Nephrotic Syndrome Associated With Heavy Metals Exposure: A Case Report and Literature Review.

Heavy metals are found in many products used in everyday life. In addition, many workers are exposed to higher concentrations of such metals in their work environment. Many of these metals may cause toxic effects in humans and there are many reports relating them to the occurrence of kidney disorders such as nephrotic syndrome. In this study, we present a case of a 38-year-old woman with nephrotic syndrome suspected to be related to heavy metal toxicity, after ruling out all other secondary causes. At the same time, she proved refractory to multiple therapies. Furthermore, a related literature review regarding the occurrence of nephrotic syndrome in patients with heavy metal exposure is presented with emphasis on the importance of considering them as a secondary cause, especially in cases that appear resistant to treatment.

Immune responses of patients on maintenance hemodialysis after infection by SARS-CoV-2: a prospective observational cohort study.

BACKGROUND: Immune dysregulation in patients with acute COVID-19 under chronic hemodialysis (CHD) is fully not elucidated. The changes of mononuclear counts and mediators before and after HD and associations with final outcome were studied. METHOD: In this prospective study, hospitalized patients with moderate-to-severe COVID-19 under CHD and matched comparators under HD were analyzed for their absolute counts of lymphoid cells and circulating inflammatory mediators. Blood samples were collected before start and at the end of the first HD session; dialysate samples were also collected. RESULT: Fifty-nine patients with acute COVID-19 under CHD and 20 uninfected comparators under CHD were enrolled. Circulating concentrations of tumor necrosis factor-alpha (TNFα), interleukin (IL)-10, interferon-γ and platelet-derived growth factor-A were increased in patients. Concentrations of mediators did not differ before and after HD. Significant decreases of CD4-lymphocytes and CD19-lymphocytes were found in patients. The decrease of the expression of HLA-DR on CD14-monocytes was associated with unfavorable outcome (defined as WHO-CPS 6 or more by day 28); increased counts of CD19-lymphocytes were associated with better outcomes. CONCLUSION: Patients under CHD develop an inflammatory reaction to SARS-CoV-2 characterized by increase of inflammatory mediators, decrease of circulating T-lymphocytes and decrease of the expression of HLA-DR on CD14-monocytes.

Rapidly Progressive Pauci-Immune Glomerulonephritis with Aberrant Fibrinoid Necrosis Associated with Atezolizumab, an Immune Check Point Inhibitor: A Case Report and Review of Literature.

Stimulation of the antitumor activity of the immune system using immune checkpoint inhibitors (ICIs) has proven efficacy in the treatment of multiple types of cancer, inducing the speedily expanding approval of therapeutic indications for ICIs. The literature regarding the immune-related toxicities and nephrotoxicity of ICIs is limited. Herein, we present a patient with lung cancer treated with atezolizumab, an IgG1 monoclonal antibody aimed at the programmed death ligand 1 (PD-L1), who presented with vasculitic skin rash and rapidly deteriorating renal function, new onset of significant glomerular hematuria and proteinuria. The renal biopsy revealed acute necrotizing pauci-immune vasculitis, with fibrinoid necrosis. The patient received a course of high-dose glucocorticoids with recovery of renal function and skin lesions. Further immunosuppressive therapy was withheld, due to active malignancy in the lung, while oncology consultation recommended the continuation of treatment with atezolizumab, as the patient had shown substantial response.

COVID-19 presenting with persistent hiccup and myocardial infarction in a peritoneal dialysis patient: A case report.

BACKGROUND: Persistent hiccups, lasting more than 48 h, have been described as an atypical presentation of coronavirus disease 19 (COVID-19) in the general population. To the best of our knowledge, this is the first report of persistent hiccups and non-ST elevation myocardial injury (NSTEMI) as an atypical presentation of COVID-19 in a peritoneal dialysis (PD) patient. CASE SUMMARY: A 70-year old man, who had been on PD for 3 years with a history of ischemic heart failure and reduced ejection fraction, presented for a scheduled radionuclide myocardial scan. Upon arrival, he complained of anorexia, nausea for 5 d, and unremitting hiccups for the previous 48 h. Clinical and laboratory examinations revealed an NSTEMI plus a positive nasopharyngeal reverse transcriptase polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2. COVID-19 lung involvement was mild and was resolved without specific treatment. Myocardial injury was managed by coronary catheterization and stenting, while hiccups responded only to baclofen per os. CONCLUSION: Persistent hiccups and NSTEMI can be atypical presentations of COVID-19 in peritoneal dialysis patients, which may be due to involvement of the central nervous system and myocardial injuries.

Clinical presentation and outcomes of chronic dialysis patients with COVID-19: A single center experience from Greece.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is still a menacing pandemic, especially in vulnerable patients. Morbidity and mortality from COVID-19 in maintenance hemodialysis (MHD) patients are considered worse than those in the general population, but vary across continents and countries in Europe. AIM: To describe the clinical course and outcomes of hospitalized MHD patients with COVID-19 in a retrospective observational single center study in Greece. METHODS: We correlated clinical, laboratory, and radiological data with the clinical outcomes of MHD patients hospitalized with COVID-19 during the pandemic. The diagnosis was confirmed by real-time polymerase chain reaction. Outcome was determined as survivors vs non-survivors and "progressors" (those requiring oxygen supplementation because of COVID-19 pneumonia worsening) vs "non-progressors". RESULTS: We studied 32 patients (17 males), with a median age of 75.5 (IQR: 58.5-82) years old. Of those, 12 were diagnosed upon screening and 20 with related symptoms. According to the World Health Organization (WHO) score, the severity on admission was mild disease in 16, moderate in 13, and severe in 3 cases. Chest computed tomography (CT) showed 1-10% infiltrates in 24 patients. Thirteen "progressors" were recorded among included patients. The case fatality rate was 5/32 (15.6%). Three deaths occurred among "progressors" and two in "non-progressors", irrespective of co-morbidities and gender. Predictors of mortality on admission included frailty index, chest CT findings, WHO severity score, and thereafter the increasing values of serum LDH and D-dimers and decreasing serum albumin. Predictors of becoming a "progressor" included increasing number of neutrophils and neutrophils/lymphocytes ratio. CONCLUSION: Patients on MHD seem to be at higher risk of COVID-19 mortality, distinct from the general population. Certain laboratory parameters on admission and during follow-up may be helpful in risk stratification and management of patients.

Case Report of Cardiorenal Syndrome with Ascites and Listeria monocytogenes Peritonitis: The Role of Large-Volume Paracentesis and Albumin Replacement.

BACKGROUND Spontaneous bacterial peritonitis is a common infection in hospitalized patients with ascites, particularly in patients with cirrhosis. Spontaneous bacterial peritonitis is often associated with acute kidney injury. The causative agents of spontaneous bacterial peritonitis are usually gram-negative bacteria, but lately, the prevalence of spontaneous bacterial peritonitis caused by gram-positive bacteria is rising. CASE REPORT In this report, we present the case of a 77-year-old woman with a history of cardiorenal syndrome with ascites and chronic kidney disease who was admitted with diarrhea, fever, and abdominal pain. Ascitic fluid paracentesis revealed spontaneous bacterial peritonitis due to Listeria monocytogenes. During hospitalization, her ascites gradually enlarged and her kidney function deteriorated. The deterioration of kidney function was at least partially attributed to sepsis caused by spontaneous bacterial peritonitis. In addition to proper antibiotic therapy with ampicillin and daily hemodialysis sessions, large-volume paracentesis and albumin infusions were instituted. After 5 days, she showed a fast improvement, the ascites subsided, and her renal function returned to baseline. CONCLUSIONS Spontaneous bacterial peritonitis caused by Listeria monocytogenes is associated with a poor outcome. Acute kidney injury in patients with spontaneous bacterial peritonitis is common and related with a poor outcome. Data about the role of large-volume paracentesis and albumin replacement in patients with spontaneous bacterial peritonitis are still ambiguous. In the literature, all patients with spontaneous bacterial peritonitis due to Listeria monocytogenes who underwent large-volume paracentesis survived.

Siblings with coronavirus disease 2019 infection and opposite outcome-the hemodialysis's better outcome paradox: Two case reports.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a highly contagious infection caused by the severe acute respiratory syndrome coronavirus 2 virus and has a unique underlying pathogenesis. Hemodialysis (HD) patients experience high risk of contamination with COVID-19 and are considered to have higher mortality rates than the general population by most but not all clinical series. We aim to highlight the peculiarities in the immune state of HD patients, who seem to have both immune-activation and immune-depression affecting their outcome in COVID-19 infection. CASE SUMMARY: We report the opposite clinical outcomes (nearly asymptomatic course vs death) of two diabetic elderly patients infected simultaneously by COVID-19, one being on chronic HD and the other with normal renal function. They were both admitted in our hospital with COVID-19 symptoms and received the same treatment by protocol. The non-HD sibling deteriorated rapidly and was intubated and transferred to the Intensive Care Unit, where he died despite all supportive care. The HD sibling, although considered more "high-risk" for adverse outcome, followed a benign course and left the hospital alive and well. CONCLUSION: These cases may shed light on aspects of the immune responses to COVID-19 between HD and non-HD patients and stimulate further research in pathophysiology and treatment of this dreadful disease.

Current Concepts in Compressive Neuropathies of the Upper Extremity.

The carpal and cubital tunnel syndromes are the most common compression neuropathies of the upper extremity. Although the diagnosis and management of these neuropathies have evolved over the past few decades, the ideal primary surgical treatment has not yet been established and management of recurrence remains a challenge. Revision surgery with simple repeated nerve decompression even accompanied by neurolysis does not always result in satisfactory clinical outcomes. Coverage with soft tissue or wrapping of the nerve with biologic or synthetic protective barriers can be used as an ancillary technique in the revision surgery to enhance nerve healing, preventing perineural scarring and adhesions. Future randomized larger trials combined with better understanding of nerve biology may be necessary to optimize primary and revision surgical treatment for carpal and cubital tunnel syndrome.