Gaps in Modern Heart Failure and Chronic Kidney Disease Research.

Heart failure and chronic kidney disease are common conditions and often coexist. Modern clinical trials are not entirely representative of heart failure patients in the community with respect to age and sex. Despite this, another group of heart failure patients, those with advanced chronic kidney disease, are even less represented in modern clinical trials. This review summarises the evidence for heart failure therapies across age, sex and severity of chronic kidney disease, and outlines the need for further research in these populations.

Serum CA125 a potential marker of volume status for peritoneal dialysis patients?

INTRODUCTION: Serum cancer antigen 125(SeCA125) has been reported to be increased in patients with heart failure and correlate with both extracellular water (ECW) overload and poor prognosis. Ultrafiltration failure and ECW overload are a major cause of peritoneal dialysis (PD) technique failure. We wished to determine whether SeCA125 could also be a marker of volume status in PD patients. METHODS: We contemporaneously measured SeCA125, serum N terminal brain natriuretic peptide (NTproBNP) and ECW by bioimpedance in adult PD patients attending for outpatient assessment of peritoneal membrane function. RESULTS: The median SeCA125 was 19 (12-33) U/mL in 489 PD patients, 61.3% male, median age 61.5 (interquartile range 50-75) years. SeCA125 was positively associated with the ratio of ECW/total body water (TBW) (r = 0.29, p < 0.001), 4-h peritoneal dialysate to serum creatinine ratio (r = 0.23, p < 0.001), NTproBNP) (r = 0.18, p < 0.001), and age (r = 00.17, p = 0.001) and negatively with 24-h PD ultrafiltration volume (r = -0.28, p < 0.001) serum albumin (r = -0.22, p < 0.001), and echocardiographic left ventricular ejection fraction (r = -0.20, p < 0.001), but not with residual renal function or C-reactive protein. Patients with above the median SeCA125, had greater median ECW/TBW 0.403(IQR 0.394-0.410) vs 0.395(0.387-0.404), p < 0.001 and NTproBNP (6870 (IQR 1936-20096) vs 4069 (1345-12291) vs) pg/mL, p = 0.03. CONCLUSION: Heart failure studies have reported SeCA125 is a marker of ECW overload. Our retrospective analysis suggests that SeCA125 is also associated with ECW volume in PD patients. Further studies are required to determine whether serial measurements of SeCA125 trend with changes in ECW status in PD patients and can be used to aid volume assessments.

Multidisciplinary management of complicated bilateral renal artery aneurysm in a woman of childbearing age.

Ruptured renal artery aneurysm (RAA) during pregnancy is a rare condition associated with high mortality rates to both the mother and the foetus. We report on a 41-year-old woman at her second trimester who presented with shock to the emergency department as a result of a ruptured left RAA. While the bleeding was successfully treated with angiographic embolization, a contralateral RAA, also at risk of rupture, was discovered. Due to its position on the artery bifurcation, this lesion was considered not suitable for interventional radiology and was therefore managed by hand-assisted retroperitoneoscopic nephrectomy, ex-vivo repair and autotransplantation. This was done in order to preserve renal mass and give our patient a chance of having future pregnancies without risk of rupture. Three years later, her renal function is normal, there is no evidence of recurrence, and more importantly she had two successful and uncomplicated pregnancies.

Leptospirosis presenting as haemolytic uraemic syndrome: a case report.

BACKGROUND: Leptospirosis is a rare infectious disease especially in Western Countries. Renal involvement is a recognised complication of leptospirosis but leptospirosis-associated haemolytic uraemic syndrome is extremely rare and to our knowledge has only been reported once, in 1985. CASE PRESENTATION: A 29-year-old male was transferred to our Renal Unit with fevers, myalgia and diarrhoeal illness. Laboratory investigations revealed an acute kidney injury, acute liver injury, significantly raised lactate dehydrogenase with marked anaemia, thrombocytopenia and schistocytes on a blood film. A diagnosis of haemolytic uraemic syndrome was made. Surprisingly, the stool culture was negative which led to a suspicion of leptospirosis as one of the differential diagnoses. This was subsequently confirmed by enzyme-linked immunosorbent assay and microscopic agglutination test. He received plasma exchange and antibiotics and made a complete recovery on discharge. CONCLUSION: Leptospirosis presenting as haemolytic uraemic syndrome is rare but should be considered in the differential diagnosis especially in the presence of significant liver injury, as current evidence suggests that the disease is re-emerging.

Silent obstruction in a young woman with systemic lupus erythematosus: a case report and literature review on kidney injury from ureteral endometriosis.

INTRODUCTION: Endometriosis is the most common pelvic gynaecologic disorder affecting pre-menopausal women. However ureteral endometriosis (UE) especially intrinsic urinary tract endometriosis is a rare finding that is notorious for causing silent renal insult. The pathogenesis of endometriosis still remains a mystery but studies have suggested an association between endometriosis and systemic lupus erythematosus (SLE) suggesting an immunological aspect to endometriosis. There is very little recognition in the renal literature of the significance of UE leading to progressive kidney injury and the association with autoimmune conditions in particular SLE. CASE DESCRIPTION: We present a case of a 30-year old female with a background history of SLE with a silent progressive kidney injury due to an obstructive uropathy secondary to bilateral intrinsic UE and severe loss of her left kidney function that was treated with ureteric stenting. She subsequently underwent bilateral re-implantation of her ureters as a definitive treatment plan as she expressed a wish to conceive. DISCUSSION: Progressive kidney injury as a result of UE has been reported in the past, however its true incidence is not known. The time of diagnosis is crucial as it reflects renal prognosis. This article outlines the clinical implications from the renal perspective of the disease considering the relevant health problem UE can impose to women. This paper discusses the emerging evidence of an association between SLE and endometriosis that remains poorly understood. CONCLUSION: A high index of suspicion is required to diagnose UE as the disease occurs insidiously with non-specific symptoms leading to a silent obstructive uropathy. If missed it can ultimately lead to irreversible kidney dysfunction and mortality. We suggest that patients with endometriosis especially UE should be followed up regularly with renal function testing and imaging. Any health professionals dealing with patients suffering from SLE should consider appropriate investigations and referral if any symptom that suggests endometriosis is reported.

Ethnic/Race Diversity and Diabetic Kidney Disease.

Ethnicity and race are often used interchangeably in the literature. However, the traditional definition of race and ethnicity is related to biological (bone structure and skin, hair, or eye color) and sociological factors (nationality, regional culture, ancestry, and language) respectively. Diabetes mellitus (DM) is a huge global public health problem. As the number of individuals with Type 2 DM grows, the prevalence of diabetic kidney disease (DKD), which is one of the most serious complications, is expected to rise sharply. Many ethnic and racial groups have a greater risk of developing DM and its associated macro and micro-vascular complications.

Bilateral renal artery thrombosis in inherited thrombophilia: a rare cause of acute kidney injury.

We describe the case of a 47-year-old man who developed significant acute, and subsequently chronic, kidney injury due to bilateral renal infarction. This occurred in the context of a combined inherited thrombophilia including antithrombin III deficiency and a prothrombin gene mutation. Bilateral renal artery thrombosis developed despite prophylactic treatment for thromboembolism. Arterial thrombosis is rare in the context of inherited thrombophilia and bilateral renal infarction is an unusual cause of acute kidney injury. Bilateral renal infarction due to primary renal artery thrombosis has not been previously described in antithrombin III deficiency, either as an isolated defect or in combination with other hereditary thrombophilia.

Diagnosis and localisation of insulinoma: the value of modern magnetic resonance imaging in conjunction with calcium stimulation catheterisation.

CONTEXT: Preoperative localisation of insulinoma improves cure rate and reduces complications, but may be challenging. OBJECTIVE: To review diagnostic features and localisation accuracy for insulinomas. DESIGN: Cross-sectional, retrospective analysis. SETTING: A single tertiary referral centre. PATIENTS: Patients with insulinoma in the years 1990-2009, including sporadic tumours and those in patients with multiple endocrine neoplasia syndromes. INTERVENTIONS: Patients were identified from a database, and case notes and investigation results were reviewed. Tumour localisation by computed tomography (CT), magnetic resonance imaging (MRI), octreotide scanning, endoscopic ultrasound (EUS) and calcium stimulation was evaluated. MAIN OUTCOME MEASURE(S): Insulinoma localisation was compared to histologically confirmed location following surgical excision. RESULTS: Thirty-seven instances of biochemically and/or histologically proven insulinoma were identified in 36 patients, of which seven were managed medically. Of the 30 treated surgically, 25 had CT (83.3%) and 28 had MRI (90.3%), with successful localisation in 16 (64%) by CT and 21 (75%) by MRI respectively. Considered together, such imaging correctly localised 80% of lesions. Radiolabelled octreotide scanning was positive in 10 out of 20 cases (50%); EUS correctly identified 17 lesions in 26 patients (65.4%). Twenty-seven patients had calcium stimulation testing, of which 6 (22%) did not localise, 17 (63%) were correctly localised, and 4 (15%) gave discordant or confusing results. CONCLUSIONS: Preoperative localisation of insulinomas remains challenging. A pragmatic combination of CT and especially MRI predicts tumour localisation with high accuracy. Radionuclide imaging and EUS were less helpful but may be valuable in selected cases. Calcium stimulation currently remains useful in providing an additional functional perspective.