ABSTRACT
Pigmented urine in a hospitalized patient has a broad differential diagnosis including urinary tract infection or bacterial colonization, hemolysis, rhabdomyolysis, and drugs. We present a case of purple urine in a patient who received methylene blue and hydroxocobalamin for catecholamine-refractory vasodilatory shock. The patient's purple urinary discoloration is presumed to have resulted from a combination of the blue and red pigments of methylene blue and hydroxocobalamin, respectively. As these drugs are increasingly being used to treat vasoplegia in cardiopulmonary bypass, it is important for clinicians to be aware of this benign cause of urine discoloration.
Subject(s)
Hydroxocobalamin/chemistry , Methylene Blue/chemistry , Pigmentation , Urine , Vasoplegia/drug therapy , Cardiopulmonary Bypass/adverse effects , Humans , Hydroxocobalamin/therapeutic use , Male , Methylene Blue/therapeutic use , Middle Aged , Vasoplegia/etiologyABSTRACT
A 63-year-old man with HIV (human immunodeficiency virus) infection and end-stage renal disease, treated with lanthanum carbonate phosphate binder for 4 years, presented with anemia and an upper gastrointestinal bleed. Upper endoscopy revealed a nodular hyperplastic epithelium, with an endoscopic ultrasound confirming hyperechoic material within the nodules. Light microscopy showed collections of histiocytes and multinucleated giant cells containing brown granular cytoplasmic material and extracellular crystalline material, a finding confirmed by electron microscopy. Similar pathologic findings associated with lanthanum exposure have been described recently. In our patient, lanthanum carbonate treatment was withdrawn and gastrointestinal bleeding has since ceased. The patient was exposed to a high amount of lanthanum over a long period, which may explain his adverse reaction. However, other contributing factors, such as competing medications or comorbid conditions, also may have increased his sensitivity to the drug.
Subject(s)
Foreign-Body Reaction/chemically induced , Lanthanum/adverse effects , Renal Dialysis , Humans , Male , Middle Aged , Time FactorsABSTRACT
A thrombosed dialysis access can be declotted either through an open surgical procedure or a percutaneous one. In choosing how the access should be managed, a nephrologist should balance the experience and outcomes of local providers to ensure the efficient and safe salvage of the vascular access. Percutaneous procedures often offer less disruption to the schedule of the patient and dialysis clinic, give more information about the central vasculature, are less invasive, and ultimately are preferred. Nephrologist should encourage local vascular surgeons and interventional radiologists to become proficient in these procedures to avoid unnecessary open cases.
Subject(s)
Arteriovenous Shunt, Surgical , Kidney Failure, Chronic/therapy , Nephrology/methods , Renal Dialysis , Thrombosis/surgery , Humans , Operating RoomsABSTRACT
BACKGROUND: Collapsing Glomerulopathy (CG), also known as the collapsing variant of Focal Segmental Glomerulosclerosis (FSGS), is distinct in both its clinical severity and its pathophysiologic characteristics from other forms of FSGS. This lesion occurs disproportionally in patients carrying two APOL1 risk alleles, and is the classic histologic lesion resulting from Human Immunodeficiency Virus (HIV) infection of podocytes. Other viral infections, including parvovirus B19, and drugs such as interferon that perturb the immune system, have also been associated with CG. Despite significant advances, explaining such genetic and immune/infectious associations with causative mechanisms and supporting evidence has proven challenging. CASE PRESENTATION: We report the case of a healthy (HIV-negative) pregnant 36Ā year-old Caribbean-American woman who presented with nephrotic syndrome and fetal demise in the setting of acute parvovirus B19 infection. A series of three renal biopsies and rapid clinical course showed progression from significant podocyte injury with mild light microscopy findings to classic viral-associated CG to ESRD in less than 3Ā months. Genetic analysis revealed two APOL1 G1 risk alleles. CONCLUSIONS: This is the first published case report of CG in the setting of acute parvovirus infection in a patient with two APOL1 risk allelles, and parvoviral proteins identified in renal epithelium on kidney biopsy. These findings support the causative role of parvovirus B19 infection in the development of CG on the background of APOL1 genetic risk.
Subject(s)
Apolipoprotein L1/genetics , Glomerulosclerosis, Focal Segmental/etiology , Kidney Failure, Chronic/etiology , Parvoviridae Infections/complications , Parvovirus B19, Human , Pregnancy Complications, Infectious/virology , Acute Disease , Adult , Alleles , Female , Glomerulosclerosis, Focal Segmental/pathology , Humans , PregnancySubject(s)
Copper/deficiency , Deficiency Diseases/diagnosis , Gait Disorders, Neurologic/etiology , Zinc Sulfate/adverse effects , Zinc/pharmacology , Copper/metabolism , Copper/therapeutic use , Deficiency Diseases/chemically induced , Deficiency Diseases/complications , Humans , Kidney Failure, Chronic/complications , Kidney Failure, Chronic/therapy , Magnetic Resonance Imaging , Middle Aged , Peritoneal Dialysis , Spinal Cord/diagnostic imaging , Zinc Sulfate/therapeutic useABSTRACT
Hyponatremia is the most commonly encountered electrolyte abnormality. Severe hyponatremia in pregnancy poses diagnostic and therapeutic challenges. Pregnancy involves changes in physiology that affect water and sodium homeostasis. Knowledge of these complex physiologic alterations during pregnancy is critical to managing dysnatremias in pregnancy. This teaching case describes a woman with chronic hyponatremia who presented during pregnancy with worsening hyponatremia. She had an activating vasopressin receptor mutation, which was passed on to her child, and her diagnostic workup is described.
Subject(s)
Hyponatremia/diagnosis , Hyponatremia/therapy , Pregnancy Complications/diagnosis , Pregnancy Complications/therapy , Adult , Female , Fluid Therapy , Homeostasis/physiology , Humans , Hyponatremia/genetics , Mutation/genetics , Pregnancy , Pregnancy Complications/genetics , Receptors, Vasopressin/genetics , Sodium/metabolism , Treatment OutcomeABSTRACT
Women pursue pregnancy with comorbidities such as hypertension and kidney disease, necessitating primary care physicians to remain up to date with current clinical practice. Hypertensive disorders of pregnancy pose risks to the pregnancy and to the woman in the short and long term. These risks and their management are detailed in this review. Normally, pregnancy is associated with hemodynamic and kidney-specific changes. Here the authors discuss these changes and review the impact and management of pregnancy-related acute kidney injury, chronic kidney disease, and dialysis in pregnant patients. Kidney transplant recipients may experience return of fertility and require counseling to improve outcomes.
Subject(s)
Acute Kidney Injury , Pregnancy Complications , Renal Insufficiency, Chronic , Pregnancy , Female , Humans , Pregnant Women , Renal Insufficiency, Chronic/complications , Renal Insufficiency, Chronic/epidemiology , Renal Insufficiency, Chronic/therapy , Pregnancy Complications/therapy , Acute Kidney Injury/diagnosis , Acute Kidney Injury/etiology , Acute Kidney Injury/therapyABSTRACT
Patients who are Jehovah's Witnesses frequently cross the path of nephrologists when they are acutely ill in the intensive care unit and stable in the long-term setting. It is important that we as a group have a rudimentary understanding of their philosophy about blood transfusion so that we can be proactive in their management. We use a case as a launching point to discuss the origins of the faith and the decision to refuse blood, as well as potential therapeutic strategies that can be used to improve the care of these patients. Improvement in our understanding as physicians will facilitate a more productive conversation with our patients about a complex and emotional issue.
Subject(s)
Anemia/therapy , Attitude of Health Personnel , Jehovah's Witnesses , Treatment Refusal , Anemia/etiology , Anemia/prevention & control , Anemia/psychology , Anticoagulants/adverse effects , Blood Transfusion/ethics , Blood Transfusion/psychology , Fatal Outcome , Female , Gastrointestinal Hemorrhage/complications , Gastrointestinal Hemorrhage/etiology , HIV Infections/complications , Hematinics/therapeutic use , Humans , Jehovah's Witnesses/psychology , Kidney Failure, Chronic/complications , Kidney Failure, Chronic/therapy , Kidney Transplantation/ethics , Kidney Transplantation/psychology , Middle Aged , Multiple Organ Failure/etiology , Plasma , Platelet Transfusion/ethics , Platelet Transfusion/psychology , Professional-Patient Relations/ethics , Resource Allocation/ethics , Social Support , Thrombosis/complications , Thrombosis/drug therapy , Treatment Refusal/ethics , Treatment Refusal/legislation & jurisprudence , Treatment Refusal/psychologyABSTRACT
Peritoneal dialysis-associated peritonitis from such resistant organisms as vancomycin-resistant enterococci increasingly is occurring and is challenging to treat. We describe 2 cases of vancomycin-resistant entercoccus peritonitis successfully treated with intraperitoneal daptomycin. Both patients were on automated peritoneal dialysis therapy with culture-positive vancomycin-resistant Enterococcus faecium peritonitis and were treated with 10 to 14 days of intraperitoneal daptomycin given every 4 hours through manual peritoneal dialysate exchanges. Despite the known degradation in dextrose solutions, intraperitoneal daptomycin was effective in clearing both infections. Neither patient experienced a relapse or repeated peritonitis. Additional studies of dosing and pharmacokinetics of intraperitoneal daptomycin in the treatment of patients with vancomycin-resistant enterococcus peritonitis are needed.
Subject(s)
Daptomycin/administration & dosage , Enterococcus faecium , Gram-Positive Bacterial Infections/drug therapy , Peritonitis/drug therapy , Vancomycin Resistance/drug effects , Adult , Enterococcus faecium/drug effects , Female , Gram-Positive Bacterial Infections/microbiology , Humans , Injections, Intraperitoneal , Middle Aged , Peritonitis/microbiology , Treatment Outcome , Vancomycin/therapeutic use , Vancomycin Resistance/physiologyABSTRACT
Deferasirox is a new iron chelator approved recently for chelation therapy in iron-overloaded patients. It is considered safe and efficacious in most patients, but has not been tested formally in patients with end-stage renal disease. We report a case of a patient with end-stage renal disease secondary to sickle cell nephropathy who developed recurrent symptomatic hypocalcemia while on therapy and later reexposure with this medication for iron overload from long-term blood transfusions. This is the first case report of this complication with deferasirox therapy in a patient with end-stage renal disease.