Canagliflozin Markedly Decreased Proteinuria in a Patient With IgA Nephropathy.

IgA nephropathy (IgAN) remains one of the most common forms of glomerulonephritis, especially in developed countries with a low prevalence of infectious diseases. Despite supportive measures that slow the rate of progression of chronic kidney disease (CKD) in IgAN, many patients still progress to end-stage kidney disease. Proteinuria has been shown to be an adverse prognostic factor in IgAN. Data support the use of proteinuria reduction as a reasonably likely surrogate endpoint for a treatment's effect on progression to end-stage renal disease (ESRD) in IgAN. Currently employed immunosuppressive strategies lack conclusive efficacy data, while there is evidence for treatment-induced toxicity. The current standard of care for the management of IgAN is intensive goal-directed supportive care. Recently the role of sodium-glucose cotransporter 2 (SGLT2) inhibitors in decreasing proteinuria and progression of CKD is widely being recognized. In this case report, we present a 44-year-old male with proteinuria and biopsy-proven IgAN who remained in remission after six months of steroids using the Pozzi protocol. He developed proteinuria five years after remission. At this point, canagliflozin was added to his angiotensin-receptor blocker (ARB) therapy resulting in a significant reduction in his proteinuria. Our case report may intrigue researchers to look into the role of canagliflozin in decreasing albuminuria in non-diabetic kidney disease, thus slowing the progression to ESRD.

Consequences of Interdialytic Weight Gain Among Hemodialysis Patients.

Background Interdialytic weight gain (IDWG) is a marker of higher pre-dialysis blood pressure, nutrition, and survival in hemodialysis (HD) patients. However, this relationship is incompletely characterized. In this study, we seek to define the association of IDWG/dry weight x100 (IDWG%) on blood pressure (BP), and the nutritional status of an HD population. Material and Methods This study was performed on 300 HD patients. The data was collected over four weeks, including total IDWG, IDWG%, and blood pressure. Normalized protein nitrogen appearance (nPNA), and serum albumin were used as markers of nutritional status. Participants were divided into three groups according to the mean of the IDWG% between two sessions of HD (group A < 3%, group B = 3% - 3.9%, and group C ≥ 4%); they were then compared on various aspects. Student t-test, analysis of variance (ANOVA), and linear regression analysis were used as statistical tools. Results The mean (± standard deviation (SD)) age was 61.7 ± 14.2 years with 57.7% of the patients being male and 42.3% being female. The mean IDWG% for the whole studied population was 3.72% ± 1.73%. Between these three groups, a higher IDWG% was associated with younger males (p = 0.032), lower dry weight (p = 0.009), and longer duration on HD therapy (p = 0.009). IDWG% was directly associated with lower pre-dialysis serum sodium (p = 0.04), higher pre-dialysis serum creatinine (P = 0.002), and lower body mass index (BMI) (p= 0.003). Between these three groups, interdialytic variations in weight gain were not associated with increased BP. There was no significant difference between the three groups in terms of nPNA and serum albumin.  Conclusions The most important associations of IDWG% are age, weight, pre-dialysis sodium, serum creatinine, and duration of dialysis (months). There was no association between IDWG% and increased systolic BP. IDWG% had no association with nutritional status.

Gitelman Syndrome Provisionally Diagnosed During the First Presentation of Diabetic Ketoacidosis.

Gitelman syndrome (GS) is an autosomal recessive disease characterized by hypokalemia, hypomagnesemia, metabolic alkalosis, and hypocalciuria. It is caused by mutations in gene SLC12A3 (located in chromosome 16q) encoding NaCl cotransporter. GS is usually asymptomatic for several years and is diagnosed in late childhood or adulthood. The association between GS and diabetic ketoacidosis (DKA) is rare. We present a case of a 25-year-old man with newly diagnosed diabetes mellitus and DKA with profound hypokalemia and hypomagnesemia who was provisionally found to have GS.

Prolonged Altered Mental Status in a Diabetic Hemodialysis Patient.

Osmotic demyelination syndrome (ODS) is a demyelinating disorder of the central nervous system. It usually occurs with rapid correction of severe chronic hyponatremia. ODS is rarely seen as a complication of hyperglycemia. Herein, we report a rare presentation of ODS secondary to hyperosmolar hyperglycemic state. A 28-year-old female with type 1 diabetes, hypertension, seizure disorder, and end-stage renal disease on hemodialysis was brought from a shelter with two days of unresponsiveness and developed ODS after hyperosmolar hyperglycemic state in long-standing uncontrolled diabetes with normal serum electrolyte levels.

Methadone for Fun Sake Kidneys Are at Stake!!!

Acute renal failure from rhabdomyolysis is a well-established clinical entity; however, rhabdomyolysis exclusively caused by the ingestion of methadone requiring hemodialysis is very uncommon. With a similar mechanism to opiates, methadone can cause rhabdomyolysis and further consequences. Given the increasing use of methadone as a therapy for opiate dependence, clinicians prescribing this medication should be aware of this life-threatening complication.

Influenza and End-Stage Renal Disease: A Fatal Combination.

Influenza epidemics are a major health care problem in the United States causing significant morbidity and mortality. Influenza can occur in all individuals, but immunocompromized hosts and those with chronic diseases such as end-stage renal disease are more susceptible to its fatal complications. Influenza though is largely preventable with the availability of highly efficacious vaccines. Despite the wide array of vaccine types available, the vaccination rates remain dismal, thereby leading to high incidence of the disease. In this report, we discuss a case of an unvaccinated patient with end-stage renal disease who contracted the influenza virus with fatal consequences. This report discusses multiple factors that allowed for a highly preventable disease to cause this negative outcome and provides suggestions to prevent such outcomes in the future.

Asymptomatic Cecal Perforation in a Renal Transplant Recipient After Sodium Polystyrene Sulfonate Administration.

Sodium polystyrene sulfonate (SPS) is a medication commonly used for the treatment of hyperkalemia. There have been many cases of colonic necrosis and perforation associated with administration of SPS. There are very few such cases reported in renal transplant patients. We present a case of renal transplant recipient who developed cecal perforation after a single oral dose of SPS. She had no signs or symptoms suggestive of intestinal perforation and was incidentally diagnosed with it on abdominal imaging performed to find cause of acute blood loss anemia. This case underlines the importance of recognizing this severe and potentially life-threatening complication associated with SPS. The clinicians should also consider renal/solid organ transplant and immunosuppression as potential risk factors.

Ileal Neobladder With Mucous Plugs as a Cause of Obstructive Acute Kidney Injury Requiring Emergent Hemodialysis.

Ileal neobladder is the preferred technique in the management of urinary diversion postradical cystectomy for bladder malignancy. The common complications associated with this procedure are atrophied kidney, chronic pyelonephritis, decreased renal function, ureteroileal or urethral anastomotic site stricture, urinary tract stones, incontinence, and hyperchloremic metabolic acidosis. Mucous plugs are also seen in 2%-3% patients. We present a rare presentation of a patient who required hemodialysis for severe hyperkalemia and acute kidney injury caused by mucous plugging of ileal neobladder.

Stroke in a Young Woman as a Presenting Manifestation of Membranous Nephropathy.

Stroke is one of the most severe complications of nephrotic syndrome (NS), only a few cases have been reported in previous literature. Some of those cases are not clear about whether the stroke was purely caused by NS because they also had other risk factors for stroke, such as old age, hypertension. A recent study showed that serum albumin less than 2.8 g/dL is a risk factor for thromboembolic events (venous thromboembolic events). Anticoagulation is suggested for patients with NS with low albumin by KIDIGO guideline 2012. Here, we describe a case in which a young patient presented with stroke as an initial symptom of membranous nephropathy (MN). A 36-year-old woman with no medical history came to the emergency room for left side weakness. Computed tomography of head showed right middle cerebral artery infarct. She was healthy and had no history of hypertension or peripheral vascular disease. She was not taking any medication before admission and did not have any toxic habits. She had nephrotic range of proteinuria with no active sediment in urine analysis, serum albumin of 1.7 g/dL, normal renal function, elevated blood pressure on admission, and no signs of left ventricular hypertrophy. All coagulopathy workup was negative. The renal biopsy showed MN. She was started on Coumadin and treated with steroids and cyclophosphamide. Four months after the stroke, she still could not perform daily activity independently. This case illustrates that stroke can be an initial symptom of MN, and it is important we detect and anticoagulate this high-risk group of patients before their developing stroke. Urine analysis is an inexpensive screening tool for NS and should be considered as an initial workup for a young patient who presents with stroke.

Diagnosis and Treatment of Cerebral Salt Wasting Syndrome With Cryptococcal Meningitis in HIV Patient.

Hyponatremia is one of the most common electrolyte imbalances in HIV patients. The differential diagnosis may include hypovolemic hyponatremia, syndrome of inappropriate antidiuretic hormone secretion (SIADH), and adrenal insufficiency. Here, we describe a case of hyponatremia secondary to cerebral salt wasting syndrome (CSWS) in an HIV patient with cryptococcal meningitis. A 52-year-old man with a history of diabetes and HIV was admitted for headache and found to have cryptococcal meningitis. He was also found to have asymptomatic hyponatremia. He had signs of hypovolemia, such as orthostatic hypotension, dry mucosa, decreased skin turgor, hemoconcentration, contraction alkalosis, and high BUN/Cr ratio. The laboratory findings revealed sodium of 125 mmol/L, potassium of 5.5 mmol/L, urine osmolality of 522 mOsm/kg, urine sodium of 162 mmol/L, and urine chloride of 162 mmol/L. We started normal saline for hypovolemia, each 1 L prior and after amphotericin therapy. However, hypovolemia did not improve significantly despite IV fluid. Cosyntropin stimulation test was negative, and renin level was 0.25 ng·mL·h, with the aldosterone level of <1 ng/dL, the serum brain natriuretic peptide of 15 pg/mL, and serum uric acid of 2.8 mg/dL. The diagnosis of CSWS was suspected, fludrocortisone was tried, and hypovolemia and hyponatremia improved. Cryptococcal meningitis in HIV patients can present with CSWS, and the distinction between CSWS and SIADH is important because the treatment for CSWS is different than that of SIADH. Both share a similar clinical picture except that CSWS presents with constant hypovolemia despite volume replacement. Salt tablets, normal saline, or fludrocortisone can be used for treatment.

Advanced chronic kidney disease in non-valvular atrial fibrillation: extending the utility of R2CHADS2 to patients with advanced renal failure.

BACKGROUND: The R2CHADS2 is a new prediction rule for stroke risk in atrial fibrillation (AF) patients wherein R stands for renal risk. However, it was created from a cohort that excluded patients with advanced renal failure (defined as glomerular filtration rate of <30 mL/min). Our study extends the use of R2CHADS2 to patients with advanced renal failure and aims to compare its predictive power against the currently used CHADS and CHA2DS2VaSc. METHODS: This retrospective cohort study analyzed the 1-year risk for stroke of the 524 patients with AF at Metropolitan Hospital Center. AUC and C statistics were calculated using three groups: (i) the entire cohort including patients with advanced renal failure, (ii) a cohort excluding patients with advanced renal failure and (iii) all patients with GFR < 30 mL/min only. RESULTS: R2CHADS2, as a predictor for stroke risk, consistently performs better than CHADS2 and CHA2DS2VsC in groups 1 and 2. The C-statistic was highest in R2CHADS compared with CHADS or CHADSVASC in group 1 (0.718 versus 0.605 versus 0.602) and in group 2 (0.724 versus 0.584 versus 0.579). However, there was no statistically significant difference in group 3 (0.631 versus 0.629 versus 0.623). CONCLUSION: Our study supports the utility of R2CHADS2 as a clinical prediction rule for stroke risk in patients with advanced renal failure.

Population genetics of chronic kidney disease: the evolving story of APOL1.

Advances in human genome sequencing and generation of public databases of genomic diversity enable nephrologists to re-examine the genetics of common, complex kidney diseases. Non-diabetic kidney diseases prevalent in African ancestry populations and the allelic variation described in chromosome 22q12.3 is one such illustrative example. Newly available genomic database information enabled research groups to discover common functional DNA sequence risk variants in the APOL1 gene. These variants (termed G1 and G2) evolved to confer protection from a species of trypanosomal infection and thus achieved high prominence in many geographic regions of Africa and have been carried over to African diaspora communities worldwide. Since these discoveries two years ago, new insights have been gained: localization of APOL1 in normal and disease kidney tissues; influence of the APOL1 variants on the histopathology of HIV kidney disease; possible association with kidney transplant durability; onset of kidney failure at a younger age; association with blood lipid concentrations; more precise geographic localization of individuals with these variants to western and southern African ancestry; and the absence of the variants and kidney disease predisposition in Ethiopians. The definition of APOL1 nephropathy also confirms the long-held assumption by many clinicians that kidney disease attributed to hypertension in African populations represents an underlying glomerulopathy. Still awaited is the delineation of the biologic mechanisms of cellular injury related to these variants, to provide biologic proof of the APOL1 association and to provide potential targets for preventive and therapeutic intervention.

Diffuse infiltrative lymphocytosis syndrome presenting as reversible acute kidney injury associated with Gram-negative bacterial infection in patients with newly diagnosed HIV infection.

Diffuse infiltrative lymphocytosis syndrome (DILS) is believed to be an immunologic syndrome, most likely in response to human immunodeficiency virus (HIV) antigens, and can be accompanied by decreased kidney function. The spectrum of kidney involvement includes acute or chronic kidney disease, primarily tubular proteinuria; enlarged kidneys on imaging studies; and dense lymphocytic tubulointerstitial infiltrates predominantly composed of CD8(+) T cells on kidney biopsy. We describe 3 newly diagnosed HIV-positive patients of African descent with the histologic and clinical diagnosis of DILS who presented with acute kidney injury associated with Gram-negative bacterial infections. Solely with specific antibiotic therapy without antiviral and/or corticosteroid therapy, all patients recovered from acute kidney injury and had partial to complete resolution of proteinuria and enlarged kidney size. These observations led us to hypothesize that an altered immunologic and/or inflammatory response to the endotoxin derived from Gram-negative bacteria, rather than an immunologic response directed to HIV-related antigens, may be a pathogenetic mechanism for the kidney disease associated with DILS in a subset of HIV-positive patients, especially those of immunogenetically susceptible African descent.

Purse-string suture to prevent bleeding after tunneled dialysis catheter insertion.

PURPOSE: To determine whether placing a purse-string suture at the tunnel exit site at the time of tunneled dialysis catheter (TDC) insertion will decrease postprocedural bleeding. MATERIALS AND METHODS: In a retrospective single-center, single-operator study, 51 patients in the control group had TDCs inserted without purse-string sutures at the tunnel exit site and 50 patients in the experimental group had TDCs inserted with purse-string sutures at the tunnel exit site. The patients' charts were evaluated for postprocedural progress notes describing bleeding, plasma hemoglobin levels before and after catheter insertion, and transfusion of packed red blood cells in the first 5 days after catheter insertion. RESULTS: Thirteen patients in the control group (25.4%) and three patients in the experimental group (6%) had postprocedural chart notes describing bleeding. The difference between the two groups was highly significant (P = .0124). Six percent of patients in the control group and none of the patients in the experimental group required prolonged compression or compression dressing placement after catheter insertion. There was a significant mean hemoglobin decrease of 0.3 g/dL after catheter insertion in the control group and an insignificant mean hemoglobin decrease of 0.1 g/dL in the experimental group. The difference in hemoglobin decrease between the two groups was not significant. The difference in the number of patients requiring transfusion in the 5 days after catheter insertion (eight of 51 vs nine of 50) was not significant. CONCLUSIONS: Venous bleeding after TDC insertion is a complication that merits attention. Routine purse-string suture placement at the tunnel exit site is a minor change in standard technique that can nearly eliminate this problem, as reflected in postprocedural chart notes.