Nephrotic range proteinuria: rare manifestation of scleroderma renal crisis.

The nephrotic range of proteinuria is uncommon in scleroderma renal crisis. This 46-yr-old woman with a medical history of scleroderma presented with very high blood pressure, a sudden elevation of serum creatinine, and proteinuria in the nephrotic range. Renal biopsy revealed onion-skin type of arterial changes with necrosis, confirming the presence of scleroderma nephropathy. Electron microscopy showed diffuse fusion of foot processes. Immunohistochemical staining (IHC) revealed increased expression in glomeruli of phosphorylated mammalian target of rapamycin (p-mTOR). These findings suggest that fusion of foot processes and activation of mammalian target of rapamycin-dependent pathways in podocytes are most likely responsible for the severe proteinuria in this patient with scleroderma nephropathy.

Fibrillary glomerulopathy secondary to light chain deposition disease in a patient with monoclonal gammopathy.

The pathologic manifestations of renal diseases related to monoclonal plasma cell dyscrasia include light chain deposition disease, the AL type of amyloidosis, and myeloma cast nephropathy. Light chain deposit disease (LCDD) is an uncommon condition in which monoclonal light chains are deposited in the glomeruli, tubules, and vessels causing varying degree of damage. We report a case of LCDD coincident with fibrillary glomerulonephropathy (FGN) in a 73-yr-old man with a diagnosis of monoclonal gammopathy of undetermined significance who presented with progressive renal insufficiency and mild proteinuria. The serum kappa light chain level was markedly raised. Immunofluorescent stains showed IgG along with C3 and kappa staining in glomeruli, but lambda staining was negative. Electron microscopic studies revealed diffuse punctuate-type deposits along the subendothelial areas. There were also scattered randomly oriented fibrils with a mean fibril thickness of 15-25 nm seen mainly in the glomerular mesangium, consistent with FGN. The congo red stain was negative on the histologic section. The present case illustrates that LCDD can progress to develop FGN in a patient with monoclonal gammopathy.

Outpatient erythropoietin administered through a protocol-driven, pharmacist-managed program may produce significant patient and economic benefits.

To assess the effect of a disease management program in anemia of chronic kidney disease (CKD), the authors reviewedthe records of all adults treated with epoetin alfa (EPO) at their institution between September 2003 and April 2006 and compared them with a group treated through a pharmacist-managed program with patients managed by PCPs in terms of time to target hemoglobin (Hb) (11-12.9 mg/dL), percent of Hb values maintained in target range, average weekly dose of EPO, and percent of iron-saturation (T-sat) values within target range (20%-50%) over a period of six months to one year. Although pharmacist-managed patients received lower weekly EPO doses than those managed by PCPs (6,698 vs. 12,000 units, respectively; P = .0001), they achieved goal Hb faster (47.5 vs. 62.5 days, P = .11) and maintained a higher percentage of Hb and T-sat values in target range (69.8% vs. 43.9%, P = .0001, and 64.8% (vs. 40.4%, respectively; P = .043). A pharmacist-managed program may present significant clinicaland economic benefits in anemia of CKD.

Breast cancer in elderly women: outcome as affected by age, tumor features, comorbidities, and treatment approach.

PURPOSE: The current work assessed the independent contributions of age, comorbidities, tumor features, and treatment approach to the outcome of elderly patients with breast cancer. PATIENTS AND METHODS: Records of consecutive women aged > or = 70 years with a histologic diagnosis of first invasive breast cancer between 1971 and 2001 and available medical information were reviewed. Restaging to the 2002 TNM system and comorbidity data abstraction were performed. Primary outcomes were overall survival (OS) and breast cancer-specific survival (BCSS). RESULTS: There were 992 patients with a median diagnosis age of 76 years, of whom 840 were approached with a curative intent. Significant comorbidities were recorded as none and > or = 3 in 13% and 44% of patients, respectively. The 5- and 10-year OS rates were 59% and 34%; corresponding BCSS rates were 74% and 62%, respectively. Of 693 patients who died during the study period, only 298 (43%) died from their tumors. Stage emerged as the strongest predictor determining OS and BCSS (P = 0.001). In curatively approached patients, age was the next dominant factor affecting survival length (P = 0.001). The comorbidities with significant effect on OS differed by stage and included heart failure, diabetes, and other common comorbidities in early tumors but only extremely debilitating ones in advanced-stage disease (P < 0.05). Significant favorable effect of systemic therapy emerged only in the univariate model. CONCLUSION: This study confirms tumor stage as the strongest predictor of survival in elderly patients with breast cancer. It also indicates a significant role for age and comorbidities that varies by stage. Treatment effect should be interpreted with caution because of the retrospective study nature.