Sodium-glucose co-transporter 2 inhibitors: game changers when handled with care?

Recent years have seen a paradigm shift in the management of patients with diabetes mellitus. Rather than good glycaemic control being the sole primary aim, the therapeutic focus has broadened to consider potential additional cardiovascular and renal benefits. Sodium-glucose co-transporter 2 inhibitors, such as empagliflozin, canagliflozin and dapagliflozin, have gained increasing prominence, with evidence suggesting significant improvement in outcomes in patients with established cardiovascular and renal disease. Here, we discuss the benefits and relative risks of these novel agents and highlight important clinical issues of relevance to general physicians.

Immunoglobulin A vasculitis presenting as terminal ileitis in late adulthood.

Adult-onset immunoglobulin (IgA) vasculitis presenting as terminal ileitis is a rare clinical encounter which can mimic inflammatory bowel disease or infectious gastroenteritis. A high index of clinical suspicion is required to reach the correct diagnosis and to implement the appropriate management plans. Herein, we report a case of an elderly female presenting with a short history of abdominal pain, vomiting, bloody diarrhoea, fatigue and reduced appetite. Based on the blood tests and imaging, she was initially managed as having an infective or inflammatory bowel condition. Subsequently, she developed a vasculitic rash in her lower limbs with accompanying renal involvement including haematuria and sub-nephrotic range proteinuria. She underwent a renal biopsy which confirmed the diagnosis of IgA vasculitis. She was started on a course of corticosteroid therapy which induced clinical remission.

Thrombotic microangiopathy with renal injury: an approach for the general physician

Thrombotic microangiopathy with renal dysfunction is a haematological and renal emergency warranting urgent diagnosis and intervention. As the potential underlying causes may be complex, assessment and management can be challenging for treating clinicians, and a timely and collaborative approach between general physicians, haematologists and nephrologists may be extremely helpful in order to optimise clinical outcomes. This paper will aim to build an understanding of different potential presentations of thrombotic microangiopathies and provide a practical framework for diagnosis and management, using a case-based discussion format, for acute and general physicians. Some aspects of subsequent specialist management are also discussed.

Retroperitoneal fibrosis: a rare disease for frontline clinicians.

Retroperitoneal fibrosis is a rare cause of renal dysfunction, typically presenting with obstructive uropathy (sometimes with extra-renal manifestations). Given its insidious and subtle presentation, reaching the diagnosis can be challenging. We report the case of a 65-year-old female presenting with a 6-month history of unexplained constitutional symptoms, weight loss and mild renal impairment. Abdominal imaging revealed bilateral ureteric obstruction due to retroperitoneal fibrosis and so she underwent urgent ureteric stent insertion. Subsequent treatment with oral corticosteroids led to resolution of her symptoms and regression of the retroperitoneal mass.

Multiple Faces of Chronic Lymphocytic Leukaemia: A Patient with Renal, Cardiac, and Skeletal Complications.

We describe a patient who had chronic lymphocytic leukaemia (CLL) Binet stage A at presentation with further evidence of disease at multiple sites but who initially required no treatment. However, several years later, her peripheral blood lymphocyte count started to increase, and soon after that she suffered an acute myocardial infarct (in the absence of coronary atheroma) together with proteinuric renal failure due to membranoproliferative glomerulonephritis. Her renal function improved markedly following anti-CLL chemotherapy. We postulate that her cardiac and renal disease were both complications of her CLL. In patients with CLL who develop new clinical signs or symptoms (even if apparently unrelated), consideration should be given as to whether these may be disease complications as this may serve as an indication to commence anti-CLL therapy; close liaison between different specialties is vital.

Hepatitis E infection in solid organ transplant recipients: An overlooked diagnosis?
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Hepatitis E virus (HEV) is gaining recognition as an important but under-recognized pathogen, particularly in immunocompromised individuals. It should be considered as a potential differential diagnosis in such patients presenting with acute hepatitis. We report a case of a kidney-pancreas transplant recipient who developed acute liver dysfunction; this was found to be due to HEV infection acquired through consumption of undercooked pork. His immunosuppression was cautiously reduced, and his liver biochemistry and viral PCR gradually normalized without the need for additional antiviral therapy.
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A Catastrophic Consequence of Cramp.

Quinine has long been used for the treatment of conditions such as malaria and leg cramps, and is also present at low levels in some beverages; however, it can cause serious side effects. We describe a patient who developed severe haemolysis, thrombocytopaenia, and acute kidney injury following the ingestion of a single dose of quinine. This case demonstrates the importance of awareness of such potentially life-threatening consequences of exposure to this agent.