A 14-year-old boy was admitted to a general hospital because of prolonged fever of unknown origin. After Enterococcus feacalis was detected from his urine and abdominal contrast enhanced computed tomography and 99m-Tc di...A 14-year-old boy was admitted to a general hospital because of prolonged fever of unknown origin. After Enterococcus feacalis was detected from his urine and abdominal contrast enhanced computed tomography and 99m-Tc dimercaptosuccinic acid scintigram showed multiple focal defects, he was diagnosed as acute focal bacterial nephritis (AFBN). His condition recovered as a result of Ampicillin (ABPC)and Cefotaxime infusion. There was no specific finding in voiding cystography. Six months later, his fever recurred and he was diagnosed as refractory AFBN because Enterococcus feacalis was detected in his urine again. He was treated with ABPC and Meropenem (MEPM) infusion, but the fever persisted and his renal function deteriorated. He was transferred to our hospital for intensive treatment. On admission, blood examination showed findings of inflammation (WBC 14,400/μL, CRP 3.7 mg/dL, erythrocyte sedimentation rate : 69 mm/h, IgG : 2,107 mg/dL) and renal impairment (Cr : 1.8 mg/dL, cystatin C : 2.0 mg/L). Although neither pyuria nor pathogenic bacteria were detected in his urine, Enterococcusfeacalis was detected at the hospital where he had been treated previously, hence we started treatment for AFBN with ABPC, MEPM, Levofloxacin, then Linezolid. However, the fever persisted and his renal function deteriorated (Cr 2.0 mg/dL). Kidney-specific accumulation was found in Ga scintigraphy, which suggested chronic inflammation. Clinical course and laboratory findings showed no symptoms of bacterial, viral, fungal, or tuberculous infections nor collagen disease. Although renal biopsy revealed no glomerular abnormality, tubulointerstitial edema, fibrosis and tubulitis were observed. Rupture of the tubular basal membrane and non-caseating granulomas also existed. Pathological findings did not match those of renal sarcoidosis. Ophthalmological screening negated the existence of tubulointerstitial nephritis with uveitis syndrome. After methylprednisolone pulse therapy, the fever recovered immediately and his renal impairment imroved gradually (Cr 1.49 mg/dL). He continues to undergo treatment as an outpatient. Although tubulointerstitial nephritis is rare in children, some patients have a poor renal prognosis. It is important to determine the existence of tubulointerstitial nephritis on treating a patient with renal impairment.
In Japan, two treatment guidelines exist for pediatric patients with hypertension. The Guidelines for Drug Therapy in Pediatric Patients with Cardiovascular Diseases (JCS2012), by the Japanese Circulation Society, cite t...In Japan, two treatment guidelines exist for pediatric patients with hypertension. The Guidelines for Drug Therapy in Pediatric Patients with Cardiovascular Diseases (JCS2012), by the Japanese Circulation Society, cite the stethoscopy-based American guidelines. The Guidelines for the Management of Hypertension (JSH2009), by the Japanese Society of Hypertension, focus on Japanese data obtained from automated sphygmomanometry. The frequent use of automated sphygmomanometers in clinical practice implies that the JSH2009 guidelines might be better; however with strict low reference values for the diastolic phase, overtreatment may result. Only the Japanese Circulation Society's guidelines include a therapeutic strategy, and the Chronic Kidney Disease (CKD) Guide, CKD Guidelines, and school urinary screening tests all cite these guidelines on stethoscopy-based blood pressure determination. Stethoscopy should be conducted during a medical examination; however, due to limited time in clinical practice, most physicians use automated sphygmomanometers while nevertheless relying on the Japanese Circulation Society reference values--which are stethoscopy-based. To find a compromise, we compared reference values in Japan with those from South Korea (automated sphygmomanometer-based) and those from the United States (stethoscopy-based). Moreover, we examined the results of recent accuracy tests for automated sphygmomanometers. Although the JSH2009 reference values for the systolic phase were consistent with those in the United States (stethoscopy-based), the reference values for the diastolic phase were lower. We observed the same tendency when comparing JSH2009 reference values with those in South Korea (automated sphygmomanometer-based). Conversely, there were only small differences between automated sphygmomanometry and mercury measurement, and we found it was possible to substitute the values from automated sphygmomanometry for stethoscopy. A large-scale study that takes into account patient height, measurement method, and treatment criteria is required to establish appropriate reference values. Even if automated sphygmomanometry is used until appropriate values are established, we consider the criteria provided in the American guidelines as appropriate.
Kuriyama S, Nakano T, Maruyama Y
… +12 more, Sugano N, Takane K, Suetsugu Y, Takahashi Y, Kobayashi C, Nishio S, Takahashi D, Kidoguchi S, Ichida K, Ohno I, Hosoya T, Yokoo T
Nihon Jinzo Gakkai Shi
· 2014 · PMID 25551987
AIM: Serum uric acid (UA) concentration is regulated by its production in the liver and/or intestine and its rate of excretion from the kidneys. However, little is known about skeletal muscle involvement in determining t...AIM: Serum uric acid (UA) concentration is regulated by its production in the liver and/or intestine and its rate of excretion from the kidneys. However, little is known about skeletal muscle involvement in determining the physiological UA level. The present trial explores whether muscle strength and/or muscle volume is associated with UA levels. MATERIAL & METHODS: Muscle strength was evaluated in terms of grasping power calculated as an average of right and left hand measurements in relation to other parameters in 14,333 subjects (median age; 41.2 years), who were recruited to the study. Skeletal muscle volume was calculated based on the bioimpedance method by subtracting estimated fat volume plus estimated bone weight from the total body weight. RESULTS: 1) Multiple regression analyses to explain the association with UA levels (dependent variable) revealed that BMI, BUN, triglyceride, muscle strength, AST, age and sex are independent variables. 2) Higher UA levels (assessed as 4 UA quartiles) are associated with higher muscle volume, muscle strength, BMI, DBP, and serum creatinine (Cr) concentration. 3) Greater DBP (assessed as 2 UA categories) was associated with higher BMI, muscle strength, muscle volume, UA levels and serum Cr concentration. 4) Regression coefficient "t" for muscle strength was the largest among the other parameters including serum Cr concentration in the UA level ranging from 5.5 to 6.5 mg/dL. CONCLUSION: There was an association between muscle strength/volume and UA levels in the near physiological UA range, suggesting that the circulating UA levels can be, at least in part, controlled by its production in the skeletal muscles.
Komatsu H, Nakagawa H, Iwakiri T
… +6 more, Toida T, Fukuda A, Kikuchi M, Sato Y, Kitamura K, Fujimoto S
Nihon Jinzo Gakkai Shi
· 2014 · PMID 25551986
BACKGROUND AND OBJECTIVES: Little is known about the treatment and clinical status of patients with biopsy-proven IgA nephropathy (IgAN) during long-term maintenance dialysis. METHODS: Fifty-two of 433 patients with IgAN...BACKGROUND AND OBJECTIVES: Little is known about the treatment and clinical status of patients with biopsy-proven IgA nephropathy (IgAN) during long-term maintenance dialysis. METHODS: Fifty-two of 433 patients with IgAN who had favorable survival rates of 93.3% and 65.1% at 10 and 20 years, respectively, in a previous study and had reached end-stage kidney disease were followed up for 11.1 ± 6.2 years. Forty of the 52 patients undergoing hemodialysis (HD) or peritoneal dialysis (PD) at the final observation in February 2012 were eligible for entry in this study. Laboratory findings, treatments and complications during the long-term follow-up were analyzed. RESULTS: Mean age at starting dialysis (HD, n = 39; PD, n = 1) was 44.2 ± 13.1 years. Vascular access was achieved through an arteriovenous fistula in 95% of the 39 patients. Prescription rates of anti-hypertensive agents (68%), anti-platelet agents (35%), and statins (15%) were relatively low. The cardiothoracic ratio was well-controlled (< 50%) in about 60% of all patients and mean values for hemoglobin (10.6 ± 1.31 g/dL), adjusted calcium (9.56 ± 0.81 mg/dL), phosphate(5.89 ± 1.64 mg/dL), and intact-PTH (186 ± 221 pg/mL) were within the treatment goals recommended by Japanese guidelines. Complications during follow-up comprised cardiovascular events (n = 11), malignancy (n = 4), diabetes (n = 2), and arterial fibrillation (n = 2). Patients who remained on dialysis for > 10 years (n = 22) had started dialysis when they were significantly younger, and had a higher rate of onset of malignancy and of intact PTH values than those who were on dialysis for < 10 years (n = 18). CONCLUSIONS: Patients with IgAN who remain on dialysis over the long-term can maintain stable and favorable clinical findings although the occurrence of malignant complications and bone mineral metabolic disorder should be monitored.