Acute Kidney Injury and Hair-Straightening Products: A Case Series.

RATIONALE & OBJECTIVE: Keratin-based hair-straightening treatment is a popular hair-styling method. The majority of keratin-based hair-straightening products in Israel contain glycolic acid derivatives, which are considered safe when used topically. Systemic absorption of these products is possible, and anecdotal reports have described kidney toxicity associated with their use. We report a series of cases of severe acute kidney injury (AKI) following use of hair-straightening treatment in Israel during the past several years. STUDY DESIGN: Case series. SETTING & PARTICIPANTS: We retrospectively identified 26 patients from 14 medical centers in Israel who experienced severe AKI and reported prior treatment with hair-straightening products in 2019-2022. FINDINGS: The 26 patients described had a median age of 28.5 (range, 14-58) years and experienced severe AKI following a hair-straightening procedure. The most common symptoms at presentation were nausea, vomiting, and abdominal pain. Scalp rash was noted in 10 (38%) patients. Two patients experienced a recurrent episode of AKI following a repeat hair-straightening treatment. Seven patients underwent kidney biopsies, which demonstrated intratubular calcium oxalate deposition in 6 and microcalcification in tubular cells in 1. In all biopsies, signs of acute tubular injury were present, and an interstitial infiltrate was noted in 4 cases. Three patients required temporary dialysis. LIMITATIONS: Retrospective uncontrolled study, small number of kidney biopsies. CONCLUSIONS: This series describes cases of AKI with prior exposure to hair-straightening treatments. Acute oxalate nephropathy was the dominant finding on kidney biopsies, which may be related to absorption of glycolic acid derivatives and their metabolism to oxalate. This case series suggests a potential underrecognized cause of AKI in the young healthy population. Further studies are needed to confirm this association and to assess the extent of this phenomenon as well as its pathogenesis.

Optimal peritoneal fluid white blood cell count for diagnosis of peritonitis in peritoneal dialysis patients.

BACKGROUND: The diagnosis of peritonitis among peritoneal dialysis (PD) patients is based on clinical presentation, dialysis effluent white blood cell (WBC) count, and dialysis effluent culture. Peritoneal fluid WBC count is very important in the initial diagnosis of peritonitis. The purpose of this work was to determine the optimal number of peritoneal WBCs with different clinical presentations at admission to define PD-related peritonitis. METHODS: Medical records of chronic PD patients who underwent work-up for suspected peritonitis between 2008 and 2019 were reviewed retrospectively. Results of all peritoneal WBC count tests during this period were collected. Clinical manifestations and follow-up analysis of each peritoneal WBC count were performed. RESULTS: The peritoneal WBC count cutoff of 100/µL recommended by International Society for Peritoneal Dialysis provided specificity of only 35%. Increasing peritoneal WBC count cutoff to 150, 200, and 250/µL provided sensitivity around 98% and gradually increasing specificity. The chi-square automatic interaction detector model of statistical analysis determined that peritoneal WBC count below 230/µL combined with absence of inflammatory markers (fever, increased C-reactive protein) ruled out peritonitis with 99.8% sensitivity. Peritoneal fluid WBC count cutoff of 230/µL provided specificity of 89% and good positive and negative likelihood scores of 8.3 and 0.03, respectively. Peritoneal fluid polymorphonuclear count has lower discriminating ability for peritonitis compared to peritoneal fluid WBC count. CONCLUSION: Increasing peritoneal fluid WBC count cutoff to 230/µL in suspected PD-related peritonitis could improve specificity without compromising the sensitivity of the test.

Acute Kidney Injury following Exposure to Formaldehyde-Free Hair-Straightening Products.

Formaldehyde-free hair-straightening products are hair-smoothening solutions widely used by professional beauty salons. Formaldehyde-free hair straighteners do not technically contain formaldehyde; however, they contain other chemicals such as glyoxyloyl carbocysteine which releases formaldehyde upon contact with heat. Moreover, its by-product glyoxylate may convert to oxalate; both compounds have potential nephrotoxic effect. Here, we report a case of a 41-year-old woman who presented to the emergency room with weakness, nausea, vomiting, and stage 3 acute kidney injury (AKI) according to Kidney Disease: Improving Global Outcomes (KDIGO) acute kidney injury staging shortly after exposure to formaldehyde-free hair-straightening product; other causes of AKI were excluded such as preceding acute illness, drug history, or other nephrotoxic agent exposure. On physical examination, the patient was pale, and her vital signs were normal. The urine microscopy and serologic workup were not indicative. Kidney core biopsy revealed interstitial edema, acute interstitial nephritis, and oxalate crystal nephropathy. Kidney function completely recovered after a short course of steroid therapy. In this case, AKI was a complication caused by exposure to hair-straightening products branded as formaldehyde free but actually containing other chemical products which release formaldehyde and other toxic chemicals when heated during the straightening procedure and may cause systemic toxicity, particularly kidney injury. Different cosmetic products are widely in use, but not all are under tight regulation, and therefore, it is important to raise the awareness among both medical teams and consumers of possible adverse health effects of different cosmetic products.

Treatment of Severe Renal Artery Stenosis with Acute Kidney Injury Requiring Hemodialysis by Percutaneous Transluminal Renal Angioplasty and Stent Implantation.

PURPOSE: To evaluate the outcomes of percutaneous transluminal renal angioplasty with stent implantation (PTRAS) among patients with renal artery stenosis (RAS) who become dialysis-dependent due to acute deterioration of renal function. MATERIALS AND METHODS: This was a single-center retrospective cohort study of all PTRAS procedures performed from 2003 to 2019 in a referral hospital. A total of 109 procedures were performed in 92 patients. Eleven patients (12%) presented with anuric acute kidney injury (AKI) secondary to high-grade RAS (defined as intraluminal stenosis above 70% per angiography) and underwent PTRAS after starting hemodialysis. Data collected included demographic parameters, medical background, creatinine, blood pressure, indication for intervention, procedure characteristics, adverse events, and long-term data including dialysis treatment and mortality. Among the dialysis-dependent AKI group, outcome measures were defined based on the postprocedural improvement in kidney function and discontinuation of dialysis. RESULTS: Following PTRAS, 8 of 11 patients (73%) demonstrated improved kidney function and were able to discontinue dialysis. The median time on dialysis was 18 days (range, 2-35 days) before PTRAS and 4.5 days (range, 1-24 days) to recovery of kidney function after the time of intervention. CONCLUSIONS: Patients with atherosclerotic RAS who develop RAS-related AKI may benefit from PTRAS even after several weeks of anuria and dialysis dependence.

Regular at-home abdominal paracentesis via Tenckhoff catheter in patients with refractory congestive heart failure.

BACKGROUND: Peritoneal dialysis (PD) is increasingly used for the long-term management of refractory congestive heart failure (CHF). Patients with severe CHF and ascites were treated with regular at-home abdominal paracentesis via Tenckhoff catheter. We investigated the outcome of those patients, aiming to identify potential prognostic factors for longer survival. METHODS: Patients with refractory CHF referred by cardiologists to the PD unit from years 2009 to 2019 and treated with regular at-home abdominal paracentesis via Tenckhoff catheter without peritoneal exchanges, were enrolled into this prospective observational study. RESULTS: From the total of 69 refractory CHF patients treated with PD, 18 (26%) were managed with regular at-home abdominal paracentesis via Tenckhoff catheter and improved without the need for peritoneal exchanges for fluid removal (no peripheral oedema or pulmonary congestion) or for solutes removal. Median survival of severe CHF patients treated with abdominal paracentesis was 13.5 months (0-34 months). Long-term survivors demonstrated significant improvement in the New York Heart Association (NYHA) functional class, improvement in kidney function and decrease in serum C-reactive protein (CRP) and Brain natriuretic peptide (BNP) compared with their baseline status. A subgroup of patients with shorter survival were more likely to have evidence of liver cirrhosis and significantly lower serum sodium compared with patients with longer survival. CONCLUSIONS: Refractory CHF patients with massive ascites could be successfully treated with regular at-home abdominal paracentesis via Tenckhoff catheter. This treatment provides a useful alternative to periodical percutaneous paracentesis on as-needed basis.

[TREATMENT OF SEVERE ATHEROSCLEROTIC RENAL ARTERY STENOSIS WITH ACUTE KIDNEY INJURY REQUIRING HEMODIALYSIS BY PERCUTANEOUS TRANSLUMINAL RENAL ANGIOPLASTY AND STENT IMPLANTATION].

INTRODUCTION: Treatment of atherosclerotic renal artery stenosis (RAS) is still controversial. Several randomized controlled trials have shown that percutaneous transluminal renal angioplasty with stenting (PTRAS) is not superior to medical treatment, and the procedure is commonly reserved for malignant hypertension, flash pulmonary edema or deterioration of kidney function. The most challenging symptomatic RAS cases are patients with severe stenosis resulting in acute kidney injury (AKI) requiring acute hemodialysis. The risk-benefit ratio in these cases is uncertain. While those patients might benefit the most from revascularization, the success rate after prolonged time on dialysis is unknown. This is a representative case study of a patient with solitary kidney and high grade RAS who presented with anuric AKI indicated for hemodialysis. Twenty-eight days after starting hemodialysis the patient underwent PTRAS as a rescue therapy and 5 days after the procedure urine output resumed, the patient became polyuric and kidney function improved and the patient stopped hemodialysis.

Medical students' perceptions of pathology and a proposed curricular integration with histology: a future vision of curricular change / Percepciones de los estudiantes de medicina sobre patología y una propuesta de integración curricular con histología: una visión futura de cambio curricular

Students' perceptions and feedback have a significant impact on academic progress. The aim of this study was to determine the perceptions of medical students regarding the cumulative effects of the first year general histology course and the sophomore pathology introductory course, in addition to their perceptions regarding the curricular integration of histology and pathology. In this cross-sectional study, a questionnaire was given to second-year and third-year medical students in the middle of second semester. The questionnaire comprised several items on students' attitudes toward anatomic pathology, their feedback on the first year general histology and the sophomore pathology courses, and their perceptions regarding the integration of histology and pathology courses. A five-point Likert scale was used. Data were analyzed using Statistical Package for the Social Science (SPSS) v 20 software. Two hundreds and fourteen of the 236 questionnaires distributed were analyzed (response rate = 90.7 %). More than 51 % of the respondents reported that they couldn't identify the normal tissue counterpart of most practical pathology cases. Only 31.3 % thought their practical histology knowledge was beneficial for them in practical pathology. More than 87 % agreed or strongly agreed that pathology cases need to be copresented with normal tissue examples. A significant proportion of the respondents (60.7 %) were with merging histology and pathology in integrated courses. Pathology was of career choices for only 15.4 % of the participants. The curricular integration of histology and pathology in the first year needs to be tested, and much effort is needed to increase students' affinity for anatomic pathology.

Las percepciones y comentarios de los estudiantes tienen un impacto significativo en el progreso académico. El objetivo de este estudio fue determinar las percepciones de los estudiantes de medicina con respecto a los efectos acumulativos del curso de Histología general de primer año y del curso introductorio de Patología de segundo año, además de sus percepciones con respecto a la integración curricular de Histología y Patología. En este estudio transversal, se entregó un cuestionario a estudiantes de medicina de segundo y tercer año, a mediados del segundo semestre. Asimismo, el cuestionario comprendió varios aspectos referente a la actitud de los estudiantes hacia Patología Anatómica, sus comentarios sobre la Histología general en el primer año y los cursos de Patología de segundo año. Además se incorporaron las percepciones de los estudiantes con respecto a la integración de los cursos de Histología y Patología. Se utilizó una escala de Likert de cinco puntos. Los datos se analizaron utilizando el paquete Statistical Package for Social Science (SPSS) v 20. Se analizaron 214 de los 236 cuestionarios distribuidos (tasa de respuesta = 90,7 %). Más del 51 % de los encuestados indicaron estar de acuerdo o totalmente de acuerdo, en que no lograron identificar el tejido normal, en la mayoría de los casos de Patología práctica. Solo el 31,3 % observó que su conocimiento de Histología práctica era beneficioso para ellos durante la Patología práctica. Más del 87 % estuvo de acuerdo o muy de acuerdo en que los casos de Patología deben ser analizados con muestras de tejido normal. Un grupo importante de los encuestados (60,7 %) consideraba incorporar la Histología y la Patología en cursos integrados. Patología fue de elección en la carrera para el 15,4 % de los participantes. La integración curricular de Histología y Patología en el primer año, debe ser evaluada con el propósito de incrementar la afinidad de los estudiantes con la Patología Anatómica.

Hypermagnesuria in Humans Following Acute Intravenous Administration of Digoxin.

BACKGROUND: Hypomagnesemia is a known predisposing condition for the appearance of digitalis toxicity. The detection of a genetic form of Mg urinary wasting with hypomagnesemia being caused by a mutation in the γ subunit (FXYD2) of the Na,K-ATPase, the pharmacological target of Digoxin, prompted us to investigate whether Digoxin administration increases urinary Mg excretion. METHODS: Two groups of subjects, with rapid atrial fibrillation, received intravenous Digoxin (n = 9) or verapamil (n = 8), for heart rate control. During the following 4 h, blood and urinary creatinine, sodium, potassium, calcium, and magnesium levels were determined, and fractional excretion (Fex) values for Na, K, Ca, and Mg were calculated. RESULTS: In the Digoxin group, at 60 min Fex Mg rose from 3.07 ± 1.21 to 7.58 ± 2.51% (an increase of 269 ± 107% of baseline, p < 0.001), and at 240 min to 6.05 ± 2.30% (204 ± 56% of baseline, p < 0.01). No significant change was observed for Fex Na, Fex K, and Fex Ca. A striking correlation was found between individual values of Fex Mg and serum Digoxin concentration (r = 0.678, p < 0.0001). No significant correlation was found between Fex Na or Fex K and serum Digoxin. A correlation of borderline significance was found between Fex Ca and serum Digoxin (r = 0.349, p = 0.073). CONCLUSIONS: The hypermagnesuric effect of acute Digoxin treatment is reminiscent of the effect of the missense mutation in FXYD2, which assumes that FXYD2 is a positive regulator of Na,K-ATPase in the distal convoluted tubule (DCT). The borderline calciuric effect of Digoxin may point to an additional site of action, more proximal to the DCT, that is, the thick ascending limb.

Interferon gamma, interferon-gamma-induced-protein 10, and tuberculin responses of children at high risk of tuberculosis infection.

BACKGROUND: Children in contact with adults with pulmonary tuberculosis (TB) are at risk for infection and disease progression, and chemoprophylaxis may reduce this risk. The identification of infection is based on the tuberculin skin test (TST) and interferon-gamma (INF-gamma) release assays. Other biomarkers such as interferon-gamma-induced-protein 10 (IP-10) may have potential for the diagnosis of latent TB infections. OBJECTIVES: To describe IP-10 concentrations and their association to TST and INF-gamma responses in children recently exposed to adults with smear-positive TB in Brazil and Nepal. METHODS: : Two surveys using the same design were undertaken to describe TST, INF-gamma, and IP-10 responses in 146 children in Nepal and 113 children in Brazil. RESULTS: The concordance of TST and QuantiFERON-TB gold in-tube (QFT-IT) was high (kappa 0.73 in Brazil and 0.80 in Nepal). IP-10 responses were higher in children with both positive TST and positive QFT-IT (medians 1434 pg/mL in Brazil and 1402 pg/mL in Nepal) and lowest in children with both negative TST and negative QFT-IT (medians 206 pg/mL in Brazil and 81 pg/mL in Nepal). Children with negative TST and positive QFT-IT had higher IP-10 concentrations than children with positive TST but negative QFT-IT. CONCLUSIONS: IP-10 is a potential marker to identify latent TB infections that is expressed in large quantities and with good agreement with QFT-IT. The reasons for the discrepant results observed are discussed.