Case Reports in Nephrology and Dialysis最新文献

Introduction: Primary biliary cholangitis (PBC) is a chronic and progressive cholestatic liver disease that is autoimmune in nature and characterized by circulating anti-mitochondrial antibodies. A wide range of autoimmune disorders have been concomitantly observed in patients with PBC, and although quite rare PBC has been associated with a wide variety of renal disorders. Glomerular diseases have a very rare association with PBC, and these include diffuse membranous glomerulonephritis and minimal change disease, which have been sparsely described in prior literature.

Presentation: Here we present a case of biopsy-proven minimal change disease in a patient with PBC treated with a course of steroids and achieving complete recovery.

Conclusion: Establishing the relationship between PBC and MCD has been limited in prior literature and should be kept in mind to bring forth this rare association, which may help dictate future treatment courses.

Introduction: Herbal medications have been utilized for centuries to treat various ailments, yet their potential to induce renal damage is often underestimated. The popularity of herbal remedies, especially in rural India, stems from cultural beliefs in their holistic healing properties.

Case presentations: This case series comprises 4 patients exhibiting varied renal presentations linked to herbal medication usage. Notably, oxalate nephropathy emerged as a predominant finding. Through comprehensive clinical assessments and renal biopsies, we elucidated the pathophysiological mechanisms underlying herbal nephrotoxicity. Timely recognition and discontinuation of the offending herb, alongside tailored therapeutic interventions like corticosteroid administration, facilitated favourable patient outcomes.

Conclusion: These cases underscore the importance of considering herbal remedies as potential culprits in renal dysfunction, particularly in regions where their usage is prevalent. Our findings emphasize the imperative for healthcare practitioners to proactively inquire about herbal medication use in patients with renal failure. Heightened awareness and further research into the safety and mechanisms of herbal nephrotoxicity are essential for optimizing patient care and preventing herb-induced kidney injury.

Introduction: Calciphylaxis is a systemic disease that predominantly affects individuals with chronic kidney disease, particularly in the advanced stages. It is a potentially life-threatening condition with significant morbidity. The exact underlying mechanisms leading to calciphylaxis are not fully understood. Cutaneous manifestations are the typical presentation of calciphylaxis, where patients develop painful skin ulcers affecting their extremities. However, calciphylaxis involving visceral organs are rare.

Case presentations: We present 2 cases where the initial clinical picture of calciphylaxis was atypical. The first case is a haemodialysis patient presenting with unilateral acute vision loss, mimicking giant cell arteritis. The second case is a failed transplant graft recipient on peritoneal dialysis with incidental radiological findings of heavily calcified mesenteric nodules.

Conclusion: These cases highlight the importance of a high clinical suspicion of calciphylaxis as it can masquerade other clinical conditions.

Introduction: Quetiapine is a new atypical antipsychotic with minor side effects. There have been few reports of rhabdomyolysis and acute kidney injury associated with quetiapine overdose.

Case presentation: This article presents a rare case of high-dose quetiapine poisoning that improved after treatment. The patient experienced rhabdomyolysis, acute kidney injury, long QT syndrome, and peripheral neuropathy, all of which are typical complications of quetiapine poisoning. Moreover, a kidney biopsy verified the patient's acute tubulointerstitial injury, and immunohistochemical staining demonstrated that myoglobin cast nephropathy was the cause of the injury. This patient's kidney function and associated complications recovered after receiving hemodialysis, rehabilitation, heart rate regulation, and further symptomatic interventions. Consequently, hemodialysis was discontinued.

Conclusion: Our case showed that myoglobin cast nephropathy was the cause of the acute kidney injury associated with quetiapine poisoning. The kidney biopsy is essential for accurate diagnosis and treatment.

Introduction: The aim of this study was to highlight the benefits and provide a framework for integrated multispecialty team involvement in the management of hyperkalemia in patients with heart failure (HF) and kidney disease and to ensure that patients receive optimal medical therapy to improve their clinical outcomes.

Case presentation: This report highlights a hypothetical "complex" case of a patient with an acute HF decompensation who experiences hyperkalemia following up-titration of renin-angiotensin-aldosterone system inhibitor (RAASi) therapy. Two hypothetical scenarios for treatment management are discussed; in the first, providers down-titrate guideline-directed RAASi to avoid hyperkalemia, whereas in the second, providers take a collaborative interdisciplinary approach to manage hyperkalemia directly with the aim of avoiding RAASi down-titration. In the first typical management scenario, down-titration of guideline-directed RAASi to prevent increases in serum potassium (serum K⁺) levels leads to the reoccurrence of symptoms and rehospitalization of the patient. In the second proposed management scenario, interdisciplinary team discussions around differing tolerances and approaches to raised serum K⁺ levels lead to maintenance of guideline-directed RAASi doses with the help of close monitoring of the patient, introduction of a low potassium diet, and prescription of potassium binder therapy.

Conclusion: Collaborative multispecialty team management of HF patients may enable successful management of hyperkalemia without the need for discontinuation of guideline-directed RAASi therapy. Collaboration could extend to regular virtual or face-to-face cardiorenal clinics, where complex cases can be discussed, and local guidelines and processes can be developed.

Introduction: Erythropoietin-induced pure red blood cell aplastic anemia (EPO-PRCA) is a rare anemia, which presents a significant treatment challenge, often necessitating the cessation of erythropoiesis-stimulating agents and the adoption of immunosuppressive therapies or renal transplantation.

Case presentation: In the present case, the patient developed severe anemia after 2-year EPO treatment and was diagnosed with EPO-PRCA. The treatment with the full dose of corticosteroids and testosterone for 1 month failed to increase his hemoglobin level significantly. Therefore, the patient received the combination therapy of cyclosporine A (CsA) with rituximab, which effectively cleared the anti-EPO antibody. Then, roxadustat was given to improve renal anemia. As Hb level increased gradually, the patient was recovered from EPO-PRCA.

Conclusion: This case reported an EPO-PRCA patient was successfully cured by the combination of CsA with rituximab and provided another choice for the treatment of EPO-PRCA in the future.

Introduction: Constrictive pericarditis (CP) is characterized by impaired diastolic filling of the ventricles, which typically causes right heart failure. Its diagnosis may be challenging because it mimics other disorders. Furthermore, prompt diagnosis and treatment are more crucial in cases of hemodialysis; otherwise, maintenance dialysis would be hampered by severe hypotension.

Case presentation: We report the case of a 53-year-old man on hemodialysis who developed CP with shock. His blood pressure was 55/30 mm Hg at the time of hospitalization due to presyncope. He continued hemodialysis but with some difficulty. However, right pleural effusion persisted because of impaired fluid removal by hemodialysis. Despite such severe manifestations, the distinctive clinical features of CP were lacking. By carefully evaluating the time course of computed tomography images, progressive calcification in the pericardium emerged as a significant clue. Cardiac catheterization subsequently revealed a dip-and-plateau pattern of right ventricular pressure, which led to a definitive diagnosis of CP. Soon after the diagnosis, he underwent successful surgery.

Conclusion: An important finding was that, unlike calcific lesions in the general dialysis population, the patient's calcific lesions were mostly confined to the pericardium and progressed on a monthly basis. Thus, the present case may provide deep insight into the diagnosis of CP and the management of hemodialysis patients with severe hypotension.

Introduction: When a patient with severe hyponatremia requires renal replacement therapy, a too rapid correction of sodium levels may occur. Manual dilution of the fluids during continuous renal replacement therapy (CRRT) is a method that can lead to a controlled correction of sodium. We present a case and add a systematic review to determine the feasibility of this method.

Case presentation: A female was admitted to the intensive care unit with acute kidney failure due to anti-glomerular basement membrane antibody glomerulonephritis, anuria, and an initial sodium level of 100 mmol/L. She received CRRT with manually diluted fluids for 6 days, in which sodium levels increased from 108 mmol/L to 130 mmol/L. A search in Medline, Web of Science, and Google Scholar was added for the systematic review. The search yielded 49 cases, including the current report, of which 47 were anuric or oliguric, in which the fluids were diluted to a median of 8 mmol/L (interquartile range 5-11) (range 0-17) above the serum sodium, the median CRRT dose was 27 mL/kg/h (22-30) (13-77.5). This led to an increase in serum sodium of 0.2 mmol/L/h (0.1-0.3) (0-0.7).

Conclusion: CRRT with manually diluted fluids in patients with severe hyponatremia and anuria can lead to a controlled increase serum sodium, while allowing sufficient RRT dose and fluid removal. Still, errors in dilution may occur and we recommend 4 hourly monitoring of serum sodium levels to timely detect an inadvertent increase in sodium.

Introduction: Dent disease (DD) is characterized by a triad of low-molecular-weight proteinuria, hypercalciuria, and nephrocalcinosis/nephrolithiasis. However, some cases were confounded by other clinical symptoms and signs, namely, hypokalemia and rickets, which resulted in misleading diagnoses. A diagnosis of DD could be delayed even in high-resource countries due to its variability of phenotypes and rarity, causing a lack of awareness in both medical practitioners and parents. Moreover, in low-resource countries, laboratory test limitations can hinder the diagnosis.

Case presentation: A thirteen-year-old boy presented with an acute episode of severe hypokalemia following vomiting due to COVID medication side effects. He had lower extremities weakness, salt craving, and polydipsia since childhood which were not thought to be unusual by the parents. He had a history of intrauterine polyhydramnios and maternal miscarriages. A physical examination showed hypotension, short stature, and genu valgum. His laboratory workup displayed hypokalemic metabolic alkalosis and increased urine potassium, chloride, transtubular potassium gradient, and calcium/creatinine ratio. He also had hypophosphatemia, hypomagnesemia, and decreased kidney function. Severe osteopenia was prominent on radiologic examination of all extremities. Subsequent laboratory samples sent overseas revealed low-molecular-weight proteinuria and a pathogenic variant in the CLCN5 gene confirming X-linked DD 1.

Conclusion: This case report highlights the importance of considering DD in differential diagnoses of children with the pseudo-Bartter syndrome, that is, renal salt and potassium wasting, with or without hypercalciuria and nephrocalcinosis. Additionally, in children with rickets and proteinuria, urinary low-molecular-weight protein measurement could assist in screening for the possibility of DD, particularly in low-resource settings.

Introduction: A common complication of arteriovenous fistula (AVF) is thrombosis in the venous segment, which can impair vascular access unless a successful thrombectomy is performed.

Case presentation: In this manuscript, we describe the case of a diabetic patient who had primary AVF in a snuff-box with subsequent superficialization of the medial vein of the forearm. Unfortunately, this section of the vein was occluded, although the fistula was patent through the cephalic vein (CV). Due to insufficient flow, this vascular access was unsuitable for hemodialysis. Using a vein from the subcutaneous venous network (SVN), additional AVF was performed. Our goal was to accelerate maturation by doubling arteriovenous flow, which then increased the size of the CV in the arm. After maturation, a second superficialization was performed on the arm, which allowed for successful cannulation.

Conclusion: SNV may be considered for the creation of a new AVF to improve the maturation of the primary fistula.