95% of the patients. In multivariate regression analysis, H-CPP was positively associated with eotaxin after adjusting for age, gender, smoking, serum phosphate and FGF23. L-CPP was negatively associated with IL-8 after adjusting for age, gender, serum albumin, phosphate and FGF23. High H-CPP levels were associated with pro-inflammatory response, whereas L-CPPs were associated with anti-inflammatory response. CPPs with different physical properties may impact differently on pathophysiology in HD patients.

Sternocostoclavicular Hyperostosis: An Insufficiently Recognized Clinical Entity.

A 79-year-old male chronic hemodialysis patient with no history of central venous catheterization was referred to our hospital with progressive swelling of the left upper limb ipsilateral to a forearm arteriovenous fistula. Radiological assessments revealed marked hyperostosis in the ribs, sternum, and clavicles with well-developed ossification of the sternocostoclavicular ligaments. Such characteristic structural abnormalities and our failure to identify the left subclavian vein with contrast material despite the abundant dilated collaterals in the left shoulder area encouraged us to diagnose our patient with sternocostoclavicular hyperostosis (SCCH) complicated by central vein obstruction. The structural impact of the sternocostoclavicular region as a potential risk for inducing central vein obstruction and the diagnostic concerns of SCCH in this patient are also discussed.

Challenges of caring for an advanced chronic kidney disease patient with severe thrombocytopenia.

An autogenous arteriovenous fistula has been considered to be the optimal form of vascular access for hemodialysis (HD) in the field of nephrology. Nevertheless, the decision regarding the type of access, whether it be an arteriovenous fistula, an arteriovenous graft, or a central venous catheter, must still be individualized. In the present report, we describe the case of a female patient with advanced chronic kidney disease (CKD) associated with a hemostatic disorder. Despite the exhausted peripheral vasculature, she required recurrent platelet transfusions for severe thrombocytopenia due to aplastic anemia. The goal of care for this patient was to optimize the dialysis treatment without increasing the bleeding risk. Various concerns regarding the therapeutic conundrums encountered in the case are also discussed.

Serial Tc-99m MAG3 renography evaluating the recovery of acute kidney injury associated with minimal change nephrotic syndrome.

Acute kidney injury (AKI) is a well-recognized complication of minimal change nephrotic syndrome (MCNS). Previous reports support the concept that AKI associated with MCNS is reversible; however, information regarding the hemodynamic basis of AKI in MCNS is insufficient. We herein describe a case of AKI in a man with MCNS. In this case, monitoring the longitudinal changes in renal perfusion using serial Tc-99m-MAG3 renal scanning was beneficial for evaluating the pathophysiological background associated with the development of AKI. The potential impact of serial renal scanning in MCNS patients with AKI will also be discussed.

A case of IgG4-related tubulointerstitial nephritis with left hydronephrosis after a remission of urinary tract tuberculosis.

IgG4-related systemic disease encompasses multi-organ disorders, including tubulointerstitial nephritis. This disease is accompanied by a high serum IgG4 concentration and IgG4-positive plasma cell infiltration. We herein describe a 63-year-old woman with renal failure and dryness of the eyes and mouth, who had been treated with antituberculosis agents for urinary tract tuberculosis. She had a negative finding for a PCR analysis for Mycobacterium tuberculosis, a positive QuantiFERON-TB test, high serum IgG4 concentrations (2,660 mg/dl), and low serum IgM and IgA concentrations (34 and 82 mg/dl, respectively). Imaging tests revealed swelling in the submandibular glands, pancreas, and right kidney. A renal biopsy showed IgG4-positive plasma cell infiltration in the interstitium and tubular atrophy. This case was diagnosed as IgG4-related systemic disease. Corticosteroid therapy improved renal failure and swelling in the submandibular glands, pancreas, and right kidney. The case suggests that an abnormal reaction to tuberculosis may be associated with a predominance of type-2 helper T-cell immunity, thus resulting in IgG4-related systemic disease.

Is there a link between the structural impact of thoracic outlet and the development of central venous stenosis?

Central venous stenosis (CVS) is a serious complication for chronic hemodialysis (HD) patients. Previous reports of CVS have focused on prior central venous catheterization, because of the higher prevalence and potential for prevention of such an event. However, recent studies have demonstrated that CVS may also develop without a history of central venous catheterization. Although information about the etiological backgrounds regarding the development of CVS without previous central venous catheterization have gradually accumulated, the clinical impact of the chronic compression of the central venous system by the surrounding structures, which may likely determine the central venous susceptibility to CVS, remains poorly understood. This study proposes the hypothesis that the combination of chronic venous compression at the level of thoracic outlet characterized by the natural physique and elevated venous flow induced by the creation of vascular access should be evaluated as a potential factor for the development of CVS, since they may accelerate the development of venous stenosis, presumably through the stimulation of intimal hyperplasia, and thereby the subclavian venous susceptibility to CVS should be determined.

Balloon-assisted creation and maturation of an arteriovenous fistula in a patient with small-caliber vasculature.

The major problem associated with the creation of an arteriovenous fistula (AVF), which is the optimal form of vascular access for hemodialysis, is the fact that fistulas do not necessarily mature into a usable vascular access, requiring subsequent revision and construction of another access. The caliber of the vessels used for fistula creation is a pivotal factor predicting the presumable maturation of the constructed fistula, and veins less than 2.5 mm in diameter have poor outcomes. This report describes the balloon-assisted creation and maturation of an autogenous radial-cephalic AVF in a patient with a small-caliber vein and a radial artery measuring approximately 2 and 1.5 mm in diameter, respectively. The clinical impact of percutaneous radiological intervention for expediting the maturation of an autogenous AVF with small-caliber vessels is also discussed.

Central venous stenosis among hemodialysis patients is often not associated with previous central venous catheters.

It is widely assumed that central venous stenosis (CVS) is most commonly associated with previous central venous catheterization among the chronic hemodialysis (HD) patients. We evaluated the validity of this assumption in this retrospective study. The clinical records from 2,856 consecutive HD patients with vascular access failure during a 5-year period were reviewed, and a total of 26 patients with symptomatic CVS were identified. Combined with radiological findings, their clinical characteristics were examined. Only seven patients had a history of internal jugular dialysis catheterization. Diagnostic multidetector row computed tomography angiography showed that 7 of the 19 patients with no history of catheterization had left innominate vein stenosis due to extrinsic compression between the sternum and arch vessels. These patients had a shorter period from the time of creation of the vascular access to the initial referral (9.2 ± 7.6 months) than the rest of the patients (35.5 ± 18.6 months, p = 0.0017). Our findings suggest that cases without a history of central venous catheterization may not be rare among the HD patients with symptomatic CVS. However, those still need to be confirm by larger prospective studies of overall chronic HD patients with symptomatic CVS.

Accelerated recovery from Candida peritonitis of enteric origin by early surgical drainage in a peritoneal dialysis patient.

A 62-year-old man on continuous ambulatory peritoneal dialysis was transferred to our hospital with recurrent abdominal pain and a cloudy peritoneal effluent. Three weeks before the transfer, his symptoms were successfully treated with broad-spectrum antibiotics. However, their effectiveness was lost for his recurrent symptoms. Fungal peritonitis was diagnosed because of an increased white blood cell count in the peritoneal fluid on admission and isolation of Candida albicans from a peritoneal fluid culture. Intravenous fos-fluconazole was immediately started, although it was ineffective for his deteriorating symptoms. The concomitant isolation of Candida albicans in a stool culture suggested that fungal peritonitis had an enteric origin. An emergency laparotomy revealed multiple diverticulosis and sigmoid colon diverticulitis. A surgical drainage was performed in addition to peritoneal catheter removal. Postoperatively, the patient's symptoms improved rapidly and there were no signs of recurrence with continuous administration of fos-fluconazole. Surgical drainage accelerated the recovery from fungal peritonitis. This patient is the first case showing the usefulness of stool culture in the diagnosis of fungal peritonitis secondary to prior bacterial peritonitis. This case also demonstrated the importance of laparotomy to confirm the enteric origin of the fungus, and the efficacy of early surgical drainage for the treatment.

Nephrotic syndrome and renal failure in a patient with metastatic breast cancer.

This report presents a case of nephrotic syndrome and renal failure that developed in a 53-year-old female with metastatic breast carcinoma. She was diagnosed to have osteolytic bone metastases 5 years prior to admission, and had been administered pamidronate with a total dose of approximately 6800 mg. A renal biopsy revealed tubulointerstitial damage and marked wrinkling and retraction of the glomerular basement membrane with hypertrophy and hyperplasia of the epithelial cells, compatible with the collapsing form of focal segmental glomerulosclerosis (FSGS). Despite the discontinuation of pamidronate after admission, her renal function gradually decreased. She was finally managed with continuous palliative care for advanced malignancy through a shared effort, and died 96 days after undergoing the renal biopsy. Although the clinical impact of the pamidronate-associated kidney injury on the longitudinal changes in renal function remains to be delineated, it is therefore reasonable to consider that the collapsing FSGS associated with tubulointerstitial damage may have resulted in the irreversible renal injuries that were observed in the current case. Further studies and accumulated experience with renal biopsy are required to better determine the relationship between pathological alterations and prognostic characteristics among patients with pamidronate-associated renal impairments.

Renal failure caused by plasma cell infiltration in multiple myeloma.

We report on a case of severe renal failure in a 61-year-old female with multiple myeloma (MM). Two months prior to admission, the patient was diagnosed to have anemia and progressive renal failure associated with urinary Bence Jones protein and was referred to our hospital. A bone marrow biopsy revealed 40% plasma cells with κ light chain restriction. Thus, she was considered to have MM. A renal biopsy revealed neoplastic plasma cell infiltration within the kidney, moderate interstitial fibrosis, tubular atrophy, and punctate, electron-dense material along the peripheral capillary walls, tubular basement membrane, and in the interstitium of the kidney. This suggested that a combination of compression of the tubules and the microvasculature by the infiltrative process, and local light chain deposition-mediated tissue damage might be implicated in the development of renal failure in this patient. Despite a remission of bone marrow plasmacytosis with a bortezomib-based regimen, her renal function gradually deteriorated and a periodic hemodialysis program was finally required. Although the clinical impact of the direct kidney infiltration of neoplastic plasma cells on the longitudinal changes in renal function remains to be delineated, it is reasonable to consider that the infiltration of neoplastic plasma cells associated with local light chain depositions may result in irreversible renal injuries. Obviously, further studies and accumulation of additional experience with renal biopsy are required to better determine the precise and prognostic relationship between renal outcome and morphological alterations among MM patients with varying degrees of renal impairment.

Serum adiponectin and markers of endothelial injury in hemodialysis patients with arteriosclerosis obliterans.

BACKGROUND: Arteriosclerosis obliterans (ASO) in hemodialysis patients is the dominant cause of morbidity evolving from arteriosclerosis. Adiponectin is an adipose-derived cytokine which, because of its modulation of endothelial adhesion molecules, has potential anti-inflammatory and anti-atherogenic properties. However, the implications of adiponectin and endothelial function in ASO of hemodialysis patients has not been fully elucidated. METHODS: In this study we measured serum levels of adiponectin, adhesion molecules (VCAM-1 and ICAM-1), and an endothelial cell injury marker (CD146) in patients with ASO. We sought to determine clinical and laboratory correlates of ASO in ESRD patients. A total of 80 hemodialysis patients and 82 patients with normal serum creatinine levels were enrolled. Serum levels of adiponectin, ICAM-1, VCAM-1, and CD146 were measured by ELISA. RESULTS: Serum adiponectin levels in 41 hemodialysis patients with ASO were significantly lower than in 39 patients without ASO. Serum CD146 levels in hemodialysis patients with ASO were significantly higher than in patients without ASO. There were no significant differences between levels of ICAM-1 and VCAM-1 in these two groups. Similar results were obtained for patients with normal renal function. Serum adiponectin was related to hemodialysis duration and BMI in hemodialysis patients. In patients with normal renal function, adiponectin was related to HDL-cholesterol, triglyceride, and ICAM-1. CONCLUSION: A decrease in serum adiponectin levels and an increase in serum CD146 may be closely associated with the development of ASO, regardless of renal function. However, there are different mechanisms determining serum adiponectin levels in patients with normal kidney function and in hemodialysis patients.

Rapid formation of Aspergillus mycetoma in a patient receiving corticosteroid treatment. Serial radiographic observation over two months.

This study presents the case of rapidly progressing pulmonary aspergillosis in a 47-year-old woman who had healed cavitations of pulmonary tuberculosis in the right upper lobe. She had been treated for pulmonary tuberculosis seven years prior to admission. The initial manifestations of the disease on admission included cough, dyspnea, hemoptysis, pulmonary infiltrate, and renal failure. As anti-myeloperoxidase anti-neutrophil cytoplasmic antibodies (MPO-ANCA) were positive, she was diagnosed with ANCA-associated vasculitis and treated with corticosteroids. This treatment resulted in remission of the vasculitis. However, she developed new pulmonary symptoms and an enlarged cavitary lesion associated with the rapid formation of a fungal, ball-shaped shadow that was serially observed by radiological analysis. Pulmonary resection was finally performed because of acute progressive respiratory failure due to massive recurrent hemoptysis. A subsequent pathological analysis revealed a mass of hyphae with acute-angle branching, features consistent with Aspergillus, within the cavitary lesion, and she was diagnosed with pulmonary aspergillosis. The rapid development of pulmonary aspergillosis associated with the formation of an Aspergillus mycetoma should be attributed to the loss of normal immune mechanisms due to immunosuppressive treatment.

A case of recurrent renal failure associated with metabolic alkalosis induced by protracted vomiting.

We describe a case of recurrent deterioration of renal function in a 54-year-old man who was found to have metabolic alkalosis, with a maximum PaCO(2) of 73.9 mmHg and a bicarbonate concentration of 55.3 mmol/l. He had a gradual exacerbation of nausea and vomiting due to atrophic gastritis, with a scarred, deformed pyloric part of the stomach and a duodenal bulb secondary to chronic peptic ulcer. His metabolic alkalosis and deteriorated renal function were corrected by intravenous saline with or without potassium chloride. However, his recovered creatinine clearance was at most 60 l/day (41.6 ml/min). A renal biopsy revealed cellular infiltration of mononuclear cells and atrophic change in the tubulointerstitium, suggesting chronic interstitial nephritis. Latent renal insufficiency and dehydration induced by protracted vomiting may easily induce a rapid and recurrent deterioration of renal function, and control of vomiting seemed to be the cardinal measure. Initially, his nausea and vomiting seemed to be successfully controlled by medication, however, they later became persistent and surgical correction of the stomach was carried out. Postoperative recovery was smooth, and the patient's vomiting and recurrent deterioration of renal function finally settled.