Chronic total occlusion and successful drug-eluting stent placement in Takayasu arteritis-induced renal artery stenosis.

Takayasu arteritis-induced renal artery stenosis (TARAS) is a condition rarely described in the literature. Although percutaneous transluminal angioplasty and stenting has been well-described in the treatment of atherosclerotic renal artery stenosis, its role has not been established in non-atherosclerotic TARAS. We report a case of a female, age 17 years, with Takayasu arteritis who presented to the hospital with seizures and hypertensive crisis. A renal angiogram showed chronic total occlusion (CTO) of the left renal artery. Renal angioplasty and stenting was successfully performed after multiple attempts to deliver a wire distal to the CTO. After sequential balloon predilation, a drug-eluting stent was deployed, resulting in full reperfusion of the kidney. The patient's blood pressure improved dramatically, and patency of the stent was demonstrated with magnetic resonance angiography over 9 months after the procedure.

A comparison between blood flow outcomes of tunneled external jugular and internal jugular hemodialysis catheters.

PURPOSE: The right internal jugular (RIJ) vein is preferred for placement of long-term venous catheters (CVC) for hemodialysis (HD). Use of left IJ vein potentially depletes the access site for arteriovenous fistula (AVF) or arteriovenous graft (AVF) placement because of the high rates of central venous stenosis. The right external jugular (EJ) vein is a viable alternative to the LIJ. The purpose of this study is to compare blood flow outcomes in a series of percutaneously placed external jugular (EJ), LIJ and RIJ HD catheters. METHODS: Using a prospectively collected database, we identified 46 hemodialysis patients who received a tunneled catheter during a 4-year period. Blood flow outcomes of RIJ, LIJ, and EJ catheters that were date-matched over the study period were compared. Using ANOVA, the blood flow outcomes of the 3 tunneled catheter techniques at 30-d and 90-d were compared. RESULTS: The 90-d blood flow outcomes of the 3 groups did not differ significantly. The 30-d blood flow was found to be 348.5± 56.62, 341± 22.42, and 365.7± 71.76 mL/min for RIJ, LIJ, and EJ respectively (P<.05). Using multiple regression analysis, no covariates (age, sex, race, diabetes) were found to be associated with blood flow outcomes at 30-d or 90-d. No identifiable factors were found to be associated with the difference in blood flow between 30-d and 90-d either. CONCLUSIONS: EJ blood flow outcomes at 30-d and 90-d were comparable to both LIJ and RIJ historic data. Further prospective investigation is required to define the role of EJ CVC placement as another potential long-term access modality.

Does early initiation of continuous renal replacement therapy affect outcome: experience in a tertiary care center.

BACKGROUND: Acute kidney injury (AKI) requiring dialysis commonly occurs in critically ill patients and is associated with high mortality. Factors impacting outcomes of individuals with AKI who underwent continuous renal replacement therapy (CRRT), including early versus late initiation and duration of CRRT, were examined. METHODS: Survival and recovery of renal function for patients with AKI in the intensive care unit were retrospectively examined over a 7-year period. Factors associated with mortality and renal recovery were analyzed based on severity of illness as defined by Cleveland Clinic Foundation (CCF) score. Univariate and multivariate logistic regression analysis with backward elimination was performed to determine the most significant risk factors. RESULTS: Of patients who underwent CRRT, 230/330 met inclusion criteria. During index admission 112/230 (48.7%) patients died. Median survival was 15.5 days [95% confidence interval (12.0, 18.0)]. Among survivors, renal recovery occurred in 84/118 (71.2%). Renal recovery overall was observed in 90/230 subjects (39.13%). A higher baseline CCF score correlated with higher mortality and lower probability of renal recovery. Patients initiated on CRRT > 6 days after AKI diagnosis had significantly higher mortality compared with those initiated earlier (odds ratio = 11.66, p = 0.0305). Patients receiving CRRT >10 days had a higher mortality rate compared with those with shorter exposure (71.3% vs. 45.5%, respectively, p = 0.012). CONCLUSIONS: CRRT remains an important dialysis modality in hemodynamically unstable patients with AKI. Mortality in these patients continues to be high. Renal recovery is high in survivors. Delay in initiation and length of CRRT exposure may portend poorer prognosis.

Palliative medicine referral in patients undergoing continuous renal replacement therapy for acute kidney injury.

BACKGROUND: Referral patterns for palliative medicine consultation (PMC) by intensivists for patients requiring continuous renal replacement therapy (CRRT) have not been studied. METHODS: We retrospectively analyzed clinical data on patients who received CRRT in a tertiary referral center between 1999 and 2006 to determine timeliness and effectiveness of PMC referrals and mortality rate as a surrogate for safety among patients receiving CRRT for acute kidney injury. RESULTS: Over one-fifth (21.1%) of the 230 CRRT patients studied were referred for PMC (n = 55). PMC was requested on average after median of 15 hospital and 13 intensive care unit (ICU) days. Multivariate regression analysis revealed no association between mortality risk and PMC. Total hospital length of stay for patients who died after PMC referral was 18.5 (95% CI = 15-25) days compared with 12.5 days (95% CI = 9-17) for patients who died without PMC referral. ICU care for patients who died and received PMC was longer than for patients with no PMC [11.5 (95% CI = 9-15) days vs. 7.0 (95% CI = 6-9) days, p < 0.01]. CRRT duration was longer for patients who died and received PMC referral than for those without PMC [5.5 (95% CI = 4-8) vs. 3.0 (95% CI = 3-4) days; p < 0.01]. CONCLUSIONS: PMC was safe, but referrals were delayed and ineffective in optimizing the utilization of intensive care in patients receiving CRRT. A proactive, "triggered" referral process will likely be necessary to improve timeliness of PMC and reduce duration of non-beneficial life-sustaining therapies.

Rapid reduction of severely elevated serum triglycerides with insulin infusion, gemfibrozil and niacin.

The conventional methods of treatment of severe hypertriglyceridemia are dietary restriction and lipid lowering medications, mainly fibric acid derivatives. In the medical literature, use of insulin infusion to treat hypertriglyceridemia has not been highlighted sufficiently. We report a 53-year-old male who presented with a four-day history of epigastric pain. The patient's clinical history was significant for hypertriglyceridemia, type-2 diabetes mellitus with medication noncompliance, obesity, status post-gastric bypass surgery, and alcohol abuse with prior admissions for detoxification. Physical examination revealed mild epigastric tenderness. Laboratory studies revealed severely elevated serum triglyceride (TG) level (8116 mg/dL). Computed tomography (CT) scan of the abdomen exhibited no evidence of pancreatitis. Regular insulin infusion was started at 3 U/h and gradually increased to 7-10 U/h. Dextrose infusion was titrated to avoid hypoglycemia and maintain blood glucose levels below 150 mg/dL. Gemfibrozil and niacin were also started. After 24 hours, his TG levels were decreased to 2501 mg/dL. Insulin infusion was continued for about 48 hours. A low carbohydrate diet excluding simple carbohydrates was given. The patient's serum TG levels normalized over a period of one month. Thus insulin infusion can be considered a safe modality of treatment for rapid reduction of serum TG in addition to fibrates and niacin.

Implantable cardiac defibrillator placement in a patient with persistent left superior vena cava and Brugada syndrome.

A 45-year-old man was diagnosed with new-onset atrial fibrillation. Control of ventricular rate led to spontaneous conversion to sinus rhythm. Subsequent electrocardiograms revealed ST segment changes characteristic of Brugada syndrome. Electrophysiology study demonstrated inducible ventricular fibrillation. During the placement of an implantable cardiac defibrillator the patient was found to have a persistent left superior vena cava. Persistent left superior vena cava is present in 0.3% of cases in autopsy series. To date, persistent left superior vena cava has not been reported in association with Brugada syndrome. We report such a case.

Esophageal adenocarcinoma arising from Barrett's dysplasia: a case report of double occurrence and prolonged survival after chemotherapy.

A relatively young patient with chronic gastroesophageal reflux disease (GERD), obesity, smoking, and alcohol intake presented with widespread metastatic disease in lymph nodes, liver and lungs from a lower esophageal adenocarcinoma extending into the gastroesophageal junction associated with Barrett's mucosa and dysplasia.A complete response was achieved with six cycles of chemotherapy that sustained for more than 4 years without further recurrence. Unfortunately, there was presence of esophageal metaplasia after complete response which eventually converted to low to high grade dysplasia and ultimately to a second primary localized lower esophageal adenocarcinoma that was treated with thoracoabdominal esophagectomy and lymphadenectomy. No evidence of disease recurrence was seen 2 years later. The pathogenesis of a recent increase in the incidence of GERD, Barrett's esophagus and lower esophageal adenocarcinoma are discussed. Surgery, radiotherapy and combination chemotherapy are effective in the early stages leading to tumor shrinkage and prolongation of life and even cure in some cases. Lower esophageal adenocarcinoma is frequently associated with Barrett's high-grade dysplasia. Since there has been a dramatic increase in the incidence of Barrett's dysplasia, appropriate surveillance with upper gastrointestinal endoscopy and preventive strategies, such as the use of aspirin, cyclo-oxygenase II inhibitors and other nonsteroidal antiinflammatory drugs known to be chemopreventive agents against colon, esophagus, gastric and bladder cancers, need to be studied.

Suspected clopidogrel resistance in a patient with acute stent thrombosis.

BACKGROUND: A 67-year-old man with supraventricular tachycardia associated with angina underwent coronary angiographic assessment. This investigation revealed mild coronary artery disease in his left main coronary artery and significant stenosis of the ramus medianus (left intermediate artery). A drug-eluting stent was deployed and treatment with clopidogrel and eptifibatide started. The patient subsequently developed chest pain accompanied by hypotension, hypoxemia and electrocardiographic changes that indicated acute myocardial infarction. Emergency angiography revealed occlusion of the ramus medianus despite clopidogrel therapy. INVESTIGATIONS: Coronary angiography, hypercoagulable work up and platelet function tests. DIAGNOSIS: Acute stent thrombosis and suspected clopidogrel resistance, culminating in ST-segment elevation myocardial infarction after percutaneous coronary intervention. MANAGEMENT: Warfarin, aspirin and clopidogrel drug therapy.

Medroxyprogesterone acetate binds the glucocorticoid receptor to stimulate alpha-ENaC and sgk1 expression in renal collecting duct epithelia.

Medroxyprogesterone acetate (MPA), a widely used synthetic progestational contraceptive, occasionally leads to Cushingoid side effects such as hypertension, fluid retention, and centripetal obesity. We investigated the effect of MPA on classic mineralocorticoid target genes, alpha-epithelial Na channel (ENaC) and sgk1, in the collecting duct. In adrenalectomized mice, aldosterone, dexamethasone, and MPA increased alpha-ENaC mRNA levels in kidney cortex. MPA and dexamethasone, but not progesterone, dose dependently increased alpha-ENaC and sgk1 mRNA in M-1 and in Madin-Darby canine kidney-C7 cells, both collecting duct cell lines. The stimulatory effect of MPA and dexamethasone on alpha-ENaC expression was inhibited by RU-38486, a combined glucocorticoid receptor (GR) and progesterone receptor (PR) antagonist, but not by Org31710, a pure PR antagonist. MPA and dexamethasone dose dependently increased alpha-ENaC promoter-driven luciferase activity in M-1 cells, which was not inhibited by Org31710, indicating that MPA regulates alpha-ENaC in a PR-independent manner. When tested in HT29 cells, MPA could only stimulate alpha-ENaC-driven reporter activity when GR was coexpressed, confirming the requirement for functional GR in the transcriptional effect of MPA. The activation of steroid receptors such as GR can explain the apparent glucocorticoid effects of MPA, independent of PR activation.

Bacterial pericarditis due to group F streptococci as a complication of esophagomediastinal fistula.

We report a case of group F streptococcal pericarditis, the source of which was found to be an esophagomediastinal fistula arising from a midesophageal diverticulum. The patient presented subacutely and had no preexisting symptoms of esophageal disease. Antibiotic therapy, surgical drainage, pericardiectomy, and esophageal myotomy led to a successful outcome.

Early postnephrectomy donor renal function: laparoscopic versus open procedure.

Laparoscopic donor nephrectomy (LDN) is becoming the method of choice to procure kidneys from living donors. Despite the benefits to the donor, there have been concerns over the transient deterioration of renal function in the recipient of LDN compared with standard nephrectomy. We carried out a retrospective review of all living donors at our institution between January 2000 and December 2002. On the first postoperative day, the fall in renal function in laparoscopic donors is significantly greater than the fall seen in open donors. This difference could not be explained by relative hypotension, excessive blood loss, or inadequate fluid replacement in the laparoscopic group. Importantly, this difference is no longer evident by the third postoperative day. We speculate that this may be secondary to the pneumoperitoneum or the prolonged anesthesia on glomerular filtration rate. Furthermore, this finding could explain the slower recovery of graft function in recipients of laparoscopically procured kidney transplants.

Pericarditis in myasthenia gravis.

Myasthenia gravis is an autoimmune disorder with antibodies to the acetylcholine receptors (Ach R) in skeletal muscles. Myocardial involvement can present as a myocarditis or with arrhythmias. To our knowledge, there is no documentation in the literature of pericardial involvement in myasthenia gravis. We report the presence of pericardial effusion and atrioventricular conduction block in a patient with myasthenia gravis that responded appropriately to immunosuppressive therapy and plasma exchanges.