Current Issue : April - June Volume : 2013 Issue Number : 2 Articles : 5 Articles
A 75 year-old man presented with shortness of breath and increased bilateral lower extremity edema for 3\r\nweeks. He was found to have nephrotic syndrome with a 24-hour urine protein excretion of 14 g. The serum creatinine\r\nhad increased to 2.0 mg/dL from a baseline of 1.0 mg/dL within one month. Based on the initial presentation with\r\nshortness of breath and tachycardia, the patient was empirically treated with intravenous heparin infusion for suspected\r\npulmonary embolism. The patient developed bleeding per rectum. Heparin was discontinued. A colonoscopy revealed\r\na 6 cm rectosigmoid mass with biopsy showing moderately differentiated adenocarcinoma. A renal biopsy showed\r\nnormal glomeruli on light microscopy and 100% foot process effacement on electron microscopy, consistent with\r\nminimal change disease (MCD). Treatment was initiated with prednisone 80 mg daily (1 mg/kg/d) and furosemide 40\r\nmg twice daily orally. The patient underwent surgery and adjuvant chemoradiation. Lower extremity edema improved\r\ngreatly over one month. Serum albumin increased to 2.6 g/dL Urine protein to creatinine ratio was 0.3. The serum\r\ncreatinine returned to 1.0 mg/dL at baseline. Prednisone had been gradually tapered to 5 mg/day.\r\nParaneoplastic glomerular disease is a rare manifestation of malignancy that is frequently mistaken from other\r\nglomerular diseases. In patients with nephrotic syndrome, especially elderly, the possibility of underlying malignancy\r\nshould be considered. Colorectal cancer-associated MCD is uncommon and has been reported in only 6 cases to\r\ndate. We present another case of rectal cancer-associated MCD with acute kidney injury and nephrotic syndrome.\r\nConsidering that MCD is more steroid responsive than other nephrotic diseases, early recognition and diagnosis may\r\nhelp to expedite effective therapy. Also, ablation of the tumor frequently results in remission of MCD...
Abstract\r\n\r\nObjective: There is substantial evidence for a renoprotective effect of inhibitors of the renin-angiotensin system\r\n(RAS) in diabetic kidney disease (DKD). However, it is unclear whether dual RAS blockade has additional benefits\r\nwhen compared to monotherapy in this population and whether any benefits outweigh the risks.\r\n\r\nData sources: A systematic review and meta-analysis of English language articles was performed using\r\nMEDLINE, EMBASE, CINAHL, and the Cochrane database of systematic reviews.\r\n\r\nStudy selection: All randomized, controlled trials comparing RAS blockade to monotherapy in patients with overt\r\nproteinuria were included.\r\n\r\nData extraction: Articles were reviewed independently by two of the authors using a standardized data collection\r\nform including study quality indicators.\r\n\r\nData synthesis: All pooled analyses were based on random-effects models. The primary efficacy outcome\r\nmeasure was the percent reduction in proteinuria with combination therapy versus monotherapy measured by\r\ndifference in means. Secondary outcomes included changes in systolic blood pressure (SBP), glomerular filtration\r\nrate (GFR), and serum potassium, and incidence of hyperkalemia. The primary safety outcome was hyperkalemia.\r\n\r\nResults: Compared to monotherapy, combination therapy with an angiotensin converting enzyme inhibitor (ACEI)\r\nplus angiotensin receptor blocker (ARB) reduced proteinuria by an additional 25% (mean difference -25, 95% CI -33,-\r\n17), whereas combination therapy with an aldosterone antagonist (ALDOA) plus ACEI or ARB reduced proteinuria\r\nby an additional 32% (mean difference -32, 95% CI -37,-27). SBP after treatment with combination therapy vs.\r\nmonotherapy was significantly lower with both the ACEI/ARB and ALDOA combinations. Dual therapy was associated\r\nwith an increase in serum potassium, in particular with the ALDOA combination.\r\n\r\nLimitations: Most studies were small and of short duration, and none included major patient outcome data such\r\nas kidney failure or death.\r\n\r\nConclusion: Dual RAS blockade in patients with DKD reduces proteinuria and SBP but increases the risk of\r\nhyperkalemia....
Despite the availability of current therapies that target hyperglycemia, hypertension, dyslipidemia and blockade of the renin-angiotensin-aldosterone (RAA) system, many people with diabetic chronic kidney disease (CKD) still progress to end stage renal disease (ESRD). Hence, new therapies to slow the progression of this important diabetic complication are urgently needed. Disappointingly many promising interventions for diabetic CKD have not coming to fruition when tested in large clinical trials. A recent clinical trial has shown that estimated GFR increases with bardoxolone. However, this finding awaits confirmation that it reflects changes in true GFR and translation into a reduction in clinical events. Here we discuss studies that have evaluated the effects of novel approaches to inhibiting the pathways involved in the pathogenesis of diabetic CKD...
The prevalence of nephrolihiasis and chronic kidney disease has risen over the past three decades, we sought to determine if person with a history of kidney stones have lower renal function relative to non stone formers.\r\n \r\nMethods: We conducted a case-control study utilizing 138 recurrent calcium kidney stone formers and 127 age and gender matched controls with no history of renal disease, all subjects were aged 30-55 years old, with no history of hypertension, diabetes mellitus, congestive heart failure and liver disease and also no urinary tract obstruction and medications can affect Glomerular Filtration Rate (GFR).\r\n \r\nWe estimated GFR by Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EP I) equations and categorized using cut points suggested by Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines.\r\n \r\nResults: Mean GFR in case group and control group was: 80.17(18.45) ml/min/1.73m2 and 83.80(15.75) ml/ min/1.73m2 respectively (P value: 0.09). Distribution of subjects among stone formers in stage I, II, III was 59(42.8%), 71(51.4%) and 8(5.8%) and in control group was 67(52.8%), 59(46.4%) and 1(0.8%) respectively, (p: 0.03). There was an inverse correlation between GFR and number of passed stone but there was no significant correlation between history of extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL) and estimated GFR.\r\n \r\nConclusion: Recurrent calcium stone disease may be associated with nephron damage and an increased risk of chronic kidney disease....
Immunogenetic characterization of the transplant recipient with crossmatch is used to minimize graft loss by\r\ndetecting preformed antibodies. Use of increasingly sensitive tests including flow cytometry crossmatch (FCXM) has\r\nbeen accompanied by near elimination of hyperacute rejection. We reviewed associations of crossmatch results with\r\nkidney graft outcomes in contemporary practice, and provided updates of our past publications with more recent\r\ndata in several instances. Recent United States registry data for transplants performed with a reported positive\r\ncrossmatch demonstrate immediate graft loss rates of =1.3% in FCXM+ recipients, and =3.6% in complementdependent\r\ncytotoxicity crossmatch positive (CDCXM+) recipients. One-year graft survival was reduced by =6.4% in\r\nFCXM+ versus FCXMââ?¬â?? recipients, and by =11.5% in CDCXM+ versus CDCXMââ?¬â?? recipients. Five-year graft survival\r\nwas reduced by =10.2 % in FCXM+ versus FCXMââ?¬â?? recipients, and by =8.7% in CDCXM+ versus CDCXMââ?¬â?? recipients.\r\nA possible explanation for the markedly lower graft loss risk with crossmatch positive transplants in modern practice\r\nmay be selection of recipients with low anti-HLA titers. Although a good correlation between virtual crossmatch and\r\nactual crossmatch has been demonstrated, the outcome significance of positive virtual/negative actual and negative\r\nvirtual/positive actual crossmatches is not clearly established. Post-transplant demonstration of the persistence or\r\nappearance of donor-specific antibody is of value in prognostication, but utility for adjustment of therapy is uncertain.\r\nIn summary, contemporary data suggest that, among selected transplants performed, the impact of a positive\r\ncrossmatch may be relatively small compared to other accepted clinical factors. Further study is warranted work to\r\ndetermine, prospectively, under what circumstances crossmatch positive transplants can precede with safety....
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