Bile Cast Nephropathy in Cirrhotic Patients: Effects of Chronic Hyperbilirubinemia.

OBJECTIVES: The aim of this study was to determine the prevalence of bile cast nephropathy (BCN) in autopsied cirrhotic patients and to correlate BCN with clinical and laboratory data to direct attention to this underrecognized renal complication of liver failure. METHODS: We assessed 114 autopsy cases of cirrhosis for the presence of renal intratubular bile casts using Hall stain for bile. Presence of bile casts was correlated with etiology of cirrhosis, clinical and laboratory data, and histologic findings. RESULTS: Bile casts were identified in 55% of cases. The most common etiology of cirrhosis was hepatitis C virus (HCV) infection (52%), and serum creatinine ( P = .02) and serum urea nitrogen ( P = .01) were significantly higher in the Hall-positive group. Conjugated bilirubin was below 20 mg/dL in 90%, and levels below 10 mg/dL were noted in 80% of cases. CONCLUSIONS: To our knowledge, this is the largest study of BCN in human subjects and a first report describing the association of BCN with HCV-related cirrhosis. We demonstrated that in the face of protracted chronic hyperbilirubinemia, bile casts are formed at much lower bilirubin levels than previously thought. Furthermore, we proposed an algorithm to assist in better identification of bile casts.

Levamisole-Adulterated Cocaine Nephrotoxicity: Ultrastructural Features.

OBJECTIVES: The issue of levamisole-adulterated cocaine is emerging as a rapidly growing public health concern due to an increasing number of reports describing its role in cutaneous vasculitis and agranulocytosis. Of note, levamisole is recognized as a contaminant in 69% of the cocaine used within the United States. METHODS: We describe a patient who was a chronic cocaine user and developed systemic vasculitis characterized by polyarthralgia, bullous skin lesions, agranulocytosis, and antineutrophil cytoplasmic antibody-positive rapidly progressive glomerulonephritis. RESULTS: The skin biopsy specimen demonstrated leukocytoclastic vasculitis. The renal biopsy specimen revealed pauci-immune necrotizing and crescentic glomerulonephritis and unusual deposits with medium electron density composed of granules, microspherules, and rare single fibrils on electron microscopy. CONCLUSIONS: The electron microscopic features of levamisole-adulterated cocaine toxicity are novel findings that are presented for the first time, to our knowledge, in this report.

Integrating geriatric content into a medical school curriculum: description of a successful model.

Most medical school curricula do not equip students with adequate attitudes, knowledge and skills to care for elderly populations. We describe an effective geriatric curricular infusion model compatible with preserving the overall curricula schema. Course and clerkship directors, staff and faculty from the Office of Educational Development, Center on Aging, curriculum committee and Associate/Assistant Deans of Education, and faculty from the schools of medicine, nursing, and allied health collaborated in the effort. Each of these components and institutional financial commitment were critical to successful basic science and clinical geriatric content infusion addressing the American Geriatric Society (AGS) Core Competencies. Delivery modalities included problem- based learning cases, lectures, standardized patient portrayals for teaching and assessment, and experiential activities with elderly. Assessments were conducted and outcomes tracked in several ways, including: (1) annual course reviews, focus groups, and student evaluations; (2) mandatory geriatrics 4th year graduation competency exam; and, (3) AAMC Graduation Questionnaire responses. Initial data indicate that student knowledge and competencies have increased with increasing exposure in the desired areas, and support infusion as a viable approach to enhancing gerontology and geriatric curricular content.