Refractory ascites as a presenting feature of extramedullary plasmacytoma in an end-stage renal disease patient with HIV infection.

Refractory ascites as the only presenting feature of an extramedullary plasmacytoma complicating end-stage renal disease and HIV infection has not been described yet. We describe a case of a 39-year-old female with HIV-associated nephropathy manifesting with ascites formation after transition from peritoneal dialysis (PD) to hemodialysis (HD). Earlier on, she received cycler-assisted PD for 5 years uneventfully. A few weeks after HD transition, a striking refractory ascites developed requiring multiple paracenteses (5 - 7 L every second week). Serum protein electrophoresis showed hypoalbuminemia with only small amount of monoclonal IgG-κ at 0.30 g/dL. Serum immunofixation electrophoresis showed polyclonal immunoglobulins with polyclonal light chains. Both κ and λ light chains were increased, at 66.86 mg/dL (reference range: 0.33 - 1.94) and 18.55 mg/dL (reference range: 0.57 - 2.63), respectively, with a ratio of 3.6 (reference range: 0.26 - 1.65). However, an ascitic fluid analysis showed a marked increase in plasma cells with a κ : λ ratio greater than 5 : 1. Omental biopsy confirmed κ-restricted plasma cells. Multiple myeloma work-up with skeletal survey showed no evidence of focal osseous lesions, while bone marrow aspiration and biopsy also remained unremarkable. Accordingly, the diagnosis of omental extramedullary plasmacytoma with malignant ascites was confirmed. Conversion from PD to HD may unmask an underlying pathology favoring ascites formation.

Membranoproliferative glomerulonephritis associated with influenza A infection.

A 24-year-old man with normal renal function developed influenza A with subsequent onset of hematuria, proteinuria, hypocomplementemia, hypertension and acute kidney injury. Renal biopsy showed mesangial hypercellularity, intratubular red blood cell casts, mesangial immunoglobulin M and C3 deposition, arterial C3 and C1q deposition, and foot process effacement most consistent with membranoproliferative glomerulonephritis. Six months after presentation, all manifestations of the glomerulonephritis resolved. We report the only documented case of membranoproliferative glomerulonephritis associated with influenza A is reported.

Automated reporting of estimated glomerular filtration rate alters referral patterns to a nephrology clinic.

An estimated 11% to 25% of adults in the United States have chronic kidney disease (CKD). In 2002, the National Kidney Foundation published a 5-stage classification of CKD based on estimated glomerular filtration rate (eGFR) intending to improve identification and management of prevalent cases (National Kidney Foundation, Am J Kidney Dis. 2002;39:S1-266). Nephrologists anticipated that the reporting of estimated GFR would improve early detection of CKD. The authors hypothesized that automatic eGFR reporting in our institution would subsequently result in increased new nephrology outpatient referrals at an earlier stage of CKD. The authors found that the proportion of referrals identifying earlier stages of CKD (eGFR greater than 45 mL/min) increased significantly for 2 years following the institution of eGFR reporting but was not sustained (P = 0.018); this trend was most obvious in African American women. No significant trend was seen with respect to age. The authors discuss potential reasons for automated eGFR reporting not leading to a sustained increase in nephrology referrals.