Percutaneous balloon pericardiotomy: efficacy in a series of malignant and nonmalignant cases.

OBJECTIVE: In the case of malignant pericardial effusion and cardiac tamponade, balloon pericardiotomy is an established minimally invasive option to the surgical creation of a subxiphoid pericardial window. Percutaneous balloon pericardiotomy effectively drains recurrent pericardial fluid by creating a pleuro (-abdominal-) pericardial communication. Design. A series of 26 patients with underlying malignant (n = 12) and nonmalignant (n = 14) diseases underwent percutaneous balloon pericardiotomy between 2008 and 2021. All interventions were done through a subxiphoid access under local anesthesia. Results. The mean survival in the malignant and nonmalignant groups was 1.2 versus 48.0 months, respectively (p < .001). There were neither severe periinterventional complications nor in-hospital deaths. In two patients with nonmalignant disease the surgical creation of a pericardial window was necessary during follow-up. The originally described procedure was modified by the removal of all catheters at the end of the intervention. The procedure was safe. It prevented immobility and facilitated an early discharge from the hospital. Conclusion. Our experiences show that percutaneous balloon pericardiotomy is a minimally invasive approach to successfully provide palliation in the group of patients with underlying malignant disease. On the other hand, we have shown that this technique is safe and feasible in the treatment of pericardial effusion based on nonmalignant disease. We think thereby that pericardial balloon pericardiotomy can be considered as a less invasive alternative to surgery in both groups of patients.

[Combined immunosuppression with cyclosporin A, mycophenolate mofetil (MMF) and dexamethasone for activity control of recurrent secondary hemophagocytic lymphohistiocytosis (sHLH) with underlying systemic lupus erythematosus (SLE)]. / Kombinierte Immunsuppression mit Cyclosporin A, Mycophenolatmofetil (MMF) und Dexamethason zur Aktivitätskontrolle einer rezidivierten, sekundären hämophagozytischen Lymphohistiozytose (sHLH) auf dem Boden eines systemischen Lupus erythematodes (SLE).

A 42-year-old female patient was admitted to hospital due to acute neurological symptoms (dysarthria, disorientation). After exclusion of cerebral ischemia and hemorrhage an autoimmune encephalitis was diagnosed. Shortly before as an outpatient the suspicion of the presence of systemic lupus erythematosus (SLE) was voiced. The patient showed a constellation of high levels of inflammatory laboratory parameters and within a few days developed a severe pancytopenia. In the presence of all diagnostic criteria a secondary hemophagocytic lymphohistiocytosis (sHLH) was diagnosed and confirmed by a kidney biopsy during the course of the underlying SLE. The immunosuppressive treatment with etoposide and high-dose dexamethasone according to the HLH-94 protocol only showed temporary success. After 3 weeks of treatment with a protocol-conform dose reduction, under running treatment a new exacerbation of symptoms was confirmed. A renewed dose escalation of the drugs used did not lead to control of the symptoms. The inflammatory activity could only be sustainably controlled by the use of cyclosporin A in combination with mycophenolate mofetil (MMF) and dexamethasone. After stabilization of the condition of the patient, an outpatient follow-up care was possible.

Rituximab for the second- and third-line therapy of idiopathic membranous nephropathy: a prospective single center study using a new treatment strategy.

BACKGROUND: Idiopathic membranous nephropathy (MN) is a major cause of nephrotic syndrome. Conventional treatment strategies induce remission but the relapse rates are high. Different doses of rituximab (RTX) appeared effective in reducing proteinuria in MN but long-term follow-up data are rare. METHODS: Since 2006, a total of 14 patients (median age 51 (26 - 69) years, 4 women, 10 men) with biopsy-proven MN (1 - 4 relapses, MN since 4 (1 - 13) years) were treated with RTX (4 doses of RTX 375 mg/m2 on Days 0, 30, 60, 90). All patients had prior immunosuppressive therapy with Cyclosporin A, 7 with alkylating agents. In 11 patients, an additional renal biopsy was performed 2 (1 - 10) months before RTX. RESULTS: Three months after the last RTX infusion, proteinuria decreased from a baseline of 5.5 (2.9 - 11.9) g/24 h to 1.8 (0.03 - 8.7) g/24 h (p = 0.012). Creatinine clearance remained stable (53 (29 - 160) ml/min at 3 months vs. 44 (29 - 159) at baseline). Until now, patients could be followed for a median of 3 (1 - 6) years. After 1 year, 21.4% (n = 3) had a complete response, 50.0% (n = 7) partial response. Two relapses occurred after 1 and 3.5 years. The presence of glomerulosclerosis before RTX was associated with a poorer outcome. CONCLUSIONS: The 4 × 4-weekly infusion of RTX is a reasonable option for the second- and third line therapy of MN providing a better safety profile compared to other immunosuppressive treatments of MN.

Screening and differential diagnosis of renal light chain-associated diseases.

BACKGROUND: Renal involvement in the light chain-associated diseases multiple myeloma (MM), amyloidosis (AL) and monoclonal immune position disease (MIDD) is common and differential diagnosis usually requires renal biopsy. The aim of this study was to investigate if noninvasive methods are viable to identify and differentiate between the various types of kidney diseases. PATIENTS AND METHODS: All patients with a light chain-associated disease admitted to our center from 1996 to 2008 were retrospectively evaluated. Renal biopsy data were correlated with proteinuria findings. RESULTS: Only the ratio of free κ/λ light chains showed a good sensitivity for myeloma cast nephropathy (MCN), AL and MIDD. The λ light chain was characteristic for AL, the κ light chain dominated in MIDD. Renal function at the time of diagnosis was worst in MIDD. MCN presented with a proteinuria of > 3.5 g/g creatinine. In contrast, a higher proteinuria was found in AL or MIDD. Whereas the κ/λ ratio in the urine was pathological for all three diseases, extremely high or low ratios indicated the presence of MCN. However, in AL or MIDD, the ratio was only moderately elevated. CONCLUSION: A noninvasive differentiation between MCN and other forms of renal light chain disease is possible.

Cardiac tamponade following aortic root erosion by an Amplatzer PFO-Occluder in a 41-year-old woman: Only a matter of sizing?

A 41-year-old woman who had suffered an acute stroke underwent closure of a persistent patent foramen ovale (PFO) two months later. Eleven months after PFO closure the patient was hospitalized with signs of cardiogenic shock due to cardiac tamponade. Imaging studies showed a correct position of the left occluder disc, whereas the right atrial disc was in direct contact with the aortic root. At day 6, the patient underwent surgery via a minimally invasive route under cardiopulmonary bypass. The left atrial disc of the occluder was in a correct position. A too big right atrial disc together with a sharp angle misalignment toward the right atrial wall led to an erosion of the right atrial wall and of the wall of the aortic root. The occluder was explanted and the PFO closed by direct suture. Given the increasing number of procedures performed, serious and potentially life-threatening complications - even if rare - deserve special attention. Even though device oversizing was the most likely factor causing the erosion, other factors may play a role, as the patient used whole-body vibration starting three months before the incident. This could explain why the event happened as late as 11 months after the initial PFO closure. .

Giant Aneurysm of the Right Coronary Artery: Multimodality Imaging and Interventional Management.

A large (40-mm) circular structure in the right atrioventricular groove was detected by transthoracic echocardiography and was diagnosed as a giant aneurysm of the right coronary artery. Through invasive mapping by a guide extension catheter, the aneurysm could be excluded by implantation of 3 overlapping stent grafts. (Level of Difficulty: Beginner.).

Proteinuria after conversion to sirolimus in kidney transplant recipients: impact of pre-existing proteinuria, graft function, and angiotensin-converting enzyme inhibitors/angiotensin-receptor antagonists.

BACKGROUND: Proteinuria is a known side effect of therapy with sirolimus. The effect of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers (ACEI/ARB ) on sirolimus-associated proteinuria has not yet been assessed. PATIENTS AND METHODS: A retrospective cohort study of renal transplant patients treated with sirolimus (n = 55) was performed. RESULTS: Of 55 patients, 24 (44%) had no proteinuria (<0.15 g/d) prior to conversion. Of 24 patients, 11 (46%) showed de novo proteinuria >0.15 g/d after 12 months, only 2 developed proteinuria > 1 g/d. The total number of proteinuria >1 g/d after 12 months including patients with pre-existing proteinuria >1 g/d (n = 3) was seven of 55 patients (13%). Multivariate regression analysis revealed pre-existing proteinuria > 0.15 g/d and reduced glomerular filtration rate as independent predictors for the development of proteinuria after conversion to sirolimus. CONCLUSION: Reduced glomerular filtration rate and pre-existing proteinuria but not therapy with ACEI/ARB are independent predictors for proteinuria after conversion to sirolimus. Treatment with ACEI/ARB did not reduce pre-existing proteinuria after conversion except in single cases with severe proteinuria.

Vitamin B6 metabolism in chronic kidney disease--relation to transsulfuration, advanced glycation and cardiovascular disease.

BACKGROUND: Vitamin deficiency is common in chronic kidney disease (CKD). Data on B(6) supply and possible relationships to cardiovascular events (CVE) in CKD are rare. Pyridoxamine exerts inhibitory effects on the formation of advanced glycation endproducts (AGE) implicated in the pathogenesis of CKD and atherosclerosis. METHODS: In 48 CKD patients at stage 2-4, 72 hemodialysis patients (HD), 38 renal transplant recipients (RTR) and 141 healthy controls (mean age 58 +/- 13, 61 +/- 12, 50 +/- 12 and 54 +/- 16 years, respectively), plasma and red blood cell (RBC) concentrations of pyridoxal-5'-phosphate (PLP), pyridoxal (PL), 4-pyridoxic acid (PA), pyridoxamine-5'-phosphate (PMP) and of the AGE pentosidine were measured by high-performance liquid chromatography, N(epsilon)-(carboxymethyl)lysine and imidazolone by an ELISA, and total homocysteine and cystathionine by gas chromatography-mass spectrometry. RESULTS: Despite routine low-dose vitamin supplementation in HD, plasma PLP was decreased in HD (79 +/- 69 nmol/l) compared with CKD stage 2-4 patients (497 +/- 944 nmol/l), RTR (416 +/- 604 nmol/l) and controls (159 +/- 230 nmol/l; p < 0.001). Plasma PA was significantly increased in HD (11,667 +/- 17,871 nmol/l) in comparison with CKD stage 2-4 (435 +/- 441 nmol/l), RTR (583 +/- 668 nmol/l) and controls (46 +/- 49 nmol/l; p < 0.001). B(6) forms were significantly affected by renal function (R = 0.792, p < 0.001 for CKD stage 2-4). There was no relation of vitamers with a history of CVE. Relationships between B(6) forms and AGE (RBC-PMP with pentosidine in CKD stage 2-4: R = -0.351, p < 0.05) were found. CONCLUSION: HD patients showed a deficiency in PLP in plasma but not in RBC. Prospective trials are needed to elucidate the potential role of elevated PA on cardiovascular and renal outcome in CKD. Vitamin B(6) supplementation might be successful in preventing AGE-related pathologies.

Real-world data confirm the effectiveness of caplacizumab in acquired thrombotic thrombocytopenic purpura.

Acquired thrombotic thrombocytopenic purpura (aTTP) is a rare but life-threatening condition. In 2018, the nanobody caplacizumab was approved for the treatment of adults experiencing an acute episode of aTTP, in conjunction with plasma exchange (PEX) and immunosuppression for a minimum of 30 days after stopping daily PEX. We performed a retrospective, observational analysis on the use of caplacizumab in 60 patients from 29 medical centers in Germany during acute disease management. Caplacizumab led to a rapid normalization of the platelet count (median, 3 days; mean 3.78 days). One patient died after late treatment initiation due to aTTP-associated complications. In 2 patients with initial disease presentation and in 4 additional patients with laboratory signs of an exacerbation or relapse after the initial therapy, PEX-free treatment regimens could be established with overall favorable outcome. Caplacizumab is efficacious in the treatment of aTTP independent of timing and ancillary treatment modalities. Based on this real-world experience and published literature, we propose to administer caplacizumab immediately to all patients with an acute episode of aTTP. Treatment decisions regarding the use of PEX should be based on the severity of the clinical presentation and known risk factors. PEX might be dispensable in some patients.

ADAMTS13 and VWF activities guide individualized caplacizumab treatment in patients with aTTP.

Introduction of the nanobody caplacizumab was shown to be effective in the treatment of acquired thrombotic thrombocytopenic purpura (aTTP) in the acute setting. The official recommendations include plasma exchange (PEX), immunosuppression, and the use of caplacizumab for a minimum of 30 days after stopping daily PEX. This study was a retrospective, observational analysis of the use of caplacizumab in 60 patients from 29 medical centers in Germany. Immunosuppressive treatment led to a rapid normalization of ADAMTS13 activities (calculated median, 21 days). In 35 of 60 patients, ADAMTS13 activities started to normalize before day 30 after PEX; in 11 of 60 patients, the treatment was extended beyond day 30; and in 5 patients, it was extended even beyond day 58 due to persistent autoimmune activity. In 34 of 60 instances, caplacizumab was stopped before day 30 with a favorable outcome whenever ADAMTS13 activities were >10%. In contrast, 11 of 34 patients with ADAMTS13 activities <10% at the time of stopping caplacizumab treatment developed a nonfavorable outcome (disease exacerbation or relapse). In some cases, prolongation of the treatment interval to every other day was feasible and resulted in a sustained reduction of von Willebrand factor activity. ADAMTS13 activity measurements are central for a rapid diagnosis in the acute setting but also to tailor disease management. An ADAMTS13 activity-guided approach seems safe for identifying the individual time point when to stop caplacizumab to prevent overtreatment and undertreatment; this approach will result in significant cost savings without jeopardizing the well-being of patients. In addition, von Willebrand factor activity may serve as a biomarker for drug monitoring.

Pregnancy-associated thrombotic thrombocytopenic purpura.

Thrombocytopenia during pregnancy is a common diagnostic and management problem. Several differential diagnosis must be considered including manifestations of thrombotic thrombocytopenic purpura (TTP). We report here on a case of a 21-year-old pregnant woman who presented initially severe thrombocytopenia (8 Gpt/l) in the 20(th)+1 week of gestation. The patient had an antibody against ADAMTS13, and enzyme activity was <5%. Immediate plasmapheresis treatment was initiated, followed by plasma infusions, and again plasmapheresis. A male neonate was delivered by caesarean section in the 32(nd )week of gestation. The child had an uncomplicated postnatal development. After delivery, the mother's platelet count and ADAMTS13 activity increased to normal values. This case shows interesting aspects of TTP in pregnancy and a close cooperation between obstetricians, nephrologists and pediatricians is necessary for a successful outcome of the pregnancy.

Cholesterol embolization in a renal graft.

Cholesterol embolization into native kidneys has a dim prognosis for renal function and frequently leads to irreversible renal failure. Although uncommon, cholesterol embolization may also occur in renal allografts, particularly if either the recipient or the donor has prominent atherosclerosis. We report here on a case of a 65-yr-old man with cholesterol emboli in the renal allograft and delayed graft function. The recipient's arteria iliaca externa was a potential source because of heavy atherosclerosis. The patient was dialysis-dependent for two wk after transplantation. However, renal function improved, no cholesterol emboli were found in a second biopsy of the graft and serum creatinine is 260 micromol/L six months after the transplantation. In the case of primary renal non-function or dysfunction, cholesterol embolization must be considered in the differential diagnosis. If renal cholesterol embolization originates from the recipient, allograft survival is usually good. In contrast, if cholesterol embolization is of donor origin, graft dysfunction and subsequent graft loss are common. The reason for this difference may be the more extensive embolization developing in an atherosclerotic cadaver donor occurring during the organ procurement or the severe trauma leading to death.

[Eosinophilia--a challenging differential diagnosis]. / Eosinophilie--eine differentialdiagnostische Herausforderung.

BACKGROUND: Eosinophilia is not uncommon in clinical practice. The main causes are allergies and parasitic infections. Rarely, eosinophilia is associated with pulmonary affections, malignant tumors, gastroenteritis, and autoimmune diseases. A new classification based on pathophysiological data for the hypereosinophilic syndrome in order to simplify diagnosis and therapy was introduced in 2006. CASE REPORT: A 22-year-old man was admitted to another hospital because of acute abdominal pain. An unspecific colitis was diagnosed. Blood counts showed a mild neutrophilic leukocytosis (12.6 Gpt/l) with a severe relative eosinophilia (30%), thrombocytopenia (67 Gpt/l), and an increased C-reactive protein (CRP 122 mg/l). The patient also had a deep venous thrombosis of the left leg. An explorative laparotomy was performed because of a strong suspicion of a presacral abscess. Pulmonary embolism and embolic pneumonia developed after surgery. A macular-cockade exanthema on the trunk and extremities was found. Histological examination revealed perivascular eosinophilic infiltrates. Histological and cytological analysis of bone marrow showed many eosinophilic granulocytes and a hypercellular medulla without increased numbers of blasts. No parasites in the blood and stools were found, and there was no evidence of neoplasm or cardiac involvement. p- and c-ANCAs (antineutrophil cytoplasmic antibodies), ANAs (antinuclear antibodies), and antibody against dsDNA were negative. Further genetic, FISH (fluorescence in situ hybridization), and PCR (polymerase chain reaction) analyses showed no evidence for chromosomal aberrations. An undefined hypereosinophilic syndrome with multiple organ involvement was diagnosed. Shortly after starting an oral prednisolone therapy (1 mg/kg body weight), the eosinophilia normalized. This therapy was stopped after 2 months and the patient is now, 6 months after diagnosis, in normal health. CONCLUSION: As demonstrated in this case, eosinophilia requires a broad differential diagnosis. A hypereosinophilic syndrome can involve many organs and mimic other diseases. The new classification of the hypereosinophilic syndrome from 2006, based on pathophysiological insights, may foster better diagnosis and therapy for this rare disease.

[Treatment of idiopathic membranous nephropathy. Is the anti-CD20 antibody rituximab a reasonable option?]. / Behandlung der idiopathischen membranösen Glomerulonephritis. Ist der Anti-CD20-Antikörper Rituximab eine sinnvolle Therapieoption?

BACKGROUND: Membranous nephropathy (MN) is characterized by proteinuria and other symptoms of the nephrotic syndrome. In many cases, the etiology is unknown. Whether and how to treat MN is still a controversial question. Despite the use of corticosteroids and alkylating agents, up to 40% of patients still progress to end-stage renal failure. CASE REPORT: A 40-year-old male patient with biopsy-proven idiopathic MN was initially treated with prednisolone and chlorambucil because of a proteinuria of 22 g/d. Treatment with cyclosporine was started because the nephrotic syndrome failed to improve. Proteinuria was reduced to a minimum of 4 g/d. Cyclosporine was stopped after 17 months leading to a fast relapse. Therapy with an ACE inhibitor and AT(1) receptor antagonist and retreatment with cyclosporine improved proteinuria. Cyclosporine was terminated after a total of 24 months. 5 months later, relapse occurred with a high proteinuria of 34 g/d. The monoclonal anti-CD20 antibody rituximab (375 mg/m(2)) was given four times every 4 weeks. 4 weeks and 4 months after the end of treatment, proteinuria decreased to 780 mg/d and <150 mg/d, but renal function remained impaired (creatinine clearance 65 ml/min, stage 2 according to K/DOQI). Now, remission of proteinuria (<150 mg/d) has been stable for almost 2 years. However, renal insufficiency progressed further (creatinine clearance 45 ml/min, stage 3 according to K/DOQI). CONCLUSION: Rituximab offers the possibility for a targeted treatment of idiopathic MN. Based on the existing evidence and experience from this case, rituximab can be recommended as a new treatment option for MN, possibly before starting any treatment with cytotoxic agents and high-dose prednisolone carrying the risk of severe side effects. However, long-term results of this treatment are still lacking.

The advanced glycation end product N(epsilon)-carboxymethyllysine is not a predictor of cardiovascular events and renal outcomes in patients with type 2 diabetic kidney disease and hypertension.

BACKGROUND: Advanced glycation end products (AGEs) are implicated in the pathogenesis of vascular damage, especially in patients with diabetes and renal insufficiency. The oxidatively formed AGE N(epsilon)-carboxymethyllysine (CML) is thought to be a marker of oxidative stress. METHODS: Four hundred fifty patients with type 2 diabetes and nephropathy from the Irbesartan in Diabetic Nephropathy Trial cohort (mean age, 58 +/- 8.2 years; 137 women, 313 men) with a mean glomerular filtration rate of 48.2 mL/min (0.80 mL/s; Modification of Diet in Renal Disease formula) were followed up for 2.6 years. Serum CML was measured by using an enzyme-linked immunosorbent assay. Relationships between CML levels, traditional risk factors, and cardiovascular and renal events were tested in Cox proportional hazards models. RESULTS: Mean serum CML level was 599.9 +/- 276.0 ng/mL, and mean hemoglobin A1c level was 7.5% +/- 1.6%. One hundred forty-three first cardiovascular events occurred during follow-up; 74 patients died, 44 of cardiovascular causes. Final multivariate analysis showed age (relative risk [RR], 1.87; confidence interval [CI], 1.13 to 3.11; P = 0.016 for the highest compared with lowest quartile), history of prior cardiovascular events (RR, 1.96; CI, 1.35 to 2.85; P < 0.0005), and 24-hour urinary albumin-creatinine ratio (RR, 1.29; CI, 1.11 to 1.50 per doubling; P < 0.0005) to be independent risk factors for a first cardiovascular event, but not CML level. CML level also did not correlate significantly with renal outcome. CONCLUSION: Serum CML level could not be identified as an independent risk factor for cardiovascular or renal outcomes in the examined population. This suggests that traditional risk factors might have a more important role for these end points or that other AGE compounds, as well as tissue AGE levels, might be of greater relevance compared with serum levels, which remains open to further study.

Autoantibodies against thrombospondin type 1 domain-containing 7A induce membranous nephropathy.

Membranous nephropathy (MN) is the most common cause of nephrotic syndrome in adults, and one-third of patients develop end-stage renal disease (ESRD). Circulating autoantibodies against the podocyte surface antigens phospholipase A2 receptor 1 (PLA2R1) and the recently identified thrombospondin type 1 domain-containing 7A (THSD7A) are assumed to cause the disease in the majority of patients. The pathogenicity of these antibodies, however, has not been directly proven. Here, we have reported the analysis and characterization of a male patient with THSD7A-associated MN who progressed to ESRD and subsequently underwent renal transplantation. MN rapidly recurred after transplantation. Enhanced staining for THSD7A was observed in the kidney allograft, and detectable anti-THSD7A antibodies were present in the serum before and after transplantation, suggesting that these antibodies induced a recurrence of MN in the renal transplant. In contrast to PLA2R1, THSD7A was expressed on both human and murine podocytes, enabling the evaluation of whether anti-THSD7A antibodies cause MN in mice. We demonstrated that human anti-THSD7A antibodies specifically bind to murine THSD7A on podocyte foot processes, induce proteinuria, and initiate a histopathological pattern that is typical of MN. Furthermore, anti-THSD7A antibodies induced marked cytoskeletal rearrangement in primary murine glomerular epithelial cells as well as in human embryonic kidney 293 cells. Our findings support a causative role of anti-THSD7A antibodies in the development of MN.

Polyomavirus DNA and RNA detection in renal allograft biopsies: results from a European multicenter study.

Polyomavirus mediated nephropathy is an increasingly recognized complication in renal transplant recipients. In all, 362 renal biopsies collected from 15 European transplant centers were analyzed for presence of Polyomavirus nucleic acid (BK virus [BKV] and JC virus [JCV]). We evaluated 302 biopsies of patients with renal allograft dysfunction, including three with known BKV allograft nephropathy (BKVAN), and 60 native kidney biopsies. BKV DNA was detected in 8 of the 302 (2.6 %) biopsies obtained for transplant dysfunction, but in none of the controls. BKV RNA, indicating active viral replication, was found in all BKV DNA positive biopsies available for mRNA expression studies. Retrospective immunohistochemical staining was positive for SV40 large T antigen in all seven evaluated biopsies. BKV DNA and RNA were detected in biopsy tissues from patients with inconspicuous light microscopy for BKVAN. Further studies will evaluate the potential of intrarenal viral BKV RNA as an early predictor for BKVAN.

[Pregnancy-associated thrombotic microangiopathy--a diagnostic and therapeutic challenge]. / Schwangerschaftsassoziierte thrombotische Mikroangiopathie--eine diagnostische und therapeutische Herausforderung.

BACKGROUND: Thrombotic microangiopathies are diseases rarely associated with pregnancy. The pathogenesis might be related to severe preeclampsia and HELLP syndrome. CASE REPORT: In May 2000, we saw a 26-year-old primigravida in the 39th gestational week with worsening anemia, thrombocytopenia, and increasing liver enzymes. The diagnosis of HELLP syndrome was made and delivery initiated. Postpartum liver function stabilized, but anemia, thrombocytopenia, and preexisting hypertension worsened. Additionally, renal function deteriorated, and she had to be dialyzed 12 days after delivery. Renal biopsies were performed on day 12, 34, and 60 after delivery. The material showed a thrombotic microangiopathy, initially in an active stage. Later, fibrosis of the preglomerular arterioles and the glomeruli as well as progressive tubulointerstitial damage could be shown. Plasmapheresis was started; substitution was performed with fresh frozen plasma (FFP). Simultaneously, the patient was treated with corticosteroids. After 24 days, we began with cyclophosphamide pulses. Overall, 28 plasmapheresis sessions and three cyclophosphamide pulses were given. In spite of this aggressive regimen, renal function did not recompensate, and renal replacement therapy with continuous ambulatory peritoneal dialysis (CAPD) was initiated. CONCLUSION: This course shows that mortality could be decreased using plasmapheresis therapy, but further research is needed to introduce more specific, kidney-protective regimens.

[Oscillation between BK virus nephropathy and rejection--the frustrating course of a living donor transplantation]. / Wechsel zwischen BK-Virus-Nephropathie und Abstossung--der frustrane Verlauf einer Lebendnierenspende.

CASE REPORT: A 56-year-old male patient with terminal renal insufficiency received a living donor kidney transplant from his wife in June 2007. Initial immunosuppression consisted of prednisolone, tacrolimus, and mycophenolate mofetil (MMF). 4 months after transplantation, the serum creatinine increased to 192 micromol/l and urinary analysis revealed the presence of decoy cells. A biopsy showed a focal interstitial nephritis and SV40 antigen was detected in tubular nuclei. Polymerase chain reaction (PCR) in serum and urine showed high titers of BK virus. Tacrolimus was stopped, MMF was reduced, and leflunomide (20 mg/day) was started. The patient was readmitted because the serum creatinine further increased to 262 micromol/l. Leflunomide concentrations were in the target range, but renal biopsy still revealed the presence of BK virus nephropathy. MMF was stopped. Serum creatinine stabilized at 233 micromol/l and PCR for BK virus in serum was negative. In April 2008, a deterioration of renal function occurred (serum creatinine 308 micromol/l) and renal biopsy revealed signs of acute interstitial rejection without the presence of SV40 antigen. A methylprednisolone pulse therapy for 5 days was performed and cyclosporine was added. After a few weeks serum creatinine increased to 444 micromol/l and a new biopsy revealed the reoccurrence of BK virus nephropathy. Since the tubulointerstitial injury was > 80%, no further therapy was performed and soon after dialysis therapy was initiated. CONCLUSION: BK virus nephropathy is a still rare, but increasing complication of renal transplantation, presumably mediated by intensive immunosuppression. The disease can induce graft dysfunction and may ultimately lead to graft failure. BK virus nephropathy can trigger acute rejection. Unfortunately, therapy of BK virus nephropathy and acute rejection is just the opposite: BK virus nephropathy requires a reduction of immunosuppression whereas acute rejection calls for intensification. A potential therapeutic approach may be leflunomide, an immunosuppressive substance with antiviral properties, but potential severe side effects. The described case demonstrates the frustrating course of a graft from a living donor despite initial successful therapy with leflunomide and illustrates the problems choosing between intensive and moderate immunosuppression.

Cerebral involvement in a patient with Goodpasture's disease due to shortened induction therapy: a case report.

INTRODUCTION: Goodpasture's disease is a rare immunological disease with formation of pathognomonic antibodies against renal and pulmonary basement membranes. Cerebral involvement has been reported in several cases in the literature, yet the pathogenetic mechanism is not entirely clear. CASE PRESENTATION: A 21-year-old Caucasian man with Goodpasture's disease and end-stage renal disease presented with two generalized seizures after a period of mild cognitive disturbance. Blood pressure and routine laboratory tests did not exceed the patient's usual values, and examination of cerebrospinal fluid was unremarkable. Cerebral magnetic resonance imaging (MRI) revealed multiple cortical and subcortical lesions on fluid-attenuated inversion recovery sequences. Since antiglomerular basement membrane antibodies were found to be positive with high titers, plasmapheresis was started. In addition, cyclophosphamide pulse therapy was given on day 13. Encephalopathy and MRI lesions disappeared during this therapy, and antiglomerular basement membrane antibodies were significantly reduced. Previous immunosuppressive therapy was performed without corticosteroids and terminated early after 3 months. The differential diagnostic considerations were cerebral vasculitis and posterior reversible encephalopathy syndrome. Vasculitis could be seen as an extrarenal manifestation of the underlying disease. Posterior reversible encephalopathy syndrome, on the other hand, can be triggered by immunosuppressive therapy and may appear without a hypertensive crisis. CONCLUSION: A combination of central nervous system symptoms with a positive antiglomerular basement membrane test in a patient with Goodpasture's disease should immediately be treated as an acute exacerbation of the disease with likely cross-reactivity of antibodies with the choroid plexus. In our patient, a discontinuous strategy of immunosuppressive therapy may have favored recurrence of Goodpasture's disease.