Case Reports in Nephrology The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Apolipoprotein C-II Deposition Amyloidosis: A Potential Misdiagnosis as Light Chain Amyloidosis Thu, 20 Oct 2016 14:18:44 +0000 Hereditary amyloidoses are rare and pose a diagnostic challenge. We report a case of hereditary amyloidosis associated with apolipoprotein C-II deposition in a 61-year-old female presenting with renal failure and nephrotic syndrome misdiagnosed as light chain amyloidosis. Renal biopsy was consistent with amyloidosis on microscopy; however, immunofluorescence was inconclusive for the type of amyloid protein. Monoclonal gammopathy evaluation revealed kappa light chain. Bone marrow biopsy revealed minimal involvement with amyloidosis with kappa monotypic plasma cells on flow cytometry. She was started on chemotherapy for light chain amyloidosis. She was referred to the Mayo clinic where laser microdissection and liquid chromatography mass spectrometry detected high levels of apolipoprotein C-II, making a definitive diagnosis. Apolipoprotein C-II is a component of very low-density lipoprotein and aggregates in lipid-free conditions to form amyloid fibrils. The identification of apolipoprotein C-II as the cause of amyloidosis cannot be solely made with routine microscopy or immunofluorescence. Further evaluation of biopsy specimens with laser microdissection and mass spectrometry and DNA sequencing of exons should be done routinely in patients with amyloidoses for definitive diagnosis. Our case highlights the importance of determining the subtype of amyloidosis that is critical for avoiding unnecessary therapy such as chemotherapy. Sadichhya Lohani, Emily Schuiteman, Lohit Garg, Dhiraj Yadav, and Sami Zarouk Copyright © 2016 Sadichhya Lohani et al. All rights reserved. Systemic Toxicity of Intraperitoneal Vancomycin Thu, 20 Oct 2016 06:51:54 +0000 Intraperitoneal vancomycin is used for empiric treatment of peritoneal dialysis peritonitis. It is dosed intermittently and a high systemic concentration is often achieved. Despite this, there are very few reports of systemic toxicity from intraperitoneal vancomycin. We report the course of a patient who developed a drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome after three weeks of intraperitoneal vancomycin. We review the literature and conclude that this is the first ever reported case of DRESS syndrome from intraperitoneal vancomycin. Teerath Kumar, Iris Teo, and Brendan B. McCormick Copyright © 2016 Teerath Kumar et al. All rights reserved. A Swelling in the Mouth in a Chronic Hemodialysis Patient Sun, 09 Oct 2016 13:29:48 +0000 Oral manifestations of severe secondary hyperparathyroidism include maxillary and mandibular deformities, brown tumors, dental abnormalities, and metastatic calcification of soft tissues. We report on a chronic hemodialysis (HD) woman with severe, uncontrolled secondary hyperparathyroidism and a painful, nontender mass in the floor of her mouth. The most likely clinical diagnosis was a bone tumoral lesion of the oral cavity, secondary to renal osteodystrophy. Unexpectedly, pathological examination showed characteristic features of ossifying fibroma (OF) of the jaw, a rare, benign fibroosseous lesion characterized by the replacement of normal bone by collagen and fibroblasts containing varying amounts of mineralized substance. The occurrence of an OF in chronic HD patients is exceptional. Differential diagnosis must be made with bone tumoral lesions secondary to renal osteodystrophy. Surgical removal is the treatment of choice. The pathogenesis of OF in the setting of secondary hyperparathyroidism remains unknown. Parathyroidectomy may not be necessary to avoid OF recurrence after surgical removal. Arnaud Devresse, Alexandros Raptis, Anne-Sophie Claes, and Laura Labriola Copyright © 2016 Arnaud Devresse et al. All rights reserved. Interstitial Nephritis in a Patient with Inflammatory Bowel Disease Wed, 14 Sep 2016 12:08:37 +0000 Tubulointerstitial nephritis in patients with inflammatory bowel disease has been linked to the use of 5-ASA derivatives. Various aspects of this theory have been challenged with a potential role for the underlying autoimmune disorder. Steroids are the mainstay of treatment and mycophenolate mofetil might be an effective alternative. We report a patient who responded well to mycophenolate despite continuing mesalamine, the suspected offending agent. Payaswini Vasanth, Michelle Parmley, Jose Torrealba, and Tamim Hamdi Copyright © 2016 Payaswini Vasanth et al. All rights reserved. Subdiaphragmatic Renal Ectopia: Case Report and Review of the Literature Wed, 07 Sep 2016 16:39:16 +0000 Background. We report the case of a male infant whose right kidney migrated to an ectopic position after birth. The migration of a kidney in postnatal life without any symptoms has not been reported in literature so far. Case Presentation. In a series of antenatal and the first postnatal ultrasound scans, the right kidney was normally located within the right renal fossa. During the first 3 months of life, the kidney migrated to a subdiaphragmatic position. This was confirmed on MRI scan. The infant was asymptomatic with normal renal function and blood pressure. Conclusion. Postnatal migration of a kidney has been described in cases of diaphragmatic hernia or nephroptosis. In this report, we describe a case of kidney migration where there were no underlying anatomical defects to provide an explanation for the kidney migration. This is the first report in literature of a case of postnatal migration of a kidney. Eleftherios Zolotas and Rajesh G. Krishnan Copyright © 2016 Eleftherios Zolotas and Rajesh G. Krishnan. All rights reserved. An Atypical Presentation of a Male with Oral-Facial-Digital Syndrome Type 1 Related Ciliopathy Mon, 29 Aug 2016 09:51:00 +0000 Background. Oral-facial-digital syndrome type 1 (OFD1) is a rare condition with X-linked dominant inheritance caused by mutations in the Cxorf5 (OFD1) gene. This gene encodes the OFD1 protein located within centrosomes and basal bodies of primary cilia. Approximately 15–50% of patients with OFD1 progress to end-stage kidney disease following development of polycystic changes within the kidneys. This condition almost always causes intrauterine lethality in males. Description of Case Diagnosis and Treatment. A Caucasian male aged 9 years and 9 months presented with increased urinary frequency, increased thirst, and decreased appetite. Physical examination demonstrated short stature, hearing loss, photophobia, murmur, and hypogonadism. He had no other dysmorphic features. Laboratory results revealed anemia, renal insufficiency, and dilute urine with microscopic hematuria but no proteinuria. Ultrasound showed small kidneys with increased echogenicity but no evidence of cystic changes. A Ciliopathy Panel showed a novel and likely pathogenic deletion, approximately 7.9 kb, in the OFD1 gene encompassing exons 16, 17, and 19 (c.1654+833_2599+423del). Brain MRI did not demonstrate typical OFD1 findings. He is currently on chronic hemodialysis awaiting transplant from a living donor. Conclusions. We present a male patient with OFD1 mutation who lacks the classic OFD1 phenotype who presented with end-stage renal disease without evidence of polycystic changes within the kidneys. Sheena Sharma, Jennifer M. Kalish, Ethan M. Goldberg, Francis Jeshira Reynoso, and Madhura Pradhan Copyright © 2016 Sheena Sharma et al. All rights reserved. SIADH Induced by Pharyngeal Squamous Cell Carcinoma: Case Report and Literature Review Mon, 22 Aug 2016 08:38:22 +0000 Background. The Syndrome of Inappropriate Antidiuretic Hormone (SIADH) is considered to be the most common cause of euvolemic hyponatremia. The most common malignancy associated with SIADH is small cell lung cancer. We present a rare case of a patient with SIADH secondary to well differentiated squamous cell carcinoma of the naso-oropharynx. Case. A 46-year-old Caucasian woman presented to emergency department with four-week history of progressive dysphagia. On examination, she was found to have a pharyngeal mass. CT scan and MRI of neck confirmed a mass highly suspicious of carcinoma. Patient’s serum sodium level decreased to 118 mEq/L and other labs including serum and urine osmolality confirmed SIADH. She was started on fluid restriction and oral sodium tablets which gradually improved her serum sodium levels. Biopsy confirmed diagnosis of squamous cell carcinoma of pharynx. Conclusion. SIADH can be caused by squamous cell carcinoma. Appropriate management includes fluid restriction. Hafiz Muhammad Sharjeel Arshad, Aleida Rodriguez, and Faten Suhail Copyright © 2016 Hafiz Muhammad Sharjeel Arshad et al. All rights reserved. Tuberous Sclerosis and Bilateral Renal Angiomyolipomas: A Case Report and Literature Review of Emerging Treatment Strategies Mon, 25 Jul 2016 16:06:04 +0000 Tuberous sclerosis complex is a rare multisystemic genetic disorder associated with the development of benign hamartomas. Angiomyolipomas are one such characteristic finding that may be seen in 55–80% of tuberous sclerosis complex patients. While being normally asymptomatic, they can also cause significant morbidity and mortality. We present the case of a patient with tuberous sclerosis complex and recently discovered bilateral renal angiomyolipomas, admitted for hematuria who underwent left renal artery embolization; however, worsening renal function necessitated subsequent nephrectomy. Despite still being mainstays of treatment, invasive interventions are now being recommended for specific patient populations as demonstrated in our case. Emerging strategies targeting the PI3K/AKT/mTOR pathway have been shown to reduce the size of angiomyolipomas and are now used to treat asymptomatic cases >3 cm. Our review discusses these treatment options with the intention of increasing awareness of current recommendations and hopefully leading to increased application of these novel therapies that will reduce the need for invasive interventions. Francois Jo-Hoy, Omar Tolaymat, Ryan Kunjal, and Leighton R. James Copyright © 2016 Francois Jo-Hoy et al. All rights reserved. Aldosterone Response in Severe Hypokalemia and Volume Depletion: A Case Report and Review of the Recent Research Wed, 20 Jul 2016 10:46:39 +0000 We report a case of severe hypokalemia and volume depletion complicated by chronic watery diarrhea resulting from chronic alcoholism in a 57-year-old man. Prompt replacement of normal saline with potassium chloride and cessation of alcohol intake resulted in a favorable outcome. We discuss the pathophysiology of the case, emphasizing the response of aldosterone in both hypokalemia and volume depletion, and provide a review of recent research. Keiko Kai, Naoto Tominaga, Daisuke Uchida, Nanae Fukai, Yumie Matsuura, Susumu Uda, and Akio Yokochi Copyright © 2016 Keiko Kai et al. All rights reserved. Collapsing Glomerulopathy in a Child with Galloway-Mowat Syndrome Tue, 14 Jun 2016 11:44:45 +0000 Galloway-Mowat syndrome (GMS) is an autosomal recessive disorder with a poor prognosis that was first defined as a triad of central nervous system involvement, hiatal hernia, and nephrotic syndrome. However, this syndrome is now known to have a heterogeneous clinical presentation. The nephrotic syndrome is steroid resistant and is responsible for the outcome. The combination of collapsing glomerulopathy and GMS is very rare. A 26-month-old boy presented with steroid-resistant nephrotic syndrome associated with neurologic findings, including microcephaly, psychomotor retardation, and nystagmus. Magnetic resonance imaging showed marked cerebral atrophy, optic atrophy, and hypomyelination. A renal biopsy was consistent with collapsing glomerulopathy. If collapsing glomerulopathy is associated with neurological abnormalities, especially with microcephaly, clinicians should consider GMS as a possible underlying cause. Cengiz Zeybek, Gokalp Basbozkurt, Salih Hamcan, Ayhan Ozcan, Davut Gul, and Faysal Gok Copyright © 2016 Cengiz Zeybek et al. All rights reserved. A Rare Cause of Acute Kidney Injury in a Female Patient with Breast Cancer Presenting as Renal Colic Tue, 17 May 2016 13:40:38 +0000 Renal infarction is a rare cause of acute kidney injury which could lead to permanent loss of renal function. A prompt diagnosis is necessary in order to achieve a successful revascularization of the occluded artery. Given the rarity of the disease and the paucity of the reported cases in the previous literature a high index of suspicion must be maintained not only in the classical cardiac sources of systemic emboli (atrial fibrillation, dilated cardiomyopathy, or endocarditis), but also in the situations when a hypercoagulable state is presumed. The unspecific presenting symptoms often mask the true etiology of the patient’s complaints. We present here a rare case of renal infarction that occurred in the setting of a hypercoagulable state, in a female patient with a history of breast cancer and documented hepatic metastases. Roxana Jurubita, Bogdan Obrisca, and Gener Ismail Copyright © 2016 Roxana Jurubita et al. All rights reserved. Cystatin C Falsely Underestimated GFR in a Critically Ill Patient with a New Diagnosis of AIDS Tue, 17 May 2016 11:28:52 +0000 Cystatin C has been suggested to be a more accurate glomerular filtration rate (GFR) surrogate than creatinine in patients with acquired immunodeficiency syndrome (AIDS) because it is unaffected by skeletal muscle mass and dietary influences. However, little is known about the utility of this marker for monitoring medications in the critically ill. We describe the case of a 64-year-old female with opportunistic infections associated with a new diagnosis of AIDS. During her course, she experienced neurologic, cardiac, and respiratory failure; yet her renal function remained preserved as indicated by an eGFR ≥ 120 mL/min and a urine output > 1 mL/kg/hr without diuresis. The patient was treated with nephrotoxic agents; therefore cystatin C was assessed to determine if cachexia was resulting in a falsely low serum creatinine. Cystatin C measured 1.50 mg/L which corresponded to an eGFR of 36 mL/min. Given the >60 mL/min discrepancy, serial 8-hour urine samples were collected and a GFR > 120 mL/min was confirmed. It is unclear why cystatin C was falsely elevated, but we hypothesize that it relates to the proinflammatory state with AIDS, opportunistic infections, and corticosteroids. More research is needed before routine use of cystatin C in this setting can be recommended. Caitlin S. Brown, Kianoush B. Kashani, Jeremy M. Clain, and Erin N. Frazee Copyright © 2016 Caitlin S. Brown et al. All rights reserved. Granulomatosis with Polyangiitis Presenting as Pauci-Immune Crescentic Glomerulonephritis in Pregnancy Wed, 11 May 2016 13:47:14 +0000 Antineutrophil cytoplasmic antibody (ANCA) associated vasculitis rarely affects females of reproductive age. A 28-year-old African American woman presented at 8 weeks of gestation with intractable vomiting attributed to hyperemesis gravidarum. She was found to have acute kidney injury that was unresponsive to vigorous fluid resuscitation and urine sediment examination was suggestive of an underlying glomerulonephritis. Serum c-ANCA and PR3 were elevated and there was no peripheral eosinophilia. During her course she also developed one episode of small volume hemoptysis with right upper lobe infiltrates on CT Chest. There were no cutaneous manifestations of vasculitis or upper respiratory symptoms. Renal biopsy revealed a pauci-immune crescentic glomerulonephritis (PICGN). The diagnosis was consistent with granulomatosis with polyangiitis (GPA). Management initially comprised teratogen sparing agents; steroids, intravenous immunoglobulin; and plasma exchange. The response was suboptimal and she became dependent on daily renal replacement therapy. Ultimately the pregnancy was terminated allowing for traditional treatment approaches with dramatic effect. This is the first case of GPA presenting as PICGN in pregnancy and highlights the challenges of its management. Ryan Kunjal, Raafat Makary, and Andreea Poenariu Copyright © 2016 Ryan Kunjal et al. All rights reserved. Febuxostat and Increased Dialysis as a Treatment for Severe Tophaceous Gout in a Hemodialysis Patient Thu, 21 Apr 2016 12:39:09 +0000 Uric acid accumulates in renal failure and is thought to be a uremic toxin—that is, higher levels of uric acid are more damaging to the kidneys. Urate crystals can precipitate in the kidney tubules, cause urate stones, and promote inflammatory changes in the renal interstitium and vascular endothelium. Uric acid is also a small non-protein-bound molecule and therefore easily dialyzable. Here, we present the case of an anuric hemodialysis patient with severe tophaceous gout who regained some renal function and whose gout burden significantly decreased resulting in marked improvement in functional status using a new gout medication, febuxostat, and increased frequency of dialysis. Lynda Ann Frassetto and Suzanne Gibson Copyright © 2016 Lynda Ann Frassetto and Suzanne Gibson. All rights reserved. Suppression of Parathyroid Hormone in a Patient with Severe Magnesium Depletion Thu, 14 Apr 2016 08:15:38 +0000 Hypomagnesemia is often associated with coexisting electrolyte abnormalities like hypokalemia and hypocalcemia. Hypocalcemia has been shown to be secondary to hypoparathyroidism induced by hypomagnesemia. Here, we discuss a case of a patient with severe hypomagnesemia and associated hypocalcemia. A 38-year-old lady was admitted to the hospital for weakness of lower extremities and an eventual fall. The exam was significant for decreased motor strength and some paresthesias. The laboratory data was significant for hypomagnesemia, hypokalemia, and low parathyroid level in the face of hypocalcemia. After replacing magnesium, the parathyroid hormone levels normalized and led to eventual correction of calcium levels without any additional calcium replacement therapy. There was complete symptom resolution with correction of electrolyte abnormalities. This case highlights the importance of looking for all associated abnormalities in a patient with hypomagnesemia and starting the replacement therapy by first replacing the magnesium and then the others as needed. Replacing the magnesium alone may correct the hypoparathyroidism and eliminate the need for calcium replacement. Sangeeta Mutnuri, Isaac Fernandez, and Tina Kochar Copyright © 2016 Sangeeta Mutnuri et al. All rights reserved. Reversible Fluindione-Induced Chronic Interstitial Nephritis Tue, 05 Apr 2016 10:52:39 +0000 Fluindione is well known to induce acute drug-induced interstitial nephritis (IN). Most cases occurred soon after the onset of treatment. We report a unique case of severe subacute fluindione-induced IN diagnosed 2 years after the treatment was begun. Renal function dramatically improved after fluindione withdrawal and steroid therapy. Thomas Crepin, Jamal Bamoulid, Cécile Courivaud, Omar Dahmani, Sophie Felix, and Didier Ducloux Copyright © 2016 Thomas Crepin et al. All rights reserved. A Case of Primary Hypoparathyroidism Presenting with Acute Kidney Injury Secondary to Rhabdomyolysis Thu, 10 Mar 2016 13:17:07 +0000 Hypoparathyroidism is the most common cause of symmetric calcification of the basal ganglia. Herein, a case of primary hypoparathyroidism with severe tetany, rhabdomyolysis, and acute kidney injury is presented. A 26-year-old male was admitted to the emergency clinic with leg pain and cramps, nausea, vomiting, and decreased amount of urine. He had been treated for epilepsy for the last 10 years. He was admitted to the emergency department for leg pain, cramping in the hands and legs, and agitation multiple times within the last six months. He was prescribed antidepressant and antipsychotic medications. He had a blood pressure of 150/90 mmHg, diffuse abdominal tenderness, and abdominal muscle rigidity on physical examination. Pathological laboratory findings were as follows: creatinine, 7.5 mg/dL, calcium, 3.7 mg/dL, alanine transaminase, 4349 U/L, aspartate transaminase, 5237 U/L, creatine phosphokinase, 262.000 U/L, and parathyroid hormone, 0 pg/mL. There were bilateral symmetrical calcifications in basal ganglia and the cerebellum on computerized tomography. He was diagnosed as primary hypoparathyroidism and acute kidney injury secondary to severe rhabdomyolysis. Brain calcifications, although rare, should be considered in dealing with patients with neurological symptoms, symmetrical cranial calcifications, and calcium metabolism abnormalities. Abdullah Sumnu, Zeki Aydin, Meltem Gursu, Sami Uzun, Serhat Karadag, Egemen Cebeci, Savas Ozturk, and Rumeyza Kazancioglu Copyright © 2016 Abdullah Sumnu et al. All rights reserved. Resin-Induced Colonic Pseudotumor: Rare Complication from Chronic Use of Potassium Binders in a Hemodialysis Patient Mon, 29 Feb 2016 11:55:26 +0000 Potassium-binding resins are widely used in the treatment of hyperkalemia, mostly in the acute setting. Gastrointestinal adverse events, although reported, are not frequently seen due to its short course of use. This report describes a case involving an end-stage renal disease patient on hemodialysis who developed a colonic mass after being on sodium polystyrene sulfonate chronically for persistent hyperkalemia. Gastrointestinal symptoms developed late during the treatment rather than early as reported previously in the literature. This mass was mistaken for a carcinomatous lesion, which initiated an extensive work-up as well as hospitalization that nearly resulted in a subtotal colectomy. Mary Bui, Shyan-Yih Chou, Pierre Faubert, Pablo Loarte, and Ronny Cohen Copyright © 2016 Mary Bui et al. All rights reserved. Bile Nephropathy in Flucloxacillin-Induced Cholestatic Liver Dysfunction Wed, 24 Feb 2016 07:35:57 +0000 Kidney injury in the context of cholestatic liver dysfunction is not uncommon; this has been historically referred to as cholemic nephrosis implying a direct deleterious renal effect of cholemia. However, scepticism about the exact role that bile and its constituents play in this injury has led to the disappearance of the term. We describe a case of severe AKI due to bile nephropathy with bile casts in flucloxacillin-induced liver dysfunction. We also discuss the recent literature reviving the concept of bile nephropathy. Basil Alnasrallah, John F. Collins, and L. Jonathan Zwi Copyright © 2016 Basil Alnasrallah et al. All rights reserved. IgA Nephropathy in a Patient Presenting with Pseudotumor Cerebri Tue, 16 Feb 2016 16:37:59 +0000 IgA nephropathy is the most common glomerulonephritis worldwide and typically has minimal signs for chronicity in histopathology at the time of initial presentation. Pseudotumor cerebri (PTC) is characterized by increased intracranial pressure in the absence of any intracranial lesions, inflammation, or obstruction. PTC has been reported in renal transplant and dialysis patients, but we are unaware of any reports of pseudotumor cerebri in patients with IgA nephropathy. We report a case of a young female who presented with signs and symptoms of pseudotumor cerebri and was subsequently diagnosed with IgA nephropathy and end-stage renal disease. To our knowledge this is the first report of IgA nephropathy presenting as end-stage renal disease in a patient who presented with pseudotumor cerebri. Umair Syed Ahmed, Patrick Bacaj, Hafiz Imran Iqbal, and Songul Onder Copyright © 2016 Umair Syed Ahmed et al. All rights reserved. Drug-Induced Acute Interstitial Nephritis with Nifedipine Wed, 03 Feb 2016 12:11:54 +0000 Background. Acute interstitial nephritis (AIN) is a frequent cause of Acute Kidney Injury (AKI). Drug hypersensitivity is the most common etiology and the list of drugs that can induce AIN is not exhaustive yet. Case Report. Here, we describe the case of a 43-year-old man who was treated with nifedipine (Adalate®) for Raynaud’s syndrome. After nifedipine introduction, serum creatininemia progressively increased from 91 to 188 μmol/L in a few months and AKI was diagnosed. Laboratory work-up results indicated the presence of tubular proteinuria and nonspecific inflammatory syndrome. Histological analysis found granulomatous interstitial nephropathy without necrosis in 20% of the kidney biopsy without immunofluorescent deposit. Nifedipine was stopped and corticosteroid treatment was started with a rapid but incomplete reduction of serum creatininemia level to 106 μmol/L. Conclusion. This is the first case of AIN caused by nifedipine. Léonard Golbin, Thibault Dolley-Hitze, Nolwenn Lorcy, Nathalie Rioux-Leclercq, and Cécile Vigneau Copyright © 2016 Léonard Golbin et al. All rights reserved. Successful Pregnancy Using the NxStage Home Hemodialysis System Tue, 02 Feb 2016 07:09:02 +0000 Pregnancy in the setting of the uremic milieu of renal disease has a lower success rate than in the normal population and is a rare event. While intensified renal replacement therapy (RRT) during pregnancy can lead to improved outcomes, most studies have focused on nocturnal hemodialysis as the main RRT in pregnancy. Although thousands of patients use the home NxStage System One short daily hemodialysis (SDHD) machine in the United States, pregnancy outcomes with this therapy are unknown. The NxStage System One uses low-volume dialysate and hence small and middle molecule clearance may differ compared to conventional therapies and affect pregnancy outcomes. We report a case of a successful conception and pregnancy using the home NxStage system. The NxStage system may provide an alternative to the more routinely used NHD or standard SDHD therapies for women of childbearing age. Yasmin Brahmbhatt, Arinze Ikeme, Navjyot Bhogal, and Vincenzo Berghella Copyright © 2016 Yasmin Brahmbhatt et al. All rights reserved. Ganciclovir-Resistant Cytomegalovirus Infection in a Kidney Transplant Recipient Successfully Treated with Foscarnet and Everolimus Sun, 31 Jan 2016 16:44:17 +0000 Cytomegalovirus (CMV) infection remains a major cause of morbidity, graft failure, and death in kidney transplant recipients. We describe a case of a 53-year-old CMV-seronegative man who underwent renal transplant from a CMV-positive donor and who developed ganciclovir- (GCV-) resistant CMV infection. Foscarnet was started while immunosuppressive therapy was modified with the introduction of everolimus minimizing tacrolimus dosage. Only two weeks after the start of this treatment regimen was the patient’s viral load negative. At two-year follow-up the patient has no clinical or laboratory signs of CMV infection and a good and stable renal function or graft survival. In our case, administration of an mTOR inhibitor combined with foscarnet led to rapid and persistent viral clearance without compromising short- and medium-term graft function. This combination therapy supports the need for the kidney transplant community to individualize a target therapy for each type of GCV-resistant CMV infection. Viola Menghi, Giorgia Comai, Olga Baraldi, Giovanni Liviano D’Arcangelo, Tiziana Lazzarotto, and Gaetano La Manna Copyright © 2016 Viola Menghi et al. All rights reserved. Podocyturia: A Clue for the Rational Use of Amiloride in Alport Renal Disease Thu, 28 Jan 2016 12:51:42 +0000 No specific or efficient treatment exists for Alport syndrome, an X-linked hereditary disease caused by mutations in collagen type IV, a crucial component of the glomerular basement membrane. Kidney failure is usually a major complication of the disease, and patients require renal replacement therapy early in life. Microhematuria and subsequently proteinuria are hallmarks of kidney involvement, which are due to primary basement membrane alterations that mainly cause endothelial thrombosis and podocyte contraction and ulterior irreversible detachment. Commonly drug-based approaches include angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, which are employed to reduce proteinuria and thus retard kidney disease progression and cardiovascular morbidity and mortality. However, as any hereditary disease, it is expressed as early as in the intrauterine life, and usually an index case is helpful to detect family-related cases. As no specific treatment exists, pathophysiologically based approaches are useful. The present case illustrates the reduction rate of urinary podocyte loss and proteinuria after amiloride administration and suggests the molecular pathways involved in Alport renal disease. Finally, podocyturia rather than proteinuria should be considered as an earlier biomarker of kidney involvement and disease progression in Alport disease. H. Trimarchi, R. Canzonieri, A. Muryan, A. Schiel, A. Araoz, M. Paulero, J. Andrews, T. Rengel, M. Forrester, F. Lombi, V. Pomeranz, R. Iriarte, and E. Zotta Copyright © 2016 H. Trimarchi et al. All rights reserved. Granulomatous Interstitial Nephritis Presenting as Hypercalcemia and Nephrolithiasis Tue, 19 Jan 2016 14:15:37 +0000 We report a case of acute kidney injury as the initial manifestation of sarcoidosis. A 55-year-old male was sent from his primary care physician’s office with incidental lab findings significant for hypercalcemia and acute kidney injury with past medical history significant for nephrolithiasis. Initial treatment with intravenous hydration did not improve his condition. The renal biopsy subsequently revealed granulomatous interstitial nephritis (GIN). Treatment with the appropriate dose of glucocorticoids improved both the hypercalcemia and renal function. Our case demonstrates that renal limited GIN due to sarcoidosis, although a rare entity, can cause severe acute kidney injury and progressive renal failure unless promptly diagnosed and treated. Saika Sharmeen, Esra Kalkan, Chunhui Yi, and Steven D. Smith Copyright © 2016 Saika Sharmeen et al. All rights reserved. Necrotizing ANCA-Positive Glomerulonephritis Secondary to Culture-Negative Endocarditis Sun, 27 Dec 2015 10:15:01 +0000 Infective endocarditis (IE) and small-vessel vasculitis may have similar clinical features, including glomerulonephritis. Furthermore the association between IE and ANCA positivity is well documented, making differential diagnosis between IE- and ANCA-associated vasculitis particularly difficult, especially in case of culture-negative IE. We report on one patient with glomerulonephritis secondary to culture-negative IE caused by Bartonella henselae which illustrates this diagnostic difficulty. Sophie Van Haare Heijmeijer, Dunja Wilmes, Selda Aydin, Caroline Clerckx, and Laura Labriola Copyright © 2015 Sophie Van Haare Heijmeijer et al. All rights reserved. A Rare Case of Central Pontine Myelinolysis in Overcorrection of Hyponatremia with Total Parenteral Nutrition in Pregnancy Tue, 22 Dec 2015 13:26:34 +0000 A 42-year-old high risk pregnant female presented with hyponatremia from multiple causes and was treated with total parenteral nutrition. She developed acute hypernatremia due to the stage of pregnancy and other comorbidities. All the mechanisms of hyponatremia and hypernatremia were summarized here in our case report. This case has picture (graph) representation of parameters that led to changes in serum sodium and radiological findings of central pontine myelinolysis on MRI. In conclusion we present a complicated case serum sodium changes during pregnancy and pathophysiological effects on serum sodium changes during pregnancy. Kalyana C. Janga, Tazleem Khan, Ciril Khorolsky, Sheldon Greenberg, and Priscilla Persaud Copyright © 2015 Kalyana C. Janga et al. All rights reserved. Three-Dimensional Imaging of a Central Venous Dialysis Catheter Related Infected Thrombus Tue, 24 Nov 2015 08:32:03 +0000 Three-dimensional (3D) echocardiography is becoming widely available and with novel applications. We report an interesting case of a 68-year-old lady with a central venous thrombosis coincident with both a dialysis catheter infection and a recent pacemaker insertion. Two-dimensional transesophageal echocardiography was unable to delineate whether the thrombosis was involved with the pacemaker wire or due to the tunneled catheter infection. The use of 3D echocardiography was able to produce distinct images aiding diagnosis. This circumvented the need for invasive investigations and inappropriate, high-risk removal of the pacing wire. This case highlights the emerging application of 3D echocardiography in routine nephrology practice. Diana Yuan Yng Chiu, Darren Green, Philip A. Kalra, and Nik Abidin Copyright © 2015 Diana Yuan Yng Chiu et al. All rights reserved. Long-Term Therapeutic Plasma Exchange to Prevent End-Stage Kidney Disease in Adult Severe Resistant Henoch-Schonlein Purpura Nephritis Tue, 03 Nov 2015 11:43:58 +0000 A 27-year-old man presented with a palpable purpuric skin rash and joint and abdominal pain in April 2010. He had acute kidney injury and his creatinine quickly deteriorated to 687 μmol/L, with associated nephrotic range proteinuria. Kidney biopsy showed crescentic Henoch-Schonlein nephritis. He was treated with intravenous cyclophosphamide and prednisolone despite which his renal function deteriorated; he required haemodialysis for a short duration and seven sessions of therapeutic plasma exchange (TPE). Renal function improved, but after discharge from hospital he suffered 2 further relapses, each with AKI, in 4 months. Cyclophosphamide was not effective and therefore Rituximab was introduced. He initially had a partial response but his renal function deteriorated despite continued therapy. TPE was the only treatment that prevented rapid renal functional deterioration. A novel long-term treatment strategy involving regular TPE every one to two weeks was initiated. This helped to slow his progression to end-stage kidney disease over a 3-year period and to prolong the need for renal replacement therapy over this time. Patrick Hamilton, Olumide Ogundare, Ammar Raza, Arvind Ponnusamy, Julie Gorton, Hana Alachkar, Jamil Choudhury, Jonathan Barratt, and Philip A. Kalra Copyright © 2015 Patrick Hamilton et al. All rights reserved. An Unexpected Cause of Severe Hypokalemia Thu, 15 Oct 2015 08:15:12 +0000 We describe an unusual case of severe hypokalemia with electrocardiographic changes, due to licorice consumption, in a 15-year-old female student with no previous medical history. Prompt replacement of potassium and cessation of licorice ingestion resulted in a favourable outcome. We also discuss the pathophysiology and diagnosis, emphasizing the importance of a detailed anamnesis to rule out an often forgotten cause of hypokalemia as the licorice poisoning. Fernando Caravaca-Fontan, Olga Martinez-Saez, Maria Delgado-Yague, Estefania Yerovi, and Fernando Liaño Copyright © 2015 Fernando Caravaca-Fontan et al. All rights reserved.