Nephrotic syndrome with acute kidney injury due to combination therapy of immune checkpoint inhibitors: a case report and review of the literature.

BACKGROUND: Recent studies have focused on immune checkpoint inhibitors. Renal complications associated with the use of immune checkpoint inhibitors are uncommon compared with other immune-related adverse events. Acute interstitial nephritis accounts for most of these renal complications, with nephrotic syndrome quite rare. We herein report a case of nephrotic syndrome associated with immune checkpoint inhibitors that was more severe than that in previous cases. By comparing this case with previous reports, the possible reasons for the particular severity of this case are discussed. CASE PRESENTATION: A 75-year-old man developed nephrotic syndrome with acute kidney injury after the first combination therapy of nivolumab and ipilimumab for malignant pleural mesothelioma. The results of a kidney biopsy indicated minimal change disease with mild atherosclerosis, acute interstitial nephritis, and fusion of nearly all podocyte foot processes. Nivolumab and ipilimumab therapy were stopped, and treatment with corticosteroids was initiated. We investigated previously reported cases of nephrotic syndrome using immune checkpoint inhibitors. Seventeen cases of immune checkpoint inhibitor-related nephrotic syndrome, including ours, have been reported. Two of the 17 patients with immune checkpoint inhibitor-related nephrotic syndrome required hemodialysis treatment for acute kidney injury. Unlike many previously reported cases, the present patient was administered two different immune checkpoint inhibitors, which may be one of the reasons for the development of severe nephrotic syndrome. CONCLUSIONS: In addition to previously reported risk factors, immune checkpoint inhibitor combination therapy can exacerbate nephrotic syndrome compared to immune checkpoint inhibitor monotherapy.

A case of carcinoid syndrome probably exacerbated by hemodialysis in which prochlorperazine maleate was effective.

Carcinoid syndrome is caused by the release of serotonin and other substances, which commonly occurs due to liver metastasis of neuroendocrine tumors. It rarely occurs due to liver metastasis of neuroendocrine carcinoma. We report the case of a patient with liver metastasis of neuroendocrine carcinoma who suffered from acute abdominal pain and diarrhea triggered by hemodialysis. Various differential diagnoses were considered, but we concluded these symptoms to be probably caused by exacerbation of carcinoid syndrome, as the serum 5HIAA level was markedly elevated, and a drug with anti-serotonin activity was effective. Prochlorperazine maleate, which has anti-serotonin activity, was effective for these symptoms, and the patient was able to continue maintenance hemodialysis, which contributed to his quality of life and prognosis. We speculated the mechanism of carcinoid exacerbation was that substances such as serotonin had entered the systemic circulation via the increased extrahepatic shunt of the portal venous blood flow, entering the inferior vena cava and that this condition had been triggered by hemodialysis via the same mechanism as portal systemic encephalopathy.

High-flow arteriovenous fistula in X-linked Alport syndrome: a case report.

Most male X-linked Alport syndrome patients with COL4A5 nonsense mutations experience end-stage kidney failure by 30 years old. Although there is no definition of high-flow arteriovenous fistula, access blood flows greater than 2000 mL/min might predict the occurrence of high-output heart failure. A 50-year-old Japanese man had suffered from proteinuria at 4 years old and sensorineural hearing loss and a lenticular lens at 20 years old. He had started to receive hemodialysis treatment due to end-stage kidney disease at 22 years old. A genetic test confirmed a novel hemizygous nonsense variant COL4A5 c.2980G > T (p.Gly994Ter), and he was diagnosed with X-linked Alport syndrome. COL4A5 c.2980G > T was considered "pathogenic" according to the American College of Medical Genetics and Genomics guidelines and in vitro experiments. Shortness of breath on exertion was exaggerated, his brachial artery blood flow was over 4,236-4,353 mL/min, his cardiac output was 5,874 mL/min, and he needed radial artery banding at 51 years old. After radial artery banding surgery, the brachial artery blood flow decreased to 987-1,236 mL/min, and echocardiography showed a cardiac output at 5100 mL/min with improved E' and E/E'. His shortness of breath on exertion improved gradually. Although rare, high-output heart failure due to high-flow arteriovenous fistula should be kept in mind as a complication in X-linked Alport syndrome patients, and our patient was successfully treated with radial artery banding surgery.

Mechanical Thrombectomy for Patients with Occlusions in Both the Anterior Cerebral Artery and Middle Cerebral Artery: Case Series and Review of the Literature.

Objective: Most large-vessel occlusions (LVOs) amenable to acute recanalization occur in the internal carotid or middle cerebral artery. However, few LVOs with a multivessel disease can be difficult to treat. This study aimed to determine the outcomes of mechanical thrombectomy in patients with both anterior and middle cerebral artery occlusions. Methods: We retrospectively collected data for patients who had undergone mechanical thrombectomy since January 2016 at Fukushima Medical University and its affiliated institutions (10 institutions). Patients with occluded vessels in the anterior and middle cerebral arteries were selected, and patient background, treatment course, and outcomes were reviewed. Results: A total of 341 mechanical thrombectomies were performed during the study period. Seven patients had occlusions involving both anterior and middle cerebral arteries. In these seven patients, the median time from onset to imaging, imaging to puncture, and puncture to recanalization was 106, 60, and 74 min, respectively. Only one patient (14%) had a modified Rankin Scale of 0-2 at 90 days. Conclusion: Comorbid anterior cerebral artery occlusion may worsen the outcome of patients with middle cerebral artery occlusion.

Putting the Mouth Into the Head-to-Toe Assessment: Nursing Oral Health Assessment Training With an Oral Health Therapist.

BACKGROUND: Oral care is one of the most neglected nursing practices, lacking oral care protocols, efficient training, and awareness of the benefits for clients. In particular, there is a gap in research for nursing oral health assessment training for nursing curricula. METHOD: This study explored the effects of interprofessional collaboration (IPC) training between nurses and oral health therapists (OHT) using newly developed oral health assessment tools with an aim of reducing barriers for nursing oral health assessment. The self-efficacy and confidence of nursing students in oral health assessment were evaluated using pre- and posttraining surveys, and a focus group. RESULTS: Nursing students' confidence in incorporating oral health assessment into head-to-toe assessment improved after training. CONCLUSION: Nursing oral health assessment training with IPC, onsite OHT support, and oral health assessment tools improved the confidence and attitudes of nursing students in oral health assessment and care provision. [J Nurs Educ. 2023;62(7):399-402.].

Evaluation of the Immunological Response of Childhood Cancer Patients Treated with a Personalized Peptide Vaccine for Refractory Soft Tissue Tumor: A Four-Case Series.

This case series aimed to evaluate the peptide-specific immunoglobulin G (IgG) response, clinical effectiveness, and the safety of a personalized peptide vaccine (PPV) in four children with refractory solid cancer. Although the pre-vaccination IgG responses were suppressed, IgG levels against the vaccinated peptides after 12 vaccinations were increased in all three cases who received at least 12 vaccinations. Vaccination-related adverse effects were grade 1 injection-site local skin lesions. One patient, whose diagnosis was relapsed rhabdomyosarcoma, remains in sustained remission after 37 months. Although the pre-vaccination immune response in this patient was low, IgG levels against 2 of the 4 peptide vaccines were increased after the sixth vaccination, followed by a strong increase at the eighteenth vaccination against all 4 peptides, with a >100-fold increase vs. 2 peptides. The remaining three patients exhibited progressive disease and eventually died of their original cancer. The results of the current case series suggest that in cases of childhood solid tumors, when the tumor is controlled at the time of entry PPV may have some consolidation effect. Therefore, PPV could be a new immunotherapy modality for refractory childhood solid tumors.

Three Weeks of Treatment Induced Long-term Remission in a Patient with Micrococcus luteus-related Peritonitis.

Micrococcus luteus can cause relapsing and refractory peritoneal dialysis infection because it leads to strong biofilm formation. A 69-year-old woman who had undergone peritoneal dialysis (PD) visited the emergency department complaining of cloudy peritoneal dialysate. She was initially given intraperitoneal cefazolin (1 g/day) and ceftazidime (1 g/day). Micrococcus luteus was detected in a culture test. Thus, ceftazidime was discontinued. She remained disease-free for 22 months until she developed PD-related peritonitis. We administered antibiotics for 21 days and thereafter identified 2 important clinical issues. Micrococcus species-related peritonitis can sometimes be cured without vancomycin. Furthermore, the provision of three weeks of sufficient treatment may be important.

Integrating oral care into nursing practice in care homes.

This article details a narrative review that explored the barriers to and facilitators of integration of oral care into nursing practice in care homes to enhance nurses' delivery of oral care. Three themes were identified: gaps in oral care protocols and the complexity of nursing oral care; how interprofessional collaboration and education can improve oral care; and limitations and unresolved issues in nurses' oral care training. The review found that interprofessional collaboration and education were important in normalising oral care practice and nurse leadership in care homes. Nurse-led interprofessional oral care could enhance the quality of care in care homes by advancing interprofessional collaboration and education, coordinating care and improving organisational support.

Membranous nephropathy associated with multicentric Castleman's disease that was successfully treated with tocilizumab: a case report and review of the literature.

BACKGROUND: Multicentric Castleman's disease is a life-threatening disorder involving a systemic inflammatory response and multiple organ failure caused by the overproduction of interleukin-6. Although renal complications of Castleman's disease include AA amyloidosis, thrombotic microangiopathy, and membranoproliferative glomerulonephritis, membranous nephropathy is relatively rare. We experienced a case of secondary membranous nephropathy associated with Castleman's disease. CASE PRESENTATION: The patient was a 43-year-old Japanese man who had shown a high zinc sulfate value in turbidity test, polyclonal hypergammaglobulinemia, anemia, and proteinuria. A physical examination revealed diffuse lymphadenopathy, an enlarged spleen and papulae of the body trunk. A skin biopsy of a papule on the patient's back showed plasma cells in the perivascular area and he was diagnosed with multicentric Castleman's disease, plasma cell variant. Kidney biopsy showed the appearance of bubbling in the glomerular basement membranes in Periodic acid methenamine silver stain and electron microscopy revealed electron dense deposits within and outside the glomerular basement membranes. Since immunofluorescence study showed predominant granular deposition of IgG1 and IgG2, he was diagnosed with secondary membranous nephropathy associated with Castleman's disease. He was initially treated with prednisolone alone, however his biochemical abnormalities did not improve. After intravenous tocilizumab (700 mg every 2 weeks) was started, his C-reactive protein elevation, anemia, and polyclonal gammopathy improved. Furthermore, his urinary protein level declined from 1.58 g/gCr to 0.13 g/gCr. The prednisolone dose was gradually tapered, then discontinued. He has been stable without a recurrence of proteinuria for more than 6 months. CONCLUSIONS: Tocilizumab might be a treatment option for secondary membranous nephropathy associated with Castleman's disease.

Oral Care in Hospital Settings: Breaking the Vicious Circle of Older Adult Deconditioning.

Hospitalized older adults frequently develop aspiration pneumonia, swallowing dys-function (dysphagia), and sarcopenia. In the current study, we propose a framework that incorporates these three factors into a vicious circle that leads to deconditioning, a condition frequently experienced by this vulnerable population. Viewing aspiration pneumonia, dysphagia, and sarcopenia, along with their interrelationships through the lens of this vicious circle, illuminates the critical role that oral health plays in deconditioning. Moreover, this framework highlights oral care as a key nursing intervention for reducing deconditioning in hospitalized older adults. Supporting this view, several studies have shown that oral care can improve health outcomes for hospitalized older adults. However, despite oral care being an essential nursing intervention that restores oral function and promotes patient wellness, it is one of the most neglected nursing interventions. Missed oral care occurs due to staff's limited awareness of its significance for care-dependent older adults in hospital settings. We hope that this vicious circle paradigm helps raise awareness of the significance of oral care to prevent deconditioning in hospitalized older adults. [Journal of Gerontological Nursing, 47(6), 7-12.].

Results of Mechanical Thrombectomy 6 Hours after Stroke Onset: Analysis of Multiple Stroke Centers in Fukushima Prefecture.

Objective: The purpose of this study was to examine the efficacy and safety of mechanical thrombectomy in patients with acute occlusion of a large cerebral artery in the anterior circulation beyond 6 hours of the time last known to be well using the real-world clinical data collected from non-urban areas of Japan. Methods: We analyzed a retrospective multicenter database collected at 10 thrombectomy capable primary stroke centers in Fukushima Prefecture. In all, 188 patients were presenting a large cerebral artery occlusion in the anterior circulation, that is, internal carotid and middle cerebral artery (M1 and M2 segment). In all, 158 patients received mechanical thrombectomy within 6 hours from symptom onset (early time window), and 30 patients exceeded 6 hours (late time window). We compared the patient background, outcomes, and safety variables between the two groups. The modified Rankin Scale (mRS) score of 0-2 at 90 days after treatment and the incidence of symptomatic intracranial hemorrhage were compared between groups to evaluate treatment efficacy and safety. Results: There was no significant difference in the proportion of mRS score 0-2 at 90 days after treatment (51.3 vs. 46.7%: P = 0.644). However, symptomatic intracranial hemorrhage was more frequent in the late time window group (7.0 vs. 16.7%: P = 0.081). Symptomatic intracranial hemorrhage was a significant factor of a poor functional outcome in the late time window group (P = 0.022). Conclusion: This study reflects the real-world results of mechanical thrombectomy in the non-urban areas of Japan. The treatment efficacy in the late time window patients was equivalent to that in the early time window patients. On the other hand, the incidence of symptomatic intracranial hemorrhage showed a trend to high in patients beyond 6 hours, which was a significant factor related to a poor functional outcome.

A Kidney Transplant Recipient with Recurrent Henoch-Schönlein Purpura Nephritis Successfully Treated with Steroid Pulse Therapy and Epipharyngeal Abrasive Therapy.

There is no specific treatment for recurrent Henoch-Schönlein purpura nephritis (HSPN) in a transplanted kidney. We herein report a case of a kidney transplant recipient with recurrent HSPN that was successfully treated with steroid pulse therapy and epipharyngeal abrasive therapy (EAT). A 39-year-old Japanese man developed HSPN 4 years ago and had to start hemodialysis after 2 months despite receiving steroid pulse therapy followed by oral prednisolone, plasma exchange therapy, and cyclophosphamide pulse therapy. He had undergone tonsillectomy 3 years earlier in the hopes of achieving a better outcome of a planned kidney transplantation and received a living-donor kidney transplantation from his mother 1 year earlier. Although there were no abnormalities in the renal function or urinalysis 2 months after transplantation, a routine kidney allograft biopsy revealed evidence of mesangial proliferation and cellular crescent formation. Mesangial deposition for IgA and C3 was noted, and he was diagnosed with recurrent HSPN histologically. Since the renal function and urinalysis findings deteriorated 5 months after transplantation, 2 courses of steroid pulse therapy were performed but were ineffective. EAT using 0.5% zinc chloride solution once per day was combined with the third course of steroid pulse therapy, as there were signs of chronic epipharyngitis. His renal function recovered 3 months after daily EAT and has been stable for 1.5 years since transplantation. Daily EAT continued for >3 months might be a suitable strategy for treating recurrent HSPN in cases of kidney transplantation.

Acute paradoxical brain herniation after decompressive craniectomy for severe traumatic brain injury: A case report.

BACKGROUND: Sinking skin flap syndrome or paradoxical brain herniation is an uncommon neurosurgical complication, which usually occurs in the chronic phase after decompressive craniectomy. We report a unique case presenting with these complications immediately after decompressive craniectomy for severe traumatic brain injury. CASE DESCRIPTION: A 65-year-old man had a right acute subdural hematoma (SDH), contusion of the right temporal lobe, and diffuse traumatic subarachnoid hemorrhage with midline shift to the left side. He underwent an emergency evacuation of the right SDH with a right decompressive frontotemporal craniectomy. Immediately after the operation, his neurological and computed tomography (CT) findings had improved. However, within 1 h after the surgery, his neurological signs deteriorated. An additional follow-up CT showed a marked midline shift to the left, i.e., paradoxical brain herniation, and his skin flap overlying the decompressive site was markedly sunken. We immediately performed an urgent cranioplasty with the right temporal lobectomy. He responded well to the procedure. We suspected that a cerebrospinal fluid leak had caused this phenomenon. CONCLUSION: Decompressive craniectomy for severe traumatic brain injury can lead to sinking skin flap syndrome and/or paradoxical brain herniation even in the acute phase. We believe that immediate cranioplasty allows the reversal of such neurosurgical complications.

Acute kidney injury due to thin basement membrane disease mimicking Deferasirox nephrotoxicity: a case report.

BACKGROUND: Although the renal toxicity of Deferasirox, an oral iron chelator, has been reported to be mild, there have been reports of acute interstitial nephritis or Fanconi syndrome due to this agent. Thin basement membrane disease (TBMD) is a hereditary disease characterized primarily by hematuria, with gross hematuria also observed in about 7% of cases. We herein report a case of TBMD that presented with acute kidney injury and gross hematuria during treatment with Deferasirox. CASE PRESENTATION: The patient was a 63-year-old man who had been diagnosed with myelodysplastic syndrome 6 years ago. He had started taking Deferasirox at 125 mg due to post-transfusion iron overload 6 months ago. Deferasirox was then increased to 1000 mg three months ago. When the serum creatinine level increased, Deferasirox was reduced to 500 mg three weeks before hospitalization. Although the serum creatinine level decreased once, he developed a fever and macroscopic hematuria one week before hospitalization. The serum creatinine level increased again, and Deferasirox was stopped four days before hospitalization. He was admitted for the evaluation of acute kidney injury and gross hematuria. Treatment with temporary hemodialysis was required, and a kidney biopsy was performed on the eighth day of admission. Although there was no major abnormality in the glomeruli, the leakage of red blood cells into the Bowman's space was observed. Erythrocyte cast formation was observed in the tubular lumen, which was associated with acute tubular necrosis. The results of an electron microscopic study were compatible with TBMD. CONCLUSION: Although Deferasirox is known to be nephrotoxic, gross hematuria is relatively rare. When we encounter a case of acute kidney injury with gross hematuria during treatment with Deferasirox, TBMD should be considered as a possible cause of gross hematuria.

A case report on parainfluenza virus type 4a infection in a 1-year-old boy with biphasic fever.

A 1-year-old boy was infected with parainfluenza virus type 4a (PIV4a) during an influenza epidemic in January 2016. His body temperature was 38.2 °C on day 1 of the illness followed by an intermittent phase of 36.5 °C on days 2 and 3, and it rose again on day 3 and peaked at 39.6 °C on day 4, of which the fever pattern was reminiscent of an influenza case with biphasic fever. However, results of rapid influenza virus (IFV) antigen tests performed at the first clinical visit and during the second fever phase on day 4 were both negative. The PIV4a was isolated from all the nasal aspirate specimens on days 1, 4, and 7. Other common respiratory viruses were negative in all the specimens in the viral isolation trials using the multiplex cell culture system and RT-PCR tests. The fever disappeared within 5 days after the onset without any antibiotic treatment, which strongly suggested the PIV4a as the causative agent of the patient's illness. On the basis of the incubation period required for the appearance of the cytopathic effect (CPE) in the infected cells, from specimen inoculation to the cells, the viral load in the nasal cavity was speculated to be greatest on day 4. His cough started on day 1 and persisted until day 9, and the viral isolation indicated that the shedding of the active virus continued with the coughing even after the termination of fever.

Improvement of Alveolar Hemorrhaging in an Elderly and Renally Impaired Patient with Relapsing Anti-neutrophil Cytoplasmic Autoantibody-associated Vasculitis by Single Infusion of Rituximab.

Rituximab (RTX) has become a therapeutic option for inducing remission of anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV). However, the optimum dosage of RTX to induce remission of AAV and reduce adverse events, such as infection, remains unclear. We herein report an elderly and renally impaired patient with alveolar hemorrhaging due to refractory AAV who was successfully treated with single infusion of RTX. Single infusion of RTX may be a therapeutic option in refractory AAV patients who are vulnerable to infections.

A bioinformatics-to-clinic sequential approach to analysis of prostate cancer biomarkers using TCGA datasets and clinical samples: a new method for precision oncology?

Biomarker-driven cancer therapy has met with significant clinical success. Identification of a biomarker implicated in a malignant phenotype and linked to poor clinical outcome is required if we are to develop these types of therapies. A subset of prostate adenocarcinoma (PACa) cases are treatment-resistant, making them an attractive target for such an approach. To identify target molecules implicated in shorter survival of patients with PACa, we established a bioinformatics-to-clinic sequential analysis approach, beginning with 2-step in silico analysis of a TCGA dataset for localized PACa. The effect of candidate genes identified by in silico analysis on survival was then assessed using biopsy specimens taken at the time of initial diagnosis of localized and metastatic PACa. We identified PEG10 as a candidate biomarker. Data from clinical samples suggested that increased expression of PEG10 at the time of initial diagnosis was linked to shorter survival time. Interestingly, PEG10 overexpression also correlated with expression of chromogranin A and synaptophysin, markers for neuroendocrine prostate cancer, a type of treatment-resistant prostate cancer. These results indicate that PEG10 is a novel biomarker for shorter survival of patients with PACa. Also, PEG10 expression at the time of initial diagnosis may predict focal neuroendocrine differentiation of PACa. Thus, PEG10 may be an attractive target for biomarker-driven cancer therapy. Thus, bioinformatics-to-clinic sequential analysis is a valid tool for identifying targets for precision oncology.

Granulomatous interstitial nephritis due to chronic lymphocytic leukemia: a case report.

BACKGROUND: Renal failure due to the infiltration of chronic lymphocytic leukemia (CLL) cells into the tubulointerstitial area of the kidney is uncommon. Furthermore, granulomatous interstitial nephritis (GIN) is a rare histological diagnosis in patients undergoing a renal biopsy. We herein report a case of GIN due to the diffuse infiltration of CLL cells in a patient who developed progressive renal failure. CASE PRESENTATION: The patient was a 55-year-old man who had been diagnosed with CLL 4 years earlier and who had been followed up without treatment. Although his serum creatinine level had remained normal for three and a half years, it started to increase in the six months prior to his presentation. A urinalysis showed mild proteinuria without any hematuria at the time of presentation. A renal biopsy revealed the diffuse infiltration of CLL cells into the tubulointerstitial area with non-caseating epithelioid cell granulomas. Despite cyclophosphamide treatment, his renal function did not improve, and he ultimately required maintenance hemodialysis. CONCLUSION: When progressive renal failure is combined with CLL, GIN due to the direct infiltration of CLL cells should be considered as a differential diagnosis.

Intracranial hemorrhage and platelet transfusion after administration of anti-platelets agents: Fukushima Prefecture.

We conducted a case series study to assess intracerebral hemorrhage (ICH) in the context of anti-platelets agents (APAs) and platelet (PLT) transfusion in Fukushima Prefecture.This study included patients who were newly diagnosed with ICH between January 2008 and June 2014 in the neurosurgical hospitals of Fukushima Prefecture.　Four of ten neurosurgical hospitals responded to our questionnaire.　Of 287 ICH patients, 51 (20.6%) were on APA therapy, of whom PLT transfusion was given to only one persistently bleeding patient who was on dual anti-platelet therapy.　In a follow-up survey, 30 out of 51 ICH patients on APA therapy, average age 75 years, were analyzed, of whom 21 (70%) were male.　The predominant underlying disease was diabetes mellitus.　It is interesting to note that peripheral artery disease and aortic aneurysm were among the indications for APAs.　ICH was mainly observed supratentorially.　Hematoma enlargement was observed in 13 (44.8%) cases.　By day 7, 3 patients (10%) had died from complications of ICH.　In this study, we show that ICH during APA therapy matched what was observed in Kanagawa Prefecture.　Whether or not a national survey differs, we anticipate greater statistical validity and an opportunity to improve patient outcomes in Japan and around the world.