Mycoplasma hominis bursitis in a simultaneous pancreas-kidney transplant recipient: case report and literature review.

Mycoplasma hominis can be isolated frequently from the genitourinary tract of some healthy individuals. On rare occasions, it acts as a pathogen in immunocompromised patients such as transplant recipients. Here, we describe the case of a 39-year-old man with end-stage kidney disease secondary to diabetic nephropathy who received a simultaneous pancreas-kidney transplant. He developed pancreatitis and arterial thrombosis 2 weeks post-transplant and required a pancreatectomy. His kidney allograft function remained normal. He developed severe left hip pain 2 weeks post-transplant with a trochanteric bursal effusion detected on magnetic resonance imaging. The effusion grew M. hominis. The patient was treated with 100 mg of doxycycline twice daily for 9 months with full resolution of the effusion at 4 months post-treatment. We also review all previously reported M. hominis infections in transplant recipients.

Atypical Haemolytic Uraemic Syndrome Associated with Clostridium difficile Infection Successfully Treated with Eculizumab.

Clostridium difficile infection is a rare precipitant of atypical haemolytic uraemic syndrome (aHUS). A 46-year-old man presented with watery diarrhoea following an ileocaecal resection. He developed an acute kidney injury with anaemia, thrombocytopaenia, raised lactate dehydrogenase, low haptoglobin, and red cell fragments. Stool sample was positive for C. difficile toxin B. He became dialysis-dependent as his renal function continued to worsen despite treatment with empiric antibiotics and plasma exchange. The ADAMTS13 level was normal consistent with a diagnosis of aHUS. The commencement of eculizumab led to the resolution of haemolysis and stabilisation of haemoglobin and platelets with an improvement in renal function.

Minimal change disease associated with newly diagnosed mantle cell lymphoma.

Mantle cell lymphoma (MCL) is a rare but aggressive form of non-Hodgkin's lymphoma. Involvement of the kidney is an infrequent occurrence in patients with MCL and can be the result of direct infiltration or paraneoplastic glomerulopathy. Proliferative glomerulonephritis, membranoproliferative glomerulonephritis and focal segmental glomerulosclerosis have previously been reported in association with MCL. We report a 55-year-old woman who developed nephrotic syndrome due to biopsy proven minimal change disease (MCD) in association with MCL. Proteinuria decreased with prednisolone treatment and MCD remains in remission without any immunosuppressant after the treatment of the underlying MCL.

Methylated arginines and nitric oxide in end-stage renal disease: impact of inflammation, oxidative stress and haemodialysis.

OBJECTIVES: To determine whether inflammation (C-reactive protein, CRP), oxidative stress (malondialdehyde, MDA) or haemodialysis (HD) affect associations between asymmetric (ADMA), symmetric (SDMA) dimethylarginine, NG-monomethyl-L-arginine (L-NMMA) and nitrite/nitrate (NOx) in end-stage renal disease (ESRD). METHOD: Metabolites were measured pre-HD, after 1 hour and end-HD in 40 ESRD patients (age 63 ± 14 years). RESULTS: Positive associations between NOx and ADMA (p = 0.04), SDMA (p < 0.001) and L-NMMA (p = 0.04) were observed pre-HD. Associations weakened during HD but were not significantly influenced by CRP or MDA. CONCLUSIONS: HD, oxidative stress or inflammation did not significantly affect the positive associations between methylated arginines and NOx in ESRD.

Leflunomide for inflammatory arthritis in end-stage renal disease on peritoneal dialysis: a pharmacokinetic and pharmacogenetic study.

OBJECTIVE: To study the pharmacokinetics and pharmacogenetics of leflunomide and document its efficacy and safety in the treatment of inflammatory arthritis in a patient with end-stage renal disease (ESRD) who was on peritoneal dialysis. CASE SUMMARY: Therapy for a 78-year-old man with ESRD who required peritoneal dialysis was started with leflunomide 10 mg/day for psoriatic arthritis. The dosage was increased to 20 mg/day after 3 months. Monitoring was continued until the patient's unexpected death from myocardial infarction at 8 months. Total and unbound teriflunomide (the active metabolite of leflunomide) concentrations were measured by liquid-chromatography-tandem mass spectrometry. Genotyping for CYP2C19 and ABCG2 polymorphisms, both known to influence teriflunomide pharmacokinetics, was also performed. DISCUSSION: Total concentrations of teriflunomide varied between 5.2 and 23.2 mg/L, while unbound concentrations varied between 0.0306 and 0.1468 mg/L. The unbound fraction varied between 0.367% and 0.71%. Teriflunomide was found in the dialysate at a concentration of 0.0981 mg/L. A single CYP2C19 loss of function allele was present, as was wild-type ABCG2. Leflunomide appeared to be therapeutically effective, as evidenced by a reduction in daily prednisolone dosage from 20 mg to 6mg; the Disease Activity Score in 28 joints (DAS28) was 5.46 at enrollment and 4.03 after 7 months. Health Assessment Questionnaire-Disability Index improved from 0.5 to 0.125 at 7 months. Numerous significant adverse events that were considered unrelated to leflunomide occurred. CONCLUSIONS: Dose adjustment for leflunomide does not appear to be required in the context of ESRD requiring peritoneal dialysis. We present novel evidence that a small amount of teriflunomide is removed by peritoneal dialysis. This case suggests that leflunomide is safe to use as therapy for inflammatory arthritis despite the presence of ESRD requiring peritoneal dialysis.

Bladder Rupture following Conversion to Enteric Drainage after Pancreatic Transplantation.

Complications associated with bladder-drained pancreatic transplant are not uncommon and include urinary tract infections and reflux pancreatitis. Bladder rupture with peritoneal leak is a rare complication after pancreatic transplantation and can present as an acute abdomen with rapidly deteriorating renal function. We describe the first case of a urine leak into the peritoneal cavity occurring after conversion from bladder to enteric drainage. A high index of suspicion is required to diagnose such a complication.

Successful treatment of calcific uremic arteriolopathy with sodium thiosulfate in a renal transplant recipient.

Abstract Calcific uremic arteriolopathy (CUA) is a rare but life-threatening disorder of arteriolar calcification. It frequently leads to severe ischemia, intense pain, and tissue necrosis with non-healing skin ulcerations. CUA usually occurs in patients with chronic kidney disease (CKD), especially those on dialysis, and its occurrence is rare in kidney transplant recipients. The treatment of this disorder is not clearly defined, and no randomized prospective trials are available. Treatment has focused on optimizing dialysis treatment, control of bone mineral parameters, wound care, experimental anticalcification therapies-using bisphosphonates, cinacalcet, parathyroidectomy, and hyperbaric oxygen. Such treatments are based on the pathophysiological considerations and evidences from case reports or series. Recently, several cases have reported about the emerging benefits of intravenous sodium thiosulfate (STS) in the treatment of CUA. STS has resulted in rapid pain relief, wound healing, and prevention of death. We report a case of CUA in a 63-year-old Caucasian man with a functioning renal allograft. In this patient, intravenous STS was administered for 8 months, which was the principal therapy, which resulted in complete resolution of the CUA and skin healing.

Malignant pleural mesothelioma with associated minimal change disease and acute renal failure.

Paraneoplastic manifestations in malignant pleural mesothelioma are rare. We report a case of malignant pleural mesothelioma associated with minimal change disease (MCD). A 58-year-old man with occupational exposure to asbestos presented with severe peripheral edema, heavy proteinuria, and acute renal failure shortly after the diagnosis of mesothelioma had been confirmed. The renal biopsy demonstrated MCD. The underlying pathogenesis of this association remains unknown.

Bilateral renal inflammatory pseudotumour effectively treated with corticosteroid.

Inflammatory pseudotumour (IPT) is a rare disease of unknown cause that most commonly involves the lung but can occur in almost any site in the body. Occurrence in the kidneys is very rare and bilateral renal involvement even rarer. There are 34 previously reported cases in the English-language medical literature between 1966 and 2008. Herein we report a case of IPT infiltrating both kidneys. We have also reviewed the clinical features, radiological findings, treatment and outcome of renal IPT. Clinical features at presentation are commonly non-specific. Features on imaging are inadequate to make a diagnosis of IPT or to clearly distinguish it from malignancy. Consequently diagnosis has frequently been made after nephrectomy and on a few occasions with the aid of percutaneous or open biopsies. The majority of renal IPT (83%) have been treated with nephrectomy and those cases with bilateral IPT have received corticosteroids.

Effects of pre- vs. intra-dialysis folic acid on arterial wave reflections and endothelial function in patients with end-stage renal disease.

BACKGROUND: Haemodialysis (HD) is associated with the acute loss through the dialysis membrane of biochemical factors either enhancing [folic acid (F)] or impairing [asymmetric dimethylarginine (ADMA)] arterial function. Changes in these opposing factors might explain the absence of significant modifications in arterial function during HD. We speculated that intra-HD, instead of pre-HD, F administration would provide beneficial effects on arterial wave reflections and endothelial function by preventing HD-induced F loss. METHODS: Arterial wave reflections [augmentation index (AIx), pulse-wave analysis], endothelium-dependent vasodilation (salbutamol-mediated changes in AIx) and plasma concentrations of F and ADMA were measured pre-HD and end-HD in 10 patients (age 67.7 +/- 10.3 years). Each subject received F 5 mg either pre-HD or intra-HD in two separate studies 2-4 weeks apart, in an open-label randomized cross-over trial. RESULTS: Pre-HD F administration did not prevent significant reductions in F during HD (end-HD vs. pre-HD, -865 +/- 465 nmol l(-1), P < 0.001), but no significant changes in AIx (+1.4 +/- 5.7%) or salbutamol-mediated AIx modifications (+0.4 +/- 5.5%) were observed. By contrast, intra-HD F administration was associated with significant increases in F (+298 +/- 283 nmol l(-1), P = 0.010) and a significant reduction of AIx (-4.7 +/- 7.2%, P = 0.013), but no effects on salbutamol-mediated AIx changes (+1.5 +/- 4.4%). There was a trend towards greater HD-induced reductions in plasma ADMA concentrations with intra-HD F administration (P = 0.066). CONCLUSIONS: Intra-HD F administration reduces arterial wave reflections but not endothelial function during HD. Given the prognostic significance of arterial wave reflections in HD patients, the timing of F administration is important in the design of interventional trials in this cohort.

Symmetric dimethylarginine is an independent predictor of intradialytic hypotension.

BACKGROUND: Hemodialysis (HD) is associated with significant reductions in the plasma concentrations of the nitric oxide (NO) inhibitors N(G)-monomethyl L-arginine (L-NMMA), asymmetric dimethylarginine (ADMA), and symmetric dimethylarginine (SDMA). We sought to determine whether elevated concentrations of these NO inhibitors pre-HD and/or their acute decrease during HD might mediate intradialytic hypotension (IDH). METHODS: Systolic blood pressure (SBP), L-arginine, L-NMMA, ADMA, and SDMA were measured at the beginning (pre-HD) and at the end (end-HD) in 52 consecutive HD patients (age 64.4 +/- 13.4 years). IDH was defined as a SBP reduction of >20 mm Hg end-HD vs. pre-HD. RESULTS: Fourteen patients demonstrated IDH. The mean SBP reduction during HD in this group was -35 +/- 13 mm Hg compared to an increase of +2 +/- 12 mm Hg among the 38 patients without IDH (no-IDH). Baseline demographic, clinical, and biochemical parameters did not differ between the IDH and no-IDH groups. However, the IDH group had higher pre-HD SBP (155 +/- 17 vs. 132 +/- 14 mm Hg, P < 0.001), pre-HD plasma SDMA concentrations (1.98 +/- 0.61 vs. 1.64 +/- 0.46 micromol/l, P = 0.04), and greater SDMA reductions during HD (-0.78 +/- 0.43 vs. -0.56 +/- 0.32 micromol/l, P = 0.06) than the no-IHD group. After adjusting for pre-HD SBP, the odds of IDH occurring were higher with increased pre-HD SDMA plasma concentrations (OR = 1.31 per 0.1 micromol/l SDMA increase; 95% CI = 1.04-1.65, P = 0.02) and with decreases in SDMA during HD (OR = 1.39 per 0.1 micromol/l SDMA decrease; 95% CI = 1.02-1.91, P = 0.04). CONCLUSION: Increased pre-HD SDMA plasma concentrations and greater SDMA reductions during HD independently predict IDH after adjusting for demographic and clinical variables, pre-HD SBP, and other methylated forms of L-arginine.