Risk factors of ceftriaxone-associated biliary pseudolithiasis in adults: influence of renal dysfunction.

BACKGROUND: Ceftriaxone (CTRX) is a known cause of biliary pseudolithiasis (BPL) mainly in children. Biliary elimination of CTRX increases in patients with renal dysfunction. However, the influence of renal dysfunction on the incidence of CTRX-associated BPL has not been well investigated. The aim of this study was to investigate the cumulative incidence of CTRX-associated BPL in adults and to assess if renal dysfunction is a risk factor. METHODS: We retrospectively analyzed the medical records of 478 patients treated with CTRX to assess the incidence and risk factors of CTRX-associated BPL. We examined age, sex, body weight, dosage, and duration of CTRX therapy, and the concentrations of serum creatinine, estimated glomerular filtration rate (eGFR), albumin, and serum calcium in all the patients. The cumulative incidence of BPL was calculated using a competing risk model. The multivariate analysis of each variable for the development of BPL was assessed by a Cox proportional hazards model. RESULTS: A total of 362 patients (75.7%) had renal dysfunction (eGFR: < 60 mL/min). The cumulative incidence of BPL in patients with renal dysfunction was significantly higher than that in patients with normal kidney function (4.1 vs. 0.6%, p = 0.017). Renal dysfunction (Hazard ratio (HR) 8.14, 95% CI 1.05-63.0, p = 0.045) and female sex (HR 5.35, 95% CI 1.17-24.5, p = 0.031) were independent risk factors of CTRX-associated BPL, which was confirmed using multivariate analysis (renal dysfunction: HR 7.93, 95% CI 1.04-60.5, p = 0.046) (female sex HR 4.65, 95% CI 1.03-21.1, p = 0.046). CONCLUSIONS: Renal dysfunction is an independent risk factor of CTRX-associated BPL in adults.

Infected hepatic and renal cysts: differential impact on outcome in autosomal dominant polycystic kidney disease.

BACKGROUND: Infected cysts are a frequent and serious complication of autosomal dominant polycystic kidney disease. Such infections are classified into those affecting hepatic cysts and those affecting renal cysts. The purpose of this study was to compare the clinical course of infected hepatic cysts with that of infected renal cysts in patients with autosomal dominant polycystic kidney disease. METHODS: We analyzed 43 patients referred to us for additional treatment of severely infected cysts between January 2004 and December 2006. All patients who required further treatment in addition to antibiotic therapy were included. RESULTS: Aspiration was performed in all 28 patients with infected hepatic cysts. As a result, 17 patients were cured, 4 remain under treatment, and 6 died. One patient was cured by partial hepatectomy. Among the 15 patients with renal cysts, aspiration was performed in 4 with identifiable infected cysts, while renal transcatheter arterial embolization after appropriate antibiotic therapy was performed in 11 without identifiable infected cysts. No patient developed recurrence. CONCLUSION: In patients with infected renal cysts, aspiration or renal transcatheter arterial embolization after appropriate antibiotic therapy was effective. Although aspiration was often effective in patients with infected hepatic cysts, a good outcome was less likely than in those with renal cysts.

Mycosis fungoides in a hemodialysis patient with intractable pruritus.

A 69-year-old Japanese man developed pruritus 3 years after beginning hemodialysis. Although eczema was not apparent at first, erythematous patches and plaques developed gradually on the affected skin. Secondary hyperparathyroidism was considered to be a main cause of this patient's pruritus, but skin lesions worsened even after parathyroidectomy had markedly decreased parathyroid hormone concentrations. Two months later, he developed an antibiotic-refractory fever of unknown origin and cervical, axillary, and inguinal lymphadenopathy. Elevations of soluble interleukin-2 receptor with 7410 U/mL and IgE with 24 600 U/mL in serum were noted, as was eosinophilia. The skin showed multiple slightly scaly patches and infiltrative plaques, which were reddish brown and distributed widely over the body surface except for the scalp and face. Mycosis fungoides, a cutaneous T-cell lymphoma, was diagnosed from biopsy specimens findings in skin and lymph node. Mycosis fungoides has not been documented as a cause of pruritus in hemodialysis patients. However, if skin lesions steadily worsen in hemodialysis patients, malignant diseases such as mycosis fungoides should be considered.

Pelvic insufficiency fracture related to autosomal dominant polycystic kidney disease.

We report the case of a patient with autosomal dominant polycystic kidney disease (ADPKD) and an insufficiency-type fracture of the pelvis. A 60-year-old Japanese woman was admitted because of pain in the right ischium and pubis that began suddenly with no precipitating cause. Computed tomography showed the bony pelvis to be compressed by enlarged dependent kidneys and an enlarged liver. We relieved compression on the pelvic bones by means of transarterial embolization (TAE) to the kidneys and liver after initiation of hemodialysis therapy. The fracture healed gradually after TAE, and the patient could walk 4 months later. In an iliac bone specimen obtained before TAE, cancellous bone was intact, but periosteal and endosteal surfaces of cortical bone showed marked resorption and were irregular. Normally, many ligaments are connected tightly to the periosteal surface, supporting the cortical bone. However, because of extensive surface resorption associated with pressure from enlarged kidneys, connections between ligaments and the periosteal surface presumably became fragile, promoting an insufficiency fracture from unapparent external forces. Thus, ADPKD is a potential cause of insufficiency fracture owing to abnormalities of cortical bone.

[Case of autosomal dominant polycystic kidney disease associated with pelvic insufficiency fracture].

We experienced a case of A-59-year-old woman having autosomal dominant polycystic kidney disease with renal insufficiency associated with pelvic insufficiency fracture. On admission the pelvic bone compressed by the enlarged kidney and liver due to polycystic disease was demonstrated on the pelvic CT. Her bone mineral density was not significantly decreased contrary to our expectation. The prominent bone absorption in the endosteal and exosteal surface of the cortical bone was demonstrated in the bone specimen form iliac bone although the state of the cancellous bone and bone formation rate was normal. We performed the transcatheter embolization (TAE) to the kidney and liver to diminish their sizes. The fracture was rapidly improved and she could walk 6 months later after the TAE. In this case, we considered that the longstanding compression to the pelvic bone by the enlarged liver and kidney made the cortical and the binding of muscle/tendon and cortical bone fragile and it led to the pelvic insufficiency fracture.

Intravascular embolization therapy in a patient with an enlarged polycystic liver.

Because the kidneys in patients with autosomal dominant polycystic kidney disease (ADPKD) are usually supplied by well-developed arteries, the authors attempted renal contraction therapy in such patients with renal transcatheter arterial embolization (TAE) using intravascular coils. In most patients with marked nephromegaly, renal TAE was effective. However, in patients with marked hepatomegaly without significant nephromegaly, renal TAE was not effective, and hepatic treatment was always required. In June 2001, the authors obtained approval for a new treatment,"TAE for enlarged polycystic liver," from an ethics committee discussing new treatment at their hospital. A 56-year-old man undergoing hemodialysis for 2 months was referred to the authors' institute with the complaint of severe abdominal distension and loss of appetite in March 2001. Most of the liver (about 90%) had been replaced by multiple cysts, and near-intact hepatic parenchyma was quite scarce. The kidneys were quite small compared with the liver. Angiography results showed that almost all hepatic arterial branches were well developed, although most of the portal vein was obstructed, and only the left medial portal vein was spared; the former corresponded to the hepatic region replaced by multiple cysts and the latter to the preserved intact hepatic parenchyma. The target of TAE was the hepatic arterial branches of the former. Microcoils were used as embolization material. Two years after TAE, abdominal distension has markedly decreased because of decrease in liver size (to 54% of the previous value), and muscle and fat volume in the thoracic region have increased owing to improvement of appetite. Ascites became obscure. Nutrition and activities of daily living have improved. Hepatic TAE may be an option for treatment of patients in poor condition with symptomatic polycystic liver.

Hemodialysis-related portal-systemic encephalopathy.

The authors encountered a case of portal-systemic venous shunt newly diagnosed after initiation of hemodialysis. A 68-year-old Japanese woman began hemodialysis because of symptoms of uremia including loss of appetite and pulmonary edema. Loss of consciousness occurred suddenly after her ninth session of hemodialysis. No hepatic functional abnormality was found other than hyperammonemia (314 microg/dL [184 micromol/L]). Loss of consciousness subsequently occurred often after hemodialysis. Color Doppler ultrasonography and magnetic resonance angiography depicted a large shunt between the left gastric vein and left renal vein resulting in portal flow entering the systemic circulation via the renal vein. Because the shunt was large, ligation of it was performed surgically. Results of histologic examination of a liver biopsy specimen obtained intraoperatively were normal. The patient became well postoperatively. This patient's encephalopathy appeared to be caused by the flow of ammonia-rich portal venous blood into the systemic circulation via the large shunt owing to a decrease in intravenous pressure after rapid hemodialysis. Portal-systemic shunt encephalopathy should be recognized as a "new" neuropsychiatric disorder characteristic of patients undergoing hemodialysis.

Alveolar bone regeneration using poly-(lactic acid-co-glycolic acid-co-ε-caprolactone) porous membrane with collagen sponge containing basic fibroblast growth factor: an experimental study in the dog.

The aim of this study was to evaluate the effects of combining porous poly-lactic acid-co-glycolic acid-co-ε-caprolactone (PLGC) as a barrier membrane and collagen sponge containing basic fibroblast growth factor (bFGF) to promote bone regeneration in the canine mandible. In six beagle dogs, two lateral bone defects per side were created in the mandible. The lateral bone defects on the left side were treated with a PLGC membrane plus a collagen sponge containing bFGF. In half of these, the collagen sponge contained 50 µg of bFGF. In the other half, it contained 250 µg of bFGF. As a control, we treated the right-side bone defects in each animal with the same PLGC membrane but with a collagen sponge containing phosphate buffered saline. Computed tomography (CT) images were recorded at 3 and 6 months post-op to evaluate regeneration of the bone defects. After a healing period of 6 months, whole mandibles were removed for micro-CT and histological analyses. The post-op CT images showed that more bone had formed at all experimental sites than at control sites. At 3 months post-op, the volume of bone at defect sites covered with PLGC membrane plus 250 µg of bFGF was significantly greater than it was at defect sites covered with PLGC membrane plus 50 µg of bFGF. At 6 months post-op, however, this difference was smaller and not statistically significant. Micro-CT measurement showed that the volume of new bone regenerated at bone-defect sites, covered with PLGC membrane plus bFGF, was significantly greater than that of control sites. However, the presence or absence of bFGF in the collagen sponge did not significantly affect the bone density of new bone. These results suggest that the macroporous bioresorbable PLGC membrane plus collagen sponge containing bFGF effectively facilitates healing in GBR procedures.

Evaluation of guided bone regeneration with poly(lactic acid-co-glycolic acid-co-ε-caprolactone) porous membrane in lateral bone defects of the canine mandible.

PURPOSE: The aim of this study was to qualitatively evaluate a poly(lactic acid-co-glycolic acid-co-ε-caprolactone) (PLGC) membrane as a barrier for guided bone regeneration in the canine mandible and to compare it to a nonresorbable polytetrafluoroethylene (PTFE) membrane. MATERIALS AND METHODS: Two wedge-shaped bone defects were created bilaterally in the mandibles of 12 beagle dogs. The bone defects in the left mandible were divided into three groups and treated as follows: PLGC membrane alone, PLGC membrane plus autogenous cortical bone chips, and titanium-reinforced expanded PTFE (TR-PTFE) membrane. The bone defects in the right mandible of each animal were left without membranes as a control. Computed tomography (CT) was performed at 3 and 6 months postoperative to evaluate bone regeneration. After a healing period of 6 months, the mandibles were removed en bloc for micro-CT and histologic analyses. RESULTS: CT analyses at 3 and 6 months showed that there was significantly more bone augmentation at all experimental sites than at the control sites. The volume of bone at defect sites covered with TR-PTFE was significantly greater than at defect sites covered with PLGC membrane with or without autogenous cortical bone. Micro-CT measurements showed that the volume of new bone formed at sites covered with TR-PTFE was significantly greater than at sites covered with PLGC membrane. However, the density of new bone was significantly higher at sites covered with PLGC membrane, with or without cortical bone, than at sites covered with TR-PTFE. Histologic analysis verified the presence of well-vascularized loose connective tissue in the pores of the PLGC membrane. CONCLUSIONS: Compared to TR-PTFE, the macroporous bioresorbable PLGC membrane did not significantly increase the amount of new bone in defect sites, but it facilitated the regeneration of mature bone.

Tonsillectomy and corticosteroid therapy with concomitant methylprednisolone pulse therapy for IgA nephropathy.

IgA nephropathy (IgAN) is the most common chronic kidney disease in Japan, but the optimum treatment remains controversial. Our objective was to evaluate the effect of tonsillectomy and corticosteroid therapy combined with methylprednisone pulse therapy in patients at our hospital who had IgAN. Tonsillectomy plus pulse therapy was evaluated in 72 patients (33 men and 39 women) with a diagnosis of IgAN based on renal biopsy who were followed up for more than 1 year. The mean age of the patients was 35.2 +/- 10.9 years (range: 20-58 years) and the mean observation period after tonsillectomy was 20.3 +/- 9.7 months (range: 12-36 months). After tonsillectomy, steroid pulse therapy was administered (methylprednisolone at 500 mg daily for 3 days) 1-3 times and was followed by oral prednisolone from an initial dose of 30 mg on alternate days that was tapered gradually over one year. At 2 years after tonsillectomy, serum creatinine was unchanged or improved in the majority of patients, but worsened in 5 patients. Hematuria (erythrocytes/HPF) improved from Grade 3.76 (11-30/HPF) to Grade 1.94 (1-5/HPF) on average (we defined the grade of hematuria). None of the patients experienced exacerbation of hematuria. Proteinuria decreased from 1.32 g/day to 0.86 g/day (65% of the pretreatment value), and only 4 patients showed an increase of proteinuria. Mean protein loss decreased to less than 0.5 g/day in patients with creatinine clearance > or =90 ml/min and/or patients with initial protein excretion < or =1.0 g/day.

Successful renal transcatheter arterial embolization in three patients with symptomatic hydronephrosis due to ureteral obstruction.

BACKGROUND: Conventional treatments for symptomatic enlargement of a nonfunctional hydronephrotic kidney caused by obstructive uropathy include surgical treatments. METHODS: Patients included a 67-year-old woman whose obstruction was caused by a lower urinary tract stone complicating spinal tuberculosis (patient 1); a 52-year-old man with compressive complete congenital obstruction crossing the ureteropelvic junction from an aberrant renal artery (patient 2); and a 19-year-old woman with essentially complete idiopathic congenital obstruction at the ureteropelvic junction (patient 3), who required antibiotics for pyelonephritis before embolization. The renal artery was embolized using platinum microcoils. RESULTS: Although the sensation of abdominal fullness diminished within approximately two week after TAE, it took one to two years until the embolized kidney size shrank from 1377+/-634 cm3 (range, 829 to 2072) to 43+/-46 cm3 (42 to 94) by the evaluation of computed tomography. Fever after embolization persisted for 5 days in patient 1, 3 in patient 2, and 9 in patient 3. Flank pain resolved within 5 days in all. Pyelonephritis and complications of treatment have not occurred. CONCLUSION: Embolization for this indication was safe and effective.