Watarai R, Aoyama T, Kamata M
… +9 more, Miyazawa M, Ogawa M, Okina C, Murano J, Tanaka K, Aoyama M, Nakano M, Sano T, Kamata K
Nihon Jinzo Gakkai Shi
· 2015 · PMID 26665617
Pseudo-pulmonary embolism (PPE) superimposed on heparin-induced thrombocytopenia (HIT) is an important complication in patients undergoing hemodialysis (HD) treatment. We report the clinical profile of an HD patient with...Pseudo-pulmonary embolism (PPE) superimposed on heparin-induced thrombocytopenia (HIT) is an important complication in patients undergoing hemodialysis (HD) treatment. We report the clinical profile of an HD patient with acute respiratory distress induced by PPE and HIT. A 67-year-old man with diabetic nephropathy and end-stage renal failure developed congestive heart failure. He was admitted to Kitasato University Hospital. He was introduced to HD treatment using low-molecular-weight heparin as an anticoagulant for an HD session on day 1 of admission. On day 11 after admission, he suddenly developed respiratory distress and hypoxia at 30 min after the start of the fifth HD session. The HD session was immediately discontinued, and oxygen inhalation improved his complaints and hypoxia. The platelet count decreased from 220 x 10(9)/L at the start of the HD session to 80 x 10(9)/L at the end of the HD session. We suspected HIT when blood clotting occurred in his hemodialyzer and blood circuit for HD during the HD session on day 12. Chest X-ray, electrocardiogram, echocardiography, and pulmonary microcirculation scintigraphy were normal. Serum analysis was positive for heparin-platelet factor 4 (PF4) antibody. We then diagnosed him with PPE superimposed on HIT. After the anticoagulant agent for HD was changed from low-molecular-weight heparin to nafamostat mesilate, his clinical symptoms and thrombocytopenia disappeared. PPE superimposed on HIT appeared approximately 7-10 days after the initial use of heparin for the HD session. PPE also led to acute respiratory distress, blood coagulation in the hemodialyzer and blood circuit for HD, as well as thrombocytopenia with less than a 50% decrease in platelet counts. The prognosis of PEE and HIT is good after discontinuing the use of heparin.
A 68-year-old woman visited JA Toride Medical Center with asymptomatic proteinuria. Bence Jones protein-λ was identified in her serum and urine samples, and subsequent bone marrow aspiration revealed multiple myeloma (MM...A 68-year-old woman visited JA Toride Medical Center with asymptomatic proteinuria. Bence Jones protein-λ was identified in her serum and urine samples, and subsequent bone marrow aspiration revealed multiple myeloma (MM). Simultaneous renal biopsy showed only minor glomerular abnormality and preserved interstitium. Since the clinical stage was not advanced, aggressive treatment was avoided. During the following six months, her renal function gradually deteriorated with sustained elevation of urine protein and β2 microglobulin excretion, although other routine blood tests yielded stable results. In contrast to the first renal biopsy, the second biopsy specimen exhibited findings suggestive of inflammatory cell infiltration associated with light chain deposition along the tubular basement membrane. However, her myeloma did not cause symptoms other than mild renal disorder and remained in the category of indolent myeloma. Therefore a moderate dose of steroid therapy according to the regimen of common interstitial nephritis was initiated and her renal function and urinary findings partially recovered. Subsequently, her condition was diagnosed as infiltration of plasma cells with positive λ-light chain deposition. Since direct infiltration of myeloma cells into the renal interstitium rarely causes renal failure especially at the initial stage, we did not conduct intensive chemotherapy with possible severe side effects. More intensive chemotherapy would have been administered if the patient had suffered from other organ damage. There are no reports of cases in whom steroid alone was effective against multiple myeloma, hence this case is of clinical significance in providing a treatment option for renal dysfunction caused by restricted infiltration of myeloma cells, especially for cases where intensive chemotherapy is contraindicated.
Ito C, Akimoto T, Morishita Y
… +8 more, Yamamoto H, Ogura M, Yamazaki T, Miki A, Homma S, Kusano E, Asano Y, Nagata D
Nihon Jinzo Gakkai Shi
· 2015 · PMID 26665615
BACKGROUND: Erythropoiesis-stimulating agents (ESAs) are the mainstay of treatment for renal anemia in chronic kidney disease (CKD) patients. However, the difference in hematopoietic effect between darbepoetin alfa (DA)...BACKGROUND: Erythropoiesis-stimulating agents (ESAs) are the mainstay of treatment for renal anemia in chronic kidney disease (CKD) patients. However, the difference in hematopoietic effect between darbepoetin alfa (DA) and continuous erythropoiesis receptor activator (CERA) has remained unclear in non-dialysis CKD patients. Another purpose of this study was to analyze the red blood cells indices under treatment with these two ESAs in ESA-naïve CKD patients. METHODS: This study was designed as a multicenter retrospective observational investigation, and included 61 patients receiving DA (group DA) and 36 patients receiving CERA (group CERA) for at least six months. Relative effect of these ESAs was determined by comparing means of the individual monthly average of the area under the curve above the initial level of hemoglobin (Hb), hematocrit (Hct), and red blood cell count (RBC) with the trapezoidal rule, which are maintenance ratios. Serial changes in mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) were also evaluated. RESULTS: No differences were found in the mean ratios of Hb, Hct, and RBC, and maintenance ratios of these parameters. The ratio of MCH in group CERA was decreased compared with that in group DA. Subsequent decrease in MCV was also remarkable in group CERA. CONCLUSIONS: It is speculated that iron demand increased during the administration of CERA, which was suggested by changes in the red cell indices. Reticulocyte indices and iron-related parameters could provide a more detailed explanation and the significance of iron supplementation during administration of CERA should be clarified when compared with other types of ESA.
Suzuki S, Ohishi M, Katayama N
… +2 more, Koizumi H, Namiki M
Nihon Jinzo Gakkai Shi
· 2015 · PMID 26625471
A previously healthy 67-year-old woman visited our institution because of cough that had persisted for 3 months, fever at night, left tinnitus, and hearing loss from 1 month prior. She lost 2 kg in weight over the last 6...A previously healthy 67-year-old woman visited our institution because of cough that had persisted for 3 months, fever at night, left tinnitus, and hearing loss from 1 month prior. She lost 2 kg in weight over the last 6 months, and her C-reactive protein level and leukocyte count were increased. Computed tomography revealed multiple small nodules in both lung fields. She was admitted to our hospital for further examination to determine the optimal medical treatment. Because the myeloperoxidase antineutrophil cytoplasmic antibody (ANCA) titer was 132.5 U/mL and microscopic hematuria was observed, vasculitis was considered. A percutaneous kidney biopsy was performed and revealed microscopic polyangiitis. For this reason, the case was diagnosed as ANCA-associated vasculitis. Esophageal stenosis and pseudodiverticulosis were observed on upper gastrointestinal endoscopy. Pathological changes due to inflammation were observed in the biopsy and esophagography. Pulse therapy with methylprednisolone at 1,000 mg/day was administered to the patient as the first-line treatment, followed by prednisolone at 40 mg/day as remission induction treatment. Bloody urine and lung shadows disappeared, and the steroid dose was tapered at hospital discharge. The patient's hearing ability and the esophageal pathological change that was considered to be ANCA-associated vasculitis were improved. Although a few studies have reported that esophageal stenosis and pseudodiverticulosis accompany ANCA-associated vasculitis, we think that examination for the possible presence of gastrointestinal tract lesions is important.
BACKGROUND: The ratio of elderly complicated diabetes mellitus (DM) to all hemodialysis (HD) patients has increased. The number of elderly DM patients with poor glycemic control has also increased due to complications, s...BACKGROUND: The ratio of elderly complicated diabetes mellitus (DM) to all hemodialysis (HD) patients has increased. The number of elderly DM patients with poor glycemic control has also increased due to complications, such as dementia. By means of appropriate glycemic control, the risk of cardiovascular disease might decrease among diabetic HD patients, and improvement of their prognosis could be expected. When glycemic control is poor when treating diabetic HD patients with oral hypoglycemic agents, insulin treatment could be indicated. METHODS: Using continuous glucose monitor (CGM), we evaluated the differences in glucose variability of 3 type 2 diabetic HD patients with poor glycemic control when switching from insulin glargine to degludec. RESULTS: Case 1 was a 72-year-old man with poor dietary self-management, whose glycated albumin (GA) level was 27%, and was administered lispro 6-6-6 U plus glargine 8 U daily. He was switched from glargine to degludec 6 U daily. Eight weeks later, his glycemic control improved as seen in his GA level (19%) and CGM. Case 2 was an 84-year-old solitary woman with dementia. Her GA level was 28.4%, and she was administered glargine 8 U (after HD, 3 times/week). She was switched from glargine to degludec 6 U (after HD, 3 times/week). Her glycemic control improved as seen in her GA level (25.1%) and CGM thereafter. Case 3 was a 65-year-old solitary man with liver cirrhosis and chronic pancreatitis. His GA level was 26.6%, and he was administered glargine 8 U (every day). He was switched from glargine to degludec 12 U (after HD, 3 times/week). His glycemic control improved as seen in his GA level (21.3%) and CGM thereafter. CONCLUSIONS: These results suggest that degludec is more effective than glargine in improving glycemic control and reducing the insulin dose in type 2 diabetic HD patients.