腎臓学と治療学ジャーナル

Hypertension affects up to 5% of all children in the United States. The prevalence of “essential” hypertension in particular is rising in tandem with the childhood obesity epidemic. The primary care provider acts as the first-line of contact for many of these children and has an important role in early detection and referral to subspecialty care when needed. Despite published recommendations from the American Academy of Pediatrics on blood pressure screening at well child visits, adherence to these recommendations remains suboptimal. Elevated blood pressure readings, especially in non-obese children, may be overlooked. This may be due to a variety of factors including unfamiliarity of the primary care provider with pediatric blood pressure norms, time constraints in a busy practice, or the assumption that the elevated reading is an isolated clinically insignificant finding that could be dealt with at a later visit. This is particularly worrisome for children with secondary hypertension, which tends to be more severe and almost always requires anti-hypertensive therapy to prevent end organ damage. In this mini-review we present a case of a late diagnosis of secondary hypertension that had gone unnoticed for years. We then review relevant literature and suggest a clinical approach to the hypertensive child in a concise format useful for the busy primary care provider. A consistent clinical approach and firm understanding of the basic principles of pediatric hypertension diagnosis and management can prevent untoward outcomes related to a missed diagnosis.

Aim: While mortality among hemodialysis patients has been well researched in Western countries, only few systematic studies have been reported from China. The aim of this study was explore outcome in chronic hemodialysis patients in an academic Chinese hospital.
Methods: We extracted data from consecutive incident patients who initiated hemodialysis and survived at least 90 days between 1/1/1998 and 31/12/2012 in the Renji hospital, Shanghai, China. The follow-up period ended on 30/6/2014. We used Kaplan Meier and Cox proportional hazards analysis to explore survival characteristics and associated covariates.
Results: Out of 646 patients who started dialysis, 522 patients had a documented survival beyond 90 days. Their median age at dialysis initiation was 55.3 years (range 15.4-89.6), 322 patients (61.7%) were males. By 30/6/2014, 172 patients (33%) had died, 253 (48.5%) were alive on hemodialysis, 60 patients (11.5%) were transplanted, 35 (6.7%) transferred to another center, and 1 patient each switched to peritoneal dialysis and recovered kidney function. Fiveyear and ten-year survival rates were 74.2% and 53.6%, respectively. Age at dialysis initiation (hazard ratio 1.053, 95% CI [1.039, 1.266], p<0.001) and diabetic nephropathy (HR 1.73, 95% CI [1.046, 2.081], p<0.033) were associated with increased mortality.
Conclusion: Our findings indicated a comparably low 5- and 10-year mortality in patients who had a documented survival beyond the first 90 days. This finding may in part be due to the lower age at dialysis initiation and the low prevalence of diabetes in the study population.

Two cases - primary squamous cell carcinoma of renal parenchyma and adenocarcinoma of renal pelvis are added to those so far reported. There is very scant literature on primary squamous cell carcinoma of renal parenchyma making it a very rare tumor. Association with long standing chronic infection and nephrolithiasis is emphasized. Presence of a renal stone and occult gross appearance of most of these tumors and may lead the pathologist to overlook their presence and be overwhelmed with nephrolithiasis only. Hence, any kidney with nephrolithiasis should be examined carefully to look for the presence of any tumorous growth.

Mucormycosis is a devastating fungal infection which usually occurs in patients with diabetic ketoacidosis, chronic renal failure, haematological malignancies, or solid organ transplant recipients. Pulmonary mucormycosis may present as an unresolving pneumonia, multiple nodules, or a cavitating abscess, and is associated with an overall 80% mortality. The probable diagnosis of mucormycosis requires the combination of various clinical data and the isolation of the fungus from clinical samples. Treatment requires a rapid diagnosis, correction of predisposing factors, surgical resection, debridement and appropriate antifungal therapy. We are reporting a successfully treated case of culture proven pulmonary mucormycosis in non-diabetic ESRD patient.

Though chloride is the predominant extracellular anion, it is mostly seen just as an anion accompanying sodium and hardly receives attention in textbooks. But independent evaluation of serum chloride may unearth several clinical and acid-base disorders. It is used in formulas to estimate serum anion gap, urine anion gap, and strong ion difference (Stewart method). Several critical functions of a cell such as maintenance of cell volume, neutralization of H+ in lysosomal vesicles, epithelial fluid transport, change in cell membrane potential and ligand-gated transmission in the post-synaptic membrane utilize chloride channels. In addition, chloride forms an integral part of anion exchanger proteins coded by SLC26A gene family. Chloride is an essential component of intravenous fluids used in day-to-day clinical practice. The role and contribution of chloride rich fluids and resulting acidosis in causing inferior outcomes in sepsis, renal vasoconstriction, and acute kidney injury has been debated. Numerous genetic diseases are known to be related with chloride channels and proteins abnormalities. In the following review, I would like to bring much needed attention towards importance of chloride in human physiology. The following hypothetical clinical case will be just a spark for fiery chloride.

Wilson’s disease is inherited copper metabolism defect with primarily hepatic and also extra hepatic copper accumulation. Liver and other end organs damage - mainly cornea, brain and kidney, present with wide variety of symptoms, often resulting to misdiagnosis and delayed treatment. Liver manifestations range from asymptomatic liver and spleen enlargement to acute liver failure. Renal disturbances are rather usual and basically attributed to toxic effects of copper, leading to tubular dysfunction with impaired urate, calcium, phosphate, amino acids, potassium and glucose tubular handling. Thrombocytopenia is uncommon and happens mostly along with haemolytic anaemia. Here we present a case of Wilson’s disease, manifested with severe thrombocytopenia, splenomegaly and dark urine without haemolytic anaemia.

Background: Urinary tract infections (UTI) are widespread infections in the pediatric age group which presents non-specific symptoms. “Neutrophil gelatinase-associated lipocalin” (NGAL) is one of a biomarker in determining kidney injury. The early urinary tract infections diagnosis is essential for the purpose of preventing enduring consequences.

Aim: To evaluate the use of NGAL as an early predictor of UTI in clinical practice.

Patients and methods: A cross-sectional study examined specificity and sensitivity of urinary NGAL in the early UTI diagnosis. All febrile children admitted to KAAUH (age: 0-14 years) were included. Mann-Whitney U test, Shapiro- Wilk’s test, and Spearman correlation was used to analyze the data.

Results: In terms of mean urinary NGAL, no significant difference was observed between urinary NGAL levels in patients with and without UTIs (P-value=0.17). The receiver operator characteristic (ROC) curve demonstrated 0.594 sensitivity, and 0.683 specificity. For serum CRP (ROC) curve demonstrated 0.53 sensitivity and 0.47 specificity. Spearman’s correlation was undertaken to examine an association between NGAL and CRP levels. There was a positive monotonic correlation between NGAL and CRP levels (rs= 0.503 n = 73, p < .001).

Conclusion: Urinary NGAL is a poor biomarker for the diagnosis of febrile UTI. Further investigations are required with larger groups of patient to confirm the results of this study.

We report a rare and atypical case of essential cryoglobulinemic glomerulonephritis with crescent formation in an 18yo African-American male that presented with recurrent microscopic hematuria, proteinuria, and mildly elevated creatinine. There was no antecedent history of purpura, rashes, or arthralgia/ myalgia, and autoantibodies as well as viral serology for HCV, HIV, and CMV were negative. Quantification of serum immunoglobulins was significant for an elevated IgM without the presence of rheumatoid factor and elevated kappa and lambda light chains. Kidney biopsy demonstrated sclerosis, interstitial inflammation, endocapillary and mesangial proliferation, and crescent formation. Immunofluorescent studies demonstrated granular deposits within the glomerular basement membrane and mesangium. Electron microscopy revealed podocyte foot process effacement and the presence of mesangial and subendothelial electron dense deposits of randomly arranged, slightly curved microtubular/ fibrillary structures that formed occasional fingerprints consistent with a diagnosis of cryoglobulinemic glomerulonephritis. The diagnosis was confirmed by the identification of serum cryoglobulins with subsequent immunofixation electrophoresis of the cryoprecipitate revealing a mixed cryoglobulinemia type III. Treatment with IV methylprednisolone, followed by oral prednisone and Rituximab was initiated with resolution of hematuria and normalization of creatinine.

Objective: The aim of the study was to show the effectiveness of Physical Activity (PA) during dialysis as a protective treatment against cardiovascular (CV) diseases.

Methods: Eighty volunteer patients were included in this multicentric prospective study and followed for one year: 40 patients in the Exercise group (EX), 40 patients in the Control group (CON). CV risk factors: Total Cholesterol, HDL Cholesterol (HDL-c), LDL cholesterol (LDL-c), Triglycerides (TG) and Hemoglobin (Hb), were checked. The number of antihypertensive treatments and the Erythropoietin Stimulating Agent (ESA) required doses were collected. We noted for each group during the follow-up the number of hospitalizations for CV reasons.

Results: We observed a slight decrease of total cholesterol in both groups, more important for EX (1.82 ± 0.47 at M0 (Month 0), 1.74 ± 0.51 at M12 (Month 12) than for CON (1.60 ± 0.26 at M0; 1.63 ± 0.45 at M12). HDL-c increased in both groups, but LDL-c decreased in EX and increased in CON. The TG decreased in both groups after one year. The Hb level remained more stable in the EX group (11.70 ± 1.17 to 12.06 ± 1.11, p < 0.05) than in the CON group (11.79 ± 1.01 (M0) and 11.35 ± 1.21 (M12)). There was a significant difference between EX and CON at M12 (respectively 12.06 ± 1.11 vs. 11.35 ± 1.21). At the same time, the required doses of Erythropoietin Stimulating Agent (ESA) decreased in EX and increased in CON. The number of antihypertensive drugs per patient decreased significantly (p < 0.05) in the EX group between M0 and M12 (1.85 ± 1.08 at M0 and 1.55 ± 0.85 at M12). The EX patients were 3 times less frequently hospitalized for cardiovascular reasons. There were 3 hospital stays versus 20 for the CON group.

Conclusion: Our study demonstrates that an intradialytic aerobic cycling training program promotes beneficial effects on cardiovascular protection: Lipids control, HTA control and Hb stability. Physical Activity although reduced the CV events in our population during one year follow-up.

Introduction: Acute renal failure (ARF) in the elderly is a common occurrence and will increase because of the aging population. Even though the elderly can develop any type of ARF, they are more exposed to iatrogenic ones due to polymedication.

Objective: To determine the frequency of the ARF in the elderly over 75, and evaluate its impact on mortality.

Methods: This is a retrospective study conducted in 2011 at the medical and Rehabilitation Hospital of Saint- Maurice. Were included, all patients aged 75 and over with an ARF, hospitalized during the study period.

Results: Fifty-six patients of which 23 men (41%) and 33 women (59%) were included from a total of 209 patients; a frequency of 26.8%. The mean age was of 86.5 ± 6 years. The mean creatinine clearance level was of 17.2 ± 40.8 ml/min (MDRD). Twenty-eight of our patients were on diuretics i.e. 50%. The average hospital stay was of 78 days in patients with ARF against 33 days in those who did not have ARF. We recorded 8 deaths, including six in those with acute renal failure (10.7%).

Conclusion: Acute renal failure in the elderly is a common disease that is a common morbid event. Prevention relies on the preservation of the extracellular volume and should be a marker for quality health care.