"Green Smoothie Cleanse" Causing Acute Oxalate Nephropathy.

Oxalate nephropathy is an uncommon condition that causes acute kidney injury with the potential for progression to end-stage renal disease. Diagnosis is based on the kidney biopsy findings of abundant polarizable calcium oxalate crystals in the epithelium and lumen of renal tubules. We report a case of acute oxalate nephropathy in a 65-year-old woman, temporally associated with the consumption of an oxalate-rich green smoothie juice "cleanse" prepared from juicing oxalate-rich green leafy vegetables and fruits. Predisposing factors included a remote history of gastric bypass and recent prolonged antibiotic therapy. She had normal kidney function before using the cleanse and developed acute kidney injury that progressed to end-stage renal disease. Consumption of such juice cleanses increases oxalate absorption, causing hyperoxaluria and acute oxalate nephropathy in patients with predisposing risk factors. Given the increasing popularity of juice cleanses, it is important that both patients and physicians have greater awareness of the potential for acute oxalate nephropathy in susceptible individuals with risk factors such as chronic kidney disease, gastric bypass, and antibiotic use.

Augmented Nurse Care Management in CKD Stages 4 to 5: A Randomized Trial.

BACKGROUND: Outcomes for patients with late-stage chronic kidney disease (CKD) in the United States are suboptimal. There is poor education and preparation for end-stage kidney disease, as well as a high rate of hospitalization in this group of patients. STUDY DESIGN: A randomized, parallel-group, 2-arm, controlled trial. SETTING & PARTICIPANTS: The study was conducted at 3 sites: a clinic of an academic medical center, a public hospital academic clinic, and a community-based private practice. All participants had late-stage CKD (stages 4-5 CKD). Patients were excluded only if they had significant cognitive impairment. INTERVENTION: The care management intervention involved nurse care manager coordination aided by the use of a disease-based informatics system for monitoring patients' clinical status, enhancing CKD education, and facilitating preparation for end-stage kidney disease. The comparison control group received usual late-stage CKD care alone. OUTCOMES: The primary outcome was rate of hospitalization. MEASUREMENTS: Rates of preemptive transplantation, home dialysis, hemodialysis (HD) starts without a hospitalization, and HD therapy initiation rates with catheters or with functioning accesses. RESULTS: 130 patients were randomly assigned. The hospitalization rate was significantly lower in the intervention group versus controls: 0.61 versus 0.92 per year, respectively (incidence rate ratio, 0.66; 95% CI, 0.43-0.99; P=0.04). Peritoneal dialysis or preemptive transplantation was the initial end-stage kidney disease treatment in 11 of 30 (37%) participants receiving the intervention versus 3 of 29 (10%) receiving usual care. Among HD starts, treatment was initiated without hospitalization in 11 of 19 (58%) participants in the intervention group versus 6 of 26 (23%) in the control group. At the time of HD therapy initiation, a catheter was present in 7 of 19 (37%) participants in the intervention group versus 18 of 26 (69%) in the control group. A functioning arteriovenous access was in place in 10 of 19 (53%) participants in the intervention group and 7 of 26 (27%) in the control group LIMITATIONS: Moderate sample size, limited geographic scope. CONCLUSIONS: The augmented nurse care management intervention resulted in reduced hospitalizations in late-stage CKD and there were suggestions of improved end-stage kidney disease preparation. Given suboptimal outcomes in late-stage CKD, care management interventions could potentially improve patient outcomes.

Impact of Autologous Stem Cell Transplantation on Blood Pressure and Renal Function in Multiple Myeloma Patients.

BACKGROUND: Autologous stem cell transplantation (ASCT) reverses kidney failure in one-third of multiple myeloma (MM) patients, which may lead to blood pressure (BP) improvement. We evaluate the long term impact of ASCT on BP and renal function in MM patients. METHODS: We studied 192 MM patients that underwent ASCT. We compared BP readings and glomerular filtration rate (GFR) at 4 weeks before ASCT, on day of ASCT and post-ASCT at 30, 100 and 180 days. RESULTS: Mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) on day of ASCT and at both 30 and 100 days post-ASCT was significantly lower as compared to pre-ASCT SBP and DBP. There was a significantly higher mean GFR at day of ASCT and 30 days post-ASCT and significantly lower mean GFR at 180 days post-ASCT as compared to pre-ASCT. White patients had similar patterns to the total group for SBP, DBP, and GFR except for SBP which was still significantly lower and GFR which was not significantly different at 180 days. African-American patients showed no significant reductions in the mean values of SBP and DBP and no significant increases for GFR in follow-up after day of ASCT. Furthermore, the mean value of GFR was significantly lower at 180 days post-ASCT. CONCLUSIONS: ASCT in MM patients had a positive impact on SBP and DBP and GFR but the impact was minimal for African-American patients. We recommend that clinicians consider closer follow-up of BP and kidney function and more intense therapy in African-Americans with MM.

Importance of creatinine clearance for drug dosing in nursing home residents.

Serum creatinine is often not an adequate measure of renal function, especially in advanced age or in physically debilitated patients. Estimated creatinine clearance is necessary to decide on usage of drugs such as Metformin. This study included 64 nursing home residents with diabetes treated with Metformin. Creatinine clearance (CrCl) was calculated by the Cockcroft-Gault equation modified for ideal body weight. CrCl more than or equal to 60/mL min was used as a cut-off for appropriate use of Metformin. In our sample, 20.3% had renal failure when measured by serum creatinine while 56.3% had renal failure when measured by CrCl. Age >65 years and women were more likely to be classified as normal for serum creatinine but have abnormal creatinine clearance. Use of estimated creatinine clearance should be advocated instead of serum creatinine when prescribing Metformin, especially for those of older age and among women.

Early use of hemodialysis for active rewarming in severe hypothermia: a case report and review of literature.

Deep accidental hypothermia (body temperature below 28°C) is rare. Even with modern supportive care of active external and internal rewarming techniques it is associated with a high mortality rate. We report the early and successful use of hemodialysis (HD) for active rewarming of a middle-aged alcoholic man with severe deep accidental hypothermia after failure of initial efforts of rewarming using conventional strategies. This case report and review of the literature highlights the advantages and the challenges of using HD in this setting and suggests a potential role for HD in the routine management of severe hypothermia in the absence of circulatory arrest.

Permanent hearing loss with iopamidol following aortic angiography in a hemodialysis patient: a case report and review of the literature.

Nonionic low-osmolar contrast agents are considered safe for intravenous or intra-arterial administration and are used widely in the general population, as well as in patients on hemodialysis therapy. There are data limited to case reports for contrast-induced hearing loss; however, the ototoxicity induced by contrast agents in patients with chronic kidney disease has never been described. We report a case of permanent sensorineural deafness after abdominal aortic angiography with iopamidol in a woman with end-stage renal disease on hemodialysis therapy and review the literature relating to contrast use with the development of hearing impairment.

Achieving KDOQI Guidelines for Hematocrit in HIV-Infected Hemodialysis Patients.

The primary cause of anemia in HIV-infected patients with ESRD is diminished production of erythropoietin. Although most patients respond to recombinant erythropoietin, the response may be blunted in patients with ESRD and concomitant viral or bacterial infections. Previous studies demonstrated a response to erythropoietin by HIV-infected ESRD patients, but hematocrit levels on average were only 27-29%. We were interested in determining if KDOQI guidelines could be met in these patients. Hematocrits and epogen doses of all HIV-positive patients who were undergoing hemodialysis at the Nassau University Medical Center Dialysis Unit between September 2002 and March 2003 were compared to matched controls in our hemodialysis unit. The hematocrit levels in our population were higher than those reported in earlier papers. In our patient population, the mean hematocrit was 37.5, whereas the mean hematocrit levels in the HIV group in previous papers were 27-29%. HIV-infected patients did require higher erythropoietin dosages than controls, but similar doses were used as compared to previous studies. HIV patients on hemodialysis can achieve KDOQI target hematocrits. The difference in route of iron administration and iron stores may explain the higher hematocrit levels in our HIV patient population as compared to previous trials.

Autonomic dysfunction as a delayed sequelae of acute ethylene glycol ingestion : a case report and review of the literature.

Ethylene glycol poisoning is a common form of poisoning worldwide. The clinical course of ethylene glycol poisoning usually follows a three-stage progression, although these stages may overlap. A fourth stage of delayed neurological dysfunction consisting of cranial neuropathies has been suggested in several case reports. We describe a patient with unique findings of postural hypotension and gastroparesis following ethylene glycol toxicity with the additional uncommon features of albuminocytologic dissociation and increased intracranial pressure with papilledema. In addition, we provide a review of the literature on delayed neurological manifestations in ethylene glycol toxicity and further elucidate a description of a fourth stage of delayed neurological dysfunction following ethylene glycol poisoning.

Toll-like receptor 9 and vascular endothelial growth factor levels in human kidneys from lupus nephritis patients.

BACKGROUND: In the lupus mouse and systemic lupus erythematosus (SLE) patients, DNA fragments isolated from plasma may mimic microbial DNA and trigger Toll-like receptor 9 (TLR9) signaling with formation of autoantibodies against DNA fragments and nucleosomes. Vascular endothelial growth factor (VEGF) is a tightly regulated angiogenic cytokine in the kidney. The present study investigated glomerular and tubular expression of both TLR9 and VEGF in biopsies from human subjects with lupus nephritis (LN) and normal controls. METHODS: Kidney biopsies in LN (n=8) and normal controls (n=10) were evaluated for expression of TLR9 and VEGF. The degree of kidney damage was analyzed according to the International Society of Nephrology / Renal Pathology Society classification. Immunohistochemistry was performed, and slides were incubated with antibodies against VEGF and TLR9 monoclonal antibody, stained with hematoxylin and eosin, mounted and microscopically scored at ×10 and ×20. RESULTS: We observed intense staining of glomeruli and tubules for TLR9 up to 3+ from patients with LN. Samples from LN subjects showed 3+ staining of glomeruli but only up to 2+ in tubules for VEGF. There was less significant staining for TLR9 and none for VEGF in controls. There was no correlation observed between LN class severity and intensity of staining for VEGF or TLR9. CONCLUSION: This is the first study that investigated combined expression of TLR9 and VEGF, which could be an important tool for understanding the role of TLR9 and VEGF in LN, with insights into the early detection and targeted treatment of this disease.