Effect of enhanced external counterpulsation treatment on renal function in cardiac patients.

BACKGROUND: Enhanced external counterpulsation (EECP) enhances coronary perfusion and reduces left ventricular afterload. However, the role of EECP on renal function in cardiac patients is unknown. Our aim was to assess renal function determined by serum cystatin C in cardiac patients before and after EECP treatment. METHODS: A prospective observational longitudinal study was conducted in order to evaluate renal function using serum cystatin C (Cys C) and estimated glomerular filtration rate (GFR) after 35 sessions of EECP treatment in 30 patients with chronic stable angina and/or heart failure. The median (IQR) time for follow-up period after starting EECP treatment was 16 (10-24) months. RESULTS: Cys C significantly declined from 1.00 (0.78-1.31) to 0.94 (0.77-1.27) mg/L (p < 0.001) and estimated GFR increased from 70.47 (43.88-89.41) to 76.27 (49.02-91.46) mL/min/1.73 m(2) (p = 0.006) after EECP treatment. Subgroup analysis showed that patients with baseline GFR <60 mL/min/1.73 m(2) or NT-proBNP >125 pg/mL had a significant decrease in Cys C when compared to other groups (p < 0.01). CONCLUSIONS: The study demonstrated that EECP could improve long-term renal function in cardiac patients especially in cases with declined renal function or with high NT-proBNP. TRIAL REGISTRATION: The study was registered in the clinical trial as International Standard Randomized Controlled Trial Number ISRCTN11560035.

Triple immunosuppressive therapy can accelerate the recovery of antibody-mediated pure red cell aplasia and allow successful concurrent resumption of erythropoietin.

Antibody (Ab)-mediated pure red cell aplasia (PRCA) is a rare hematologic disorder. For the first time here, the authors report the use of combination therapy which consists of mycophenolate mofetil 500-1000 mg/day, intravenous cyclophosphamide 600 mg monthly and monthly intravenous methylprednisolone 1 gm/day for 2 days followed by oral prednisolone 10 mg/day. A 62-year-old woman developed Ab-mediated PRCA after using subcutaneous erythropoietin-beta 3000 U weekly for 14 months at the predialysis stage. Ab-mediated PRCA was diagnosed based on (1) the transfusion need of more than 1 unit/wk to keep hemoglobin level stable, (2) corrected reticulocyte count 0.36% and (3) < 5% erythroblasts with normal myeloid cells and megakaryocytes in bone marrow biopsy. Serum assay confirmed the anti-erythropoietin antibody of 230 ng/mL. The patient recovered from PRCA after the triple immunosuppressive therapy for 3 months. The rapid recovery occurred despite the fact that the patient was receiving intravenous erythropoietin-alpha while having the antibody in the serum. The present case describes the acceleration of the recovery and successful resumption of erythropoietin concurrently despite the positive serum anti-erythropoietin antibody.

Isometric tubular vacuolization in renal transplant recipient: the first case report in Thailand.

Cyclosporine can cause acute and chronic nephrotoxicity. Renal biopsy is a reliable tool for the diagnosis of cyclosporine nephrotoxicity. The authors report a 56-year-old Thai female with a history of end-stage renal disease who underwent cadaveric renal transplantation. A transplanted kidney biopsy was performed on day 9 post-transplant to identify the cause of delayed graft function. Light and electron microscopic findings revealed widespread (> 50% involvement) numerous tubules filled with uniformly-sized vacuoles in cytoplasm (isometric vacuolization). Serum cyclosporine trough level was 534 ng/mL. Neither acute rejection nor acute tubular necrosis was seen. Diagnosis of acute cyclosporine nephrotoxicity was made. Isometric vacuolization in more than 50% involvement of the tubules is rare (3%) in biopsy specimens. The tubular isometric vacuolization might not have the strong impact to the long term graft outcome. This is the first case report of isometric tubular vacuolization due to cyclosporine toxicity in renal transplant recipient in Thailand.