Multi-Organ Relapse following COVID-19 in Myeloperoxidase-Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis: A Case Report.

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a complex systemic autoimmune disease characterized by small vessel vasculitis. Typically, the relapse rate is lower in patients with end-stage kidney disease (ESKD) than in those with chronic kidney disease, prior to dialysis. Here, we report a rare case of multi-organ relapse in a patient with myeloperoxidase (MPO)-AAV who underwent hemodialysis following coronavirus disease 2019 (COVID-19). A man in his 70s with type 2 diabetes and hypertension was undergoing maintenance hemodialysis for ESKD resulting from MPO-AAV glomerulonephritis. Following severe acute respiratory syndrome coronavirus 2 infection, the patient was hospitalized for persistent nausea and vomiting. No significant findings were observed, including in endoscopy. However, the patient experienced severe symptoms that hindered oral intake and was refractory to pharmacological therapy. Additionally, despite receiving antibiotics and antituberculosis treatment, the patient experienced persistent unexplained pleural effusion. Moreover, the patient's level of consciousness rapidly deteriorated during hospitalization. Although C-reactive protein levels and MPO-ANCA titers were elevated, no evidence of infection was detected on brain imaging or cerebrospinal fluid analysis. Therefore, we diagnosed this case as a relapse of AAV and promptly administered methylprednisolone pulse therapy and rituximab. Subsequently, all aforementioned symptoms in the patient improved, and the current ANCA levels remain negative. Thus, the relapse of AAV after COVID-19 is rare; however, it can present in several ways in patients undergoing dialysis. Therefore, clinicians should closely monitor ANCA titers and subtle symptoms, even in patients with dialysis-dependent AAV.

Comparison of Spiritual Needs between Patients with Progressive Terminal Kidney Disease and Their Family Caregivers.

Purpose: The purpose of this study was to compare differences in spiritual needs (SNs) and factors influencing SNs between patients with progressive terminal kidney disease and their family caregivers. Methods: An explorative comparative survey was used to identify the SNs of patients (N=102) with progressive terminal kidney disease undergoing hemodialysis and their family caregivers (N=88) at a general hospital located in Seoul, South Korea. The data were analyzed using descriptive statistics, the chi-square test, the independent t-test, one way analysis of variance, the Scheffé test, and multiple regression with dummy variables. Results: The SNs among family caregivers were higher than in the patient group. SNs were higher among those who were religious in both groups. Loving others was the highest-ranked sub-dimension in the patient group, followed in descending order by maintaining positive perspective, finding meaning, Reevaluating beliefs and life, asking "why?", receiving love and spiritual support, preparing for death, and relating to God. In the family group, the corresponding order was maintaining positive perspective, loving others, finding meaning, receiving love and spiritual support, preparing for death, relating to God, and asking "why?". The factors that had a negative influence on the level of SNs were not being religious in the patient group and having only a middle school level of education in the family group. Conclusion: The results of this study may serve as evidence that spiritual care for non-cancer patients' family caregivers should be considered as an important part of hospice and palliative care.

Tissue Doppler-derived E/e' ratio as a parameter for assessing diastolic heart failure and as a predictor of mortality in patients with chronic kidney disease.

BACKGROUND/AIMS: Diastolic dysfunction occurs frequently in patients with chronic kidney disease (CKD) and is associated with heart failure (HF) or mortality. We investigated whether the ratio of early diastolic mitral inflow velocity to early diastolic mitral annulus velocity (E/e' ratio), estimated using tissue Doppler imaging, has prognostic value for cardiovascular morbidity and all-cause mortality in patients with CKD. METHODS: For 186 patients with CKD of stages III to V, we obtained echocardiograms with tissue Doppler imaging. A 5-year follow-up of 136 patients was performed based on hospital records and telephone interviews. The enrolled patients (79 males and 57 females) were categorized into the following CKD subgroups: stage III (n = 25); stage IV (n = 22); and stage V (n = 89). RESULTS: The average follow-up period was 30.45 months and the mean age of the patients was 61.13 years. The mortality rate after 5 years was 60.0%. The causes of death were: sepsis, 21.9%; HF, 16.2%; and sudden death, 15.2%. Age (p = 0.000), increased C-reactive protein level (p = 0.018), and increased E/e' ratio (p = 0.048) were found to correlate with mortality. Age (p = 0.000), decreased ejection fraction (p = 0.003), and increased E/e' ratio (p = 0.045) correlated with cardiovascular event. CONCLUSIONS: The E/e' ratio can predict mortality and cardiovascular events in patients with CKD who have diastolic dysfunction.

Membranoproliferative glomerulonephritis following allogeneic hematopoietic stem cell transplantation.

Nephrotic syndrome after allogeneic hematopoietic stem cell transplantation has been increasingly described as a manifestation of chronic graft-versus-host disease (GVHD); however, GVHD-associated membranoproliferative glomerulonephritis is extremely rare. A 44-year-old man developed nephrotic syndrome 24 months after HSCT for acute lymphoblastic leukemia. The renal biopsy showed type I membranoproliferative glomerulonephritis. Salivary gland biopsy demonstrated mild lymphocytic infiltration, indicating chronic GVHD. Improvement of the proteinuria and recovery of renal function were achieved within 11 months of treatment with oral prednisolone and azathioprine.

Ischaemic enteritis in a patient with chronic renal failure: diagnosis and management decisions.

Ischaemic enteritis is rare in patients with chronic renal failure not on dialysis. Here we report a case of ischaemic enteritis in an 81-year-old woman with chronic renal failure secondary to hypertension (not dialysis dependent) who presented with acute onset of abdominal pain, non-bloody diarrhoea and subsequent oliguria. The abdominal CT with angiography showed diffuse segmental wall thickening and decreased perfusion of the long segment of the ileum, with decreased enhancement of the vessels that supply the distal ileum. The clinical diagnosis of ischaemic enteritis was made. The patient responded initially to total parenteral nutrition and intravenous antibiotics. After the initiation of haemodialysis, because of the oliguria, the ischaemic enteritis progressed to bowel infarction, and an open laparotomy was performed. This report illustrates some of the difficult therapeutic decisions in a patient with ischaemic enteritis and chronic renal failure.