Frequency of Hypoglycemia Assessed by Continuous Glucose Monitoring in Advanced CKD.

BACKGROUND: Hypoglycemia represents a risk for serious morbidity. We evaluated the prevalence and risk factors of hypoglycemia by continuous glucose monitoring (CGM) in patients with CKD with or without diabetes. METHODS: In this cross-sectional study, outpatients with CKD stages G3-G5 (including hemodialysis) and type 2 diabetes without CKD were enrolled and underwent intermittently scanned CGM measurements for 7 days. The burden of CGM-measured hypoglycemia was assessed using the 7-day sum of area over the curve with glucose levels <70 mg/dl and the sum of time spent <54 mg/dl. RESULTS: A total of 366 participants (148 participants with CKD and diabetes, 115 with CKD and without diabetes, and 103 without CKD and with diabetes) were included. Glucose levels of <54 mg/dl were observed in 41% of participants with CKD and diabetes, 48% of participants with CKD and without diabetes, and 14% of participants with diabetes and without CKD. However, only two participants reported hypoglycemic symptoms during CGM measurements, which were confirmed and documented by capillary blood glucose measurements. Between-group differences of 7-day area over the curve (<70 mg/dl) were as follows: hemodialysis group versus CKD stage G4 and G5 groups, -0.25 min·mg/dl per hour (95% confidence interval [CI], -6.40 to -0.59) P <0.001; CKD stage G4 and G5 groups versus CKD stage G3 group, -0.08 min·mg/dl per hour (95% CI, -0.0 to -0.50) P =0.15; and CKD stage G3 group versus diabetes without CKD group, -0.14 min·mg/dl per hour (95% CI, -0.0 to -0.20) P =0.01. In addition, the subgroup analysis of the diabetic or nondiabetic and at daytime or nighttime showed that the 7-day area over the curve (<70 mg/dl) and time spent (<54 mg/dl) was larger with worse kidney function. CONCLUSIONS: The lowering level of kidney function was strongly associated with the burden of hypoglycemia in patients with CKD.

[Ultra high-risk refractory multiple myeloma with a complex karyotype including t(14;19)].

A 78-year-old man was hospitalized because of rapid progression of chronic renal failure and diagnosed with multiple myeloma (MM) IgG-λ type ISS-III R-ISS-II with complex karyotype including t(14;19). Even after receiving bortezomib-based regimens, his renal failure progressed. He became dependent on dialysis, which was required three times a week. After introducing the daratumumab (DARA)-based regimen, his renal function improved, the frequency of dialysis decreased to twice a week, and the free light chain (FLC) ratio also improved. However, his myeloma eventually followed a refractory course; therefore, pomalidomide (POM)-dexamethasone (Pd) regimen was administered. Pd regimen had a marked effect and normalized the FLC ratio after three courses of the treatment. However, his myeloma reprogressed with multiple extramedullary masses and he became del(17p) positive; eventually, he died on the 470th day of disease. MM with t(14;19) is rare and has a poor prognosis with a highly aggressive course; however, early introduction of DARA or POM may provide long-term response.

Transarterial Interventional Therapy for Non-functioning Hemodialysis Access.

Transarterial vascular access interventional therapy (VAIVT) for non-functioning hemodialysis access has advantages over the venous approach because natural venous outflow through the fistula as well as the stump at the fistula site in total occlusion can be observed, and most strictures and/or occlusions can be treated via one access route. The brachial arterial approach is essential, but the radial arterial approach at the wrist is also necessary for certain patients. The transarterial approach can be applied to all VAIVTs; however, additional venous access is necessary in cases requiring a large device and those with unsuccessful traversal of the occluded segment via the arterial route. The high origin of the radial artery is a disadvantage of the transbrachial approach, and local hematomas are the most frequent complications.

A case of apolipoprotein E Toyonaka and homozygous apolipoprotein E2/2 showing non-immune membranous nephropathy-like glomerular lesions with foamy changes.

A 47-year-old Japanese man with mild proteinuria was treated with an ACE inhibitor and antiplatelet agent for 7 years. However, urinary protein levels increased and renal biopsy was performed. Eight out of 20 glomeruli showed global or segmental sclerosis with foamy changes or bubbles, but with a different appearance to typical foam cells or lipoprotein thrombi. "Spike" formation, as observed in membranous nephropathy (MN), was segmentally detected in methenamine silver-stained sections. In an immunofluorescence study, weak linear patterns for IgG and scanty deposits for C3 were observed in glomeruli, but were not specific for immunogenetic MN. An electron microscopy study showed highly dense deposits in the subepithelial, subendothelial, and mesangial areas, in which microbubbles appeared under a higher magnification. Since this case exhibited hypertriglyceridemia and cholesterolemia with high serum apolipoprotein E (apoE) clinically and homozygous apoE2/2 by apoE phenotype and genotype analyses, apoE2 homozygote glomerulopathy was diagnosed and various lipid-lowering agents, e.g., probucol, fenofibrate, and ezetimibe, were administered. However, renal dysfunction gradually developed and peritoneal dialysis was initiated 11 years after the diagnosis. ApoE Toyonaka (Ser197Cys) and homozygous E2/2 were recently identified by direct DNA sequencing. Therefore, non-immune MN-like lesions may develop with the combination of these apoE mutations.

Percutaneous transluminal angioplasty of a non-mainstream venous route to restore an occluded hemodialysis fistula.

PURPOSE: To report the usefulness of percutaneous transluminal angioplasty (PTA) of a non-mainstream venous route in an occluded native hemodialysis fistula when a mainstream outflow vein could not be traversed. MATERIALS AND METHODS: This cohort included seven patients with an occulted hemodialysis fistula with difficulty in traversing via a mainstream route. A non-mainstream vein near the occluded portion was traversed until it connected with a proximal large-sized vein and the route was dilated using a 4- or 5-mm balloon catheter. Metallic stent placement was performed, if necessary. Technical aspects and long-term patency was evaluated. RESULTS: PTA could be performed in all patients; however, stent placement was required in two because of residual stenosis and clotting. The clinical success rate of fistula restoration was 100 %. Fistula dysfunction recurred in six patients 17-668 days (mean ± standard deviation 229.3 ± 225.0) later. PTA was repeated in four patients, but not in two. The mean duration of the primary patency was 336.6 ± 417.2 days (range 17-1,190) and that of the secondary patency was 897.1 ± 801.4 days (range 17-2,230). CONCLUSION: PTA of a non-mainstream venous route is useful for restoring an occluded hemodialysis fistula when the mainstream outflow vein cannot be traversed.

Small needle puncture of a central venous occlusion in a hemodialysis patient that could not be traversed by a conventional technique.

A 75-year-old woman with hemodialysis-related right subclavian vein occlusion was referred to our hospital for retry of endovascular treatment. The occluded segment could not be crossed via either antegrade or retrograde approaches, including puncturing the obstruction with the stiff end of the guide wire. The obstruction was successfully punctured using a 75-cm long 21-G needle via the right median cubital vein and a metallic stent was placed to cover the occluded segment after balloon angioplasty. The recanalized segment was patent for 10 months until the patient's death from concomitant disease.

Technical success rates and long-term patency of endovascular treatment for occluded native hemodialysis fistulas: comparison between thrombotic occlusion and nonthrombotic occlusion.

PURPOSE: This study evaluated the technical success and long-term patency of endovascular treatment for occluded native hemodialysis fistulas caused by thrombotic occlusion (TO) and nonthrombotic occlusion (NTO). MATERIALS AND METHODS: This cohort included 96 consecutive occlusions (70 TOs and 26 NTOs) at the forearm. Clinical success and patency rates of endovascular treatment were calculated and compared between the TO and NTO groups. RESULTS: Overall clinical success rate was 91.6%; and primary, assisted primary, and secondary patency rates at 1, 2, and 3 years were 49.6%, 30.7%, and 28.3%, respectively; 73.8%, 48.3%, and 48.3%, respectively; and 80.7%, 72.3%, and 66.2%, respectively. Clinical success rates of the TO and NTO groups were 91.4% and 92.3%, respectively. The 1-, 2-, and 3-year primary, assisted primary, and secondary patency rates of the TO group were 54.4%, 29.3%, and 25.6%, respectively; 70.7%, 49.4%, and 49.4%, respectively, and 78%, 68.8%, and 64,2%, respectively. Those of the NTO group were 38.9%, 32.4%, and 32.4%, respectively; 81.2%, 47.3%, and 40.6%, respectively; and 87%, 80.3%, and 70.2%, respectively. There were no significant differences between the clinical success and patency rates of the two groups. CONCLUSION: Occluded native hemodialysis fistulas were restored with high frequency, without significant differences between clinical success and patency in the TO and NTO groups.

Renal involvement of polyarteritis nodosa: CT and MR findings.

BACKGROUND: To evaluate the imaging findings in patients with renal involvement of Polyarteritis nodosa (PN) to diagnose as early as possible. MATERIALS AND METHODS: Four patients diagnosed as having PN participated in the present study. Two patients underwent abdominal dynamic CT, one underwent only pre- and post-contrast CT, and the remaining patient underwent only noncontrast CT and MR imaging, including dynamic contrast study. RESULTS: The common findings of CT and MR imaging were diffuse enlargement, multiple small wedge-shaped less-enhanced areas on dynamic contrast study, and indistinctness of the margin between the cortex and medulla on equilibrium-phase CT. Renal arteriogram showed multiple microaneurysms on arterial phase image in all four cases, and PN was diagnosed. The common CT and MR findings of renal involvement of PN mimicked those of pyelonephritis, when microaneurysms were not demonstrated. CONCLUSION: The differentiation between PN and pyelonephritis on CT and MR imaging is difficult. Therefore, the radiologist should be familiar with the imaging findings of renal involvement of PN. When PN is suspected, angiography should be performed as early as possible to make a definite diagnosis.