RESUMEN
A 75-year-old man with blurred vision and nasal bleeding was diagnosed with hyperviscosity syndrome and central retinal vein occlusion secondary to Waldenström macroglobulinemia. Serum total protein and IgM levels were undetectable. Because of the severe symptoms, we determined that immediate plasma-exchange treatment was required to decrease the blood viscosity. The initial plasma exchange was performed using the membrane isolation method with a predilution standby. A saline predilution replacement was prepared to decrease the total membrane pressure (TMP); however, the predilution protocol was not used because the planned treatment volume could be achieved without increasing the TMP. After two consecutive days of membrane plasma exchange, all serum biochemical tests were measurable, and IgM was below 4000 mg/dL. After chemotherapy, his visual symptoms improved, and he was discharged. Since it is difficult to assess the risk of elevated TMP prior to initial plasma exchange, membrane plasma exchange with a predilution standby may be a useful strategy for initial plasma exchange for hyperviscosity syndrome in terms of safety and efficiency.
RESUMEN
A 74-year-old woman with reduced kidney and cardiac function and a history of coronary artery bypass surgery involving the gastroepiploic artery to the right coronary artery and posterior descending artery #4 presented with dyspnea on exertion. Shortly after the induction of peritoneal dialysis (PD), an increase in the left pleural effusion was observed, and a diagnosis of left pleuroperitoneal communication was made by puncture drainage. The pleuroperitoneal communication hole was not detected under thoracoscopic observation; however, a 10 mm-sized hole in the pericardium was found, confirming leakage of ICG-loaded peritoneal dialysate fluid (PDF). CT peritoneography using PDF mixed with iodine contrast medium revealed that the gastroepiploic artery-to-right coronary artery pathway was defective on the abdominal side. We concluded that the left pleuroperitoneal communication was caused by a two-stage fistulous pathway between the abdominal and pleural cavities through the pericardial cavity after coronary artery bypass graft surgery. Although closure of the diaphragmatic hole around the gastroepiploic artery graft should have been performed to restart PD, the patient did not wish to undergo further invasive procedures. Identification of the fistulous pathway is extremely important for prompt diagnosis and treatment of pleuroperitoneal communication.
RESUMEN
Mycophenolate mofetil is a key immunosuppressant that is metabolized into mycophenolic acid (MPA). The prognostic impact of MPA-focused therapeutic drug monitoring on allograft prognosis has not been determined in kidney transplant recipients with diabetes. In this study, we assessed the pharmacokinetics of MPA and allograft prognosis in recipients with diabetes. This study retrospectively analyzed 64 adult kidney transplant recipients. MPA blood concentration data (e.g., the time to the maximum concentration (Tmax), and the area under the concentration-time curve from 0 to 12 h (AUC0-12)) were collected at 3 weeks and 3 months after kidney transplantation. Of the 64 recipients, 15 had pre-existing diabetes. At 3 months after kidney transplantation, the Tmax of MPA was significantly longer in recipients with diabetes (mean (standard deviation): 2.8 (2.1) h) than in recipients without diabetes (1.9 (1.1) h, p = 0.02). However, the allograft estimated glomerular filtration rate and acute rejection rate, including borderline change, did not differ according to the diabetes status in patients with adjusted AUC0-12 of MPA within the target range. In conclusion, a longer Tmax of MPA was observed in recipients with diabetes; however, acceptable allograft prognosis was observed in kidney transplant recipients with diabetes and a sufficient AUC0-12 of MPA.
RESUMEN
Although cumulative evidence indicates that risk factors for arteriosclerosis have an impact on age-related changes in brain pathology, the influence of aging without major risk factors on changes in brain structures has not yet been fully elucidated. We used magnetic resonance imaging (MRI) to study how aging affects structural changes in the brain (eg, white matter lesions, hippocampal atrophy [HA], microbleeds) in normal subjects without major risk factors for cerebrovascular diseases. We studied 1108 subjects who underwent voluntary brain screening and had no cerebrovascular risk factors, such as hypertension, diabetes mellitus, or hyperlipidemia. We examined the conventional and T2-weighted MRI to define white matter hyperintensities, HA, and cerebral microbleeds in addition to all physical parameters, blood biochemical data, and neuropsychiatric symptoms. We found that the prevalence of white matter lesions and HA increased significantly with age (P < .001). Logistic analysis showed that periventricular hyperintensity was significantly related to age (P < .0001) and depressive state (P < .01). A linear relation was found between white matter lesions and HA (P < .05). Cerebral microbleeds also increased with age, and their presence was associated with HA (P < .001). White matter lesions, HA, and cortical microbleeds were associated with one another in healthy elderly subjects, and these changes were affected by the aging process independent of any cerebrovascular risk factors. Cerebral amyloid angiopathy may underlie these age-related brain changes.