Add-On Effect of Angiotensin Receptor Blockade (Candesartan) on Clinical Remission in Active IgA Nephropathy Patients Treated with Steroid Pulse Therapy and Tonsillectomy: a Randomized, Parallel-Group Comparison Trial.

BACKGROUND/AIMS: Angiotensin receptor blockers (ARBs) may be beneficial for clinical remission during conventional therapy with tonsillectomy and steroid pulse (TSP) for active IgA nephropathy. METHODS: Seventy-seven patients with active IgA nephropathy were randomly assigned to the control arm with conventional regimen (TSP followed by oral prednisolone) (n = 37) or the ARB arm with conventional regimen plus ARB candesartan for the first 6 months (n = 40). Patients not achieving proteinuria remission at 12 months in either arm were administered candesartan, which was titrated until the 24-month follow-up. The primary endpoints were remission of proteinuria (< 0.3 g/gCr) and hematuria at 12 months. RESULTS: Baseline proteinuria (g/g Cr) were comparable between the control and ARB arm (1.02 vs. 0.97, P = 0.97). Similarly, cumulative remission rates at 6, 12, and 24 months were comparable between the control and ARB arms (37.8% vs. 35% [P = 0.80], 48.7% vs. 38.5% [P = 0.37], 71.4% vs. 51.3% [P = 0.08]). Proteinuria, which was slightly worse in the control arm than in the ARB arm at 6 months, was comparable afterwards (0.20 vs. 0.23 g/g Cr at 12 months; 0.12 vs. 0.13 g/g Cr at 24 months). Significant reductions observed in urinary angiotensinogen were almost comparable between the two treatment arms at both 6 and 12 months. CONCLUSION: Early candesartan treatment combined with TSP may not benefit clinical remission regardless of the blood pressure. ARB titration later during the treatment might provide benefit for patients with active IgA nephropathy.

[A case of right femoral artery thromboembolism in steroid-dependent nephrotic syndrome].

A 37-year-old man diagnosed with minimal change nephrotic syndrome at the age of 17, was admitted to hospital with leg pain. He had relapsed nephrotic syndrome and thromboembolism of the right femoral and middle cerebral arteries. He was treated with steroid pulse therapy and thrombectomy. Right lower extremity necrosis developed and a below-knee amputation was performed. His nephrotic syndrome and the amputated lower extremity necrosis subsequently improved. Arterial thrombosis is a rare complication of nephrotic syndrome; however, it is a severe complication. Prophylactic anticoagulation should be considered in patients with an increased risk of thrombosis.

Intravenous Tranexamic Acid in Percutaneous Kidney Biopsy: A Randomized Controlled Trial.

BACKGROUND: Tranexamic acid is frequently reported to reduce bleeding-related complications in major surgery and trauma. We aimed to investigate whether tranexamic acid reduced hematoma size after percutaneous kidney biopsy. METHODS: We conducted a double-blind, parallel three-group, randomized placebo-controlled trial at a teaching hospital in Japan between January 2016 and July 2018. Adult patients with clinical indication for ultrasound-guided percutaneous biopsy of a native kidney were included. Participants were randomly assigned into three groups: high-dose tranexamic acid (1,000 mg in total), low-dose tranexamic acid (500 mg in total), or placebo (counterpart saline). Intervention drugs were intravenously administered twice, as a bolus just before the biopsy and as a continuous infusion initiated just after the biopsy. Primary outcome was post-biopsy perirenal hematoma size as measured by ultrasound on the morning after the biopsy. RESULTS: We assessed 90 adult patients for study eligibility, of whom 56 were randomly allocated into the three groups: 20 for high-dose tranexamic acid, 19 for low-dose tranexamic acid, and 17 for placebo. The median size of perirenal hematoma was 200 mm2 (interquartile range, 21-650) in the high-dose tranexamic acid group, 52 mm2 (0-139) in the low-dose tranexamic acid group, and 0 mm2 (0-339) in the placebo group (p = 0.048 for high-dose tranexamic acid vs. placebo). CONCLUSION: In this trial, the median size of post-kidney biopsy hematoma was unexpectedly larger in the high-dose tranexamic acid group than in the placebo group. Although our results do not support the routine use of tranexamic acid in percutaneous kidney biopsy at present, further studies are needed to confirm the results.

Factors Associated with Secondary Functional Patency After Percutaneous Transluminal Angioplasty of the Early Failing or Immature Hemodialysis Arteriovenous Fistula.

PURPOSE: To evaluate the efficacy of percutaneous transluminal angioplasty for early failing hemodialysis arteriovenous fistulas (AVFs) and predictors of secondary functional patency (FP). METHODS: A review of our endovascular registry database showed that 61 patients with early failure after a surgically created AVF underwent endovascular intervention between 2011 and 2016. Median time from AVF creation to first intervention was 5.6 weeks. Median duration of follow-up was 14 months. Items related to the technical success rate and primary and secondary FP, and factors associated with secondary FP were analyzed. RESULTS: Technical success was achieved in 55 (90%) of 61 patients. The primary and secondary FP rates were 42% and 65% at 12 months, respectively. Multivariate analysis showed that lesion length (HR; 1.15, P = 0.001) and lesions including juxta-AVF (the portion of fistula vein within 2 cm of the arteriovenous anastomosis, HR; 6.23, P = 0.008) were factors associated with reduced secondary FP. ROC curve analysis indicated lesion length with cutoff value ≥ 9 cm as a risk factor for reduced secondary FP. Secondary FP at 12 months for patients with no risk factors, with 1, and with 2 was 86%, 65%, and 0%, respectively. There was a significant difference in secondary FP rates among these groups (P = 0.001). CONCLUSIONS: A lesion length and juxta-AVF lesion are the risk factors for reduced secondary FP. The secondary FP rate at 12 months is acceptable in patients without risk factors.

Carotid thromboembolism associated with nephrotic syndrome treated with dabigatran.

Nephrotic syndrome (NS) may be complicated by thromboembolism, which occasionally manifests as stroke. Although the optimal, standardized approach to the prophylaxis and management of thromboembolic complications associated with NS has not been established, anticoagulation with heparin and subsequent warfarin is the de facto standard of treatment. Dabigatran, a novel direct thrombin inhibitor, has become a substitute for warfarin and heparin for many indications, including the prophylaxis of stroke associated with nonvalvular atrial fibrillation and postoperative thromboprophylaxis in orthopedic patients. We report a 35-year-old male with NS due to membranous nephropathy (MN) that presented with carotid thromboembolism. Because the patient developed drug-induced hepatitis due to warfarin, we attempted treatment with dabigatran and were successful in continuing the medication without any complications. We also reviewed the literature on stroke associated with NS. Twenty-one prior cases have been reported, and the review of these cases revealed some interesting points. The age of onset ranged from 19 to 59 years. Most of the reported cases sustained a stroke at earlier ages than patients with atherosclerosis and atrial fibrillation, which suggests that NS may independently predispose individuals to arterial and venous thromboses. MN was the most common underlying pathology. Given that a standardized approach to the prophylaxis and management of thrombotic complications associated with NS has not been established, our experience suggests that dabigatran is a valid new treatment option for thrombotic complications of NS.

The degree of chills for risk of bacteremia in acute febrile illness.

PURPOSE: Patients with acute febrile illness may experience different degrees of chills. To evaluate the different degrees of chills in predicting risk of bacteremia in patients with acute febrile illness, we performed a single-center prospective observational study. METHODS: We enrolled consecutive adult patients with acute febrile illness presenting to our emergency department. We defined mild chills as cold-feeling equivalent such as the need of an outer jacket; moderate chills as the need for a thick blanket; and shaking chills as whole-body shaking even under a thick blanket. We estimated risk ratios of the different degrees of chills for bacteremia using multivariable adjusted Poisson regression. RESULTS: Of a total 526 patients, 40 patients (7.6%) had bacteremia. There were 65 patients (12.4%) with shaking chills, 100 (19%) with moderate chills, and 105 (20%) with mild chills. By comparing patients with no chills, the risk ratios of bacteremia were 12.1 (95% confidence interval [CI] 4.1-36.2) for shaking chills, 4.1 (95% CI 1.6-10.7) for moderate chills, and 1.8 (95% CI 0.9-3.3) for mild chills. Shaking chills showed a specificity of 90.3% (95% CI 89.2-91.5) and positive likelihood ratio of 4.65 (95% CI 2.95-6.86). The absence of chills showed a sensitivity of 87.5% (95% CI 74.4-94.5) and negative likelihood ratio of 0.24 (95% CI 0.11-0.51). CONCLUSION: Evaluation of the degree of chills is important for estimating risk of bacteremia in patients with acute febrile illness. The more severe degree of chills suggests the higher risk of bacteremia.