Triple Positive Antiphospholipid Antibody Syndrome in Pregnancy with High Frequency Plasma Exchange: A Case Report.

Introduction: Triple antibody positive antiphospholipid syndrome during pregnancy carries a poor prognosis. The placental vasculature is particularly vulnerable to these antibodies resulting in a marked increased risk of fetal growth restriction, placental infarction, abruption, stillbirth, and preterm severe preeclampsia. Case Presentation: We report a case of a primigravida with triple antibody positive antiphospholipid syndrome that demonstrated placental insufficiency and fetal compromise at a previable gestation. The patient underwent plasma exchange every 48 h for 11 weeks resulting in delivery of a viable infant. Placental blood flow was improved after complete absence of end-diastolic flow in the fetal umbilical artery. Conclusion: Scheduled plasmapheresis every 48 h can be considered in select cases of antiphospholipid antibody syndrome.

Acute and Chronic Hyponatremia.

Hyponatremia is the most common electrolyte disorder in clinical practice. Catastrophic complications can occur from severe acute hyponatremia and from inappropriate management of acute and chronic hyponatremia. It is essential to define the hypotonic state associated with hyponatremia in order to plan therapy. Understanding cerebral defense mechanisms to hyponatremia are key factors to its manifestations and classification and subsequently to its management. Hypotonic hyponatremia is differentiated on the basis of urine osmolality, urine electrolytes and volume status and its treatment is decided based on chronicity and the presence or absence of central nervous (CNS) symptoms. Proper knowledge of sodium and water homeostasis is essential in individualizing therapeutic plans and avoid iatrogenic complications while managing this disorder.

Viral Nephropathies, Adding SARS-CoV-2 to the List.

Viral infections in the immunocompetent host can cause both acute and chronic kidney disease either as a direct damage to the infected kidney cells or as a consequence of systemic immune responses that impact kidney function. Since identifying these entities in the 1970s and 80s, major breakthroughs in the understanding of the viral mechanisms have occurred. Viruses have evolved mechanisms to hijack signaling pathways of infected cells to evade antiviral immune responses by the host. Over time, the clinical presentations and management of these diseases have evolved along with our in-depth understanding of the various pathophysiological mechanisms causing these conditions. Similarly, both at the cellular and systemic levels, the host has evolved mechanisms to counter viral subversion strategies for mutual survival. Since the start of the current COVID-19 pandemic, numerous cases of acute kidney injury have been reported in the literature with various possible pathophysiological mechanisms. In this review, we summarize lessons learned from prior viral pandemics related to viral mechanisms utilized in the pathogenesis of numerous renal manifestations to attempt to utilize this knowledge in predicting post-COVID-19 kidney disease.

Protective effect of allopurinol in preventing contrast-induced nephropathy among patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis.

Introduction: Contrast-induced nephropathy (CIN) is the third most common cause of iatrogenic acute renal failure and is triggered by administration of radiopaque contrast media. Periprocedural hydration is imperative in prevention of CIN, and uric acid has been recognized to have an integral role in development of renal disease. The aim of our study is to understand the efficacy of allopurinol in preventing CIN among patients undergoing percutaneous coronary intervention. Material and methods: A literature search was performed on PubMed (Medline), Science Direct and Cochrane Library using a combination of Mesh terms. We limited our search to randomized controlled trials (RCTs) and articles published in the English language. The PRISMA protocol was utilized to conduct this meta-analysis. Results: Six studies were included in the final analysis. All included studies were clinical trials conducted between 2013 and 2019. A total of 853 patients were included. There was a significant reduction in the risk of CIN among patients who were pretreated with adequate hydration plus allopurinol (100 to 600 mg) compared to hydration only before undergoing percutaneous coronary angiography (RR = 0.39, 95% CI: 0.21-0.73). A sensitivity analysis of studies using 300 mg of allopurinol only reported a significant reduction in CI-AKI compared to hydration alone (RR = 0.26, 95% CI: 0.11-0.57). Conclusions: Our study demonstrates that Allopurinol is effective in preventing contrast-induced nephropathy in patients undergoing percutaneous coronary intervention. Larger clinical trials are warranted to better understand this effect.

Severe Metabolic Acidosis: A Case of Triple Hit with Ketogenic Diet, Vinegar, and Metformin in an Obese Patient.

Obesity is an epidemic with high burden of disease. It is directly proportional to increased risk of morbidity and mortality. Ketogenic diet and herbal supplements have recently gained popularity amongst patients struggling with weight loss. There are limited data available for most of these supplements contrary to the claims laid by the mainstream media. Due to lack of awareness, this patient population is at high risk of adverse effects. We present a case of severe acidosis secondary to ketogenic diet and acetic acid (vinegar) ingestion. The use of dietary acetic acid is usually well tolerated; however, in this case, the large quantities and presence of acute renal injury may have worsened the acidosis. Severe ketosis in setting of ketogenic diets is a serious complication, which is infrequently reported in literature. Many of these diets and supplements may seem harmless, but as our case illustrates, when combined with other risk factors, patients can face adverse effects and even hospitalization. It is imperative that such dietary practices are physician supervised to avoid complications. With the recent surge of over-the-counter weight loss supplements and fat diets, physicians need to engage in dietary discussion with patients when attempting to lose weight.

Atypical rapid onset Scleroderma Renal Crisis (SRC) complicated with diffuse alveolar hemorrhage and pleuro-pericardial effusions in a patient with recently diagnosed breast cancer and a positive anti-RNA polymerase III Ab.: A case report.

Scleroderma associated Pulmonary-Renal Syndrome is a rare but severe complication with a poor prognosis and high mortality. A high index of suspicion is needed for early recognition of this potential complication in patients with systemic sclerosis and institution of appropriate treatment. With more data showing an increased association between scleroderma and malignancy, a heightened vigilance should also be exercised in patients with malignancy and scleroderma-like presentation. We report of a case rapid onset systemic sclerosis complicated by acute renal failure and diffuse alveolar hemorrhage in a woman with stage IIB right breast cancer and elevated RNA Polymerase III IgG Ab. To our knowledge, this the first case of a patient with breast cancer associated with systemic sclerosis and pulmonary-renal syndrome.

Parainfluenza virus infection associated with posterior reversible encephalopathy syndrome: a case report.

INTRODUCTION: Posterior reversible encephalopathy syndrome is a clinical and radiological entity. The most accepted theory of posterior reversible encephalopathy syndrome is a loss of autoregulation in cerebral blood flow with a subsequent increase in vascular permeability and leakage of blood plasma and erythrocytes, producing vasogenic edema. In infection-associated posterior reversible encephalopathy syndrome, a clinical pattern consistent with systemic inflammatory response syndrome develops. Parainfluenza virus has not been reported in the medical literature to be associated with posterior reversible encephalopathy syndrome. CASE PRESENTATION: We report herein the case of a 54-year-old Caucasian woman with posterior reversible encephalopathy syndrome associated with parainfluenza virus infection who presented with generalized headache, blurring of vision, new-onset seizure and flu-like symptoms. CONCLUSION: Infection-associated posterior reversible encephalopathy syndrome as well as hypertension-associated posterior reversible encephalopathy syndrome favor the contribution of endothelial dysfunction to the pathophysiology of this clinicoradiological syndrome. In view of the reversible nature of this clinical entity, it is important that all physicians are well aware of posterior reversible encephalopathy syndrome in patients presenting with headache and seizure activity. A detailed clinical assessment leading to the recognition of precipitant factors in posterior reversible encephalopathy syndrome is paramount.