Case Reports in Nephrology https://www.hindawi.com The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Large Retroperitoneal Haemorrhage Following Cyst Rupture in a Patient with Autosomal Dominant Polycystic Kidney Disease Wed, 18 Oct 2017 00:00:00 +0000 http://www.hindawi.com/journals/crin/2017/4653267/ The complications of autosomal dominant polycystic kidney disease (ADPKD) include cyst rupture and haemorrhage leading to loin pain and frank haematuria. Risk factors include large kidney volume, hypertension, and renal impairment. We present a case of a young male who, following trauma to the kidney, had a life threatening bleed from his polycystic kidney. The case was initially treated with fluid resuscitation and blood transfusion but necessitated radiological embolization of bleeding source to control the blood loss. We review the risk factors and management of cyst haemorrhage in patients with ADPKD. Contact sports should be avoided as cyst rupture can lead to severe life threatening haemorrhage. Holly Mabillard, Shalabh Srivastava, Philip Haslam, Maciej Karasek, and John A. Sayer Copyright © 2017 Holly Mabillard et al. All rights reserved. Ureteropelvic Junction Obstruction and Parathyroid Adenoma: A Case Report and Literature Review Tue, 17 Oct 2017 00:00:00 +0000 http://www.hindawi.com/journals/crin/2017/9852912/ Congenital ureteropelvic junction obstruction (UPJO) is the most common cause of upper urinary tract obstruction in children. It is generally diagnosed in the routine work-up during antenatal period and is characterized by spontaneous recovery. It can be associated with urolithiasis; hence further investigation should be carried out. We report the case of a 15-year-old boy, who is known to have right UPJO, presented with right renal colic and discovered to have bilateral kidney stones. Further studies showed primary hyperparathyroidism and genetic analysis revealed a CDC73 mutation (initially HRPT2). We believe that association of UPJO and PHPT is a rare coincidence that can be linked. Careful work-up of children with UPJO and urolithiasis is recommended to exclude an underlying metabolic disease. Surgical correction can be evitable as treatment of the primary cause can lead to complete dissolution of kidney stones and improvement of the medical condition. Salah Termos, Majd AlKabbani, Tim Ulinski, Sami Sanjad, Henri Kotobi, Francois Chalard, and Bilal Aoun Copyright © 2017 Salah Termos et al. All rights reserved. Discontinuation of Hemodialysis in a Patient with Anti-GBM Disease by the Treatment with Corticosteroids and Plasmapheresis despite Several Predictors for Dialysis-Dependence Wed, 11 Oct 2017 00:00:00 +0000 http://www.hindawi.com/journals/crin/2017/7143649/ A 26-year-old man highly suspected of having antiglomerular basement membrane (GBM) disease was treated with corticosteroid pulse therapy 9 days after initial infection-like symptoms with high procalcitonin value. The patient required hemodialysis the next day of the treatment due to oliguria. In addition to corticosteroid therapy, plasmapheresis was introduced and the patient could discontinue hemodialysis 43 days after the treatment. Kidney biopsy after initiation of hemodialysis confirmed anti-GBM disease with 86.3% crescent formation. Physician should keep in mind that active anti-GBM disease shows even high procalcitonin value in the absence of infection. To pursue recovery of renal function, the challenge of the immediate and persistent treatment with high-dose corticosteroids plus plasmapheresis for highly suspected anti-GBM disease is vitally important despite the presence of reported predictors for dialysis-dependence including oliguria and requiring hemodialysis at presentation. Yoshihide Fujigaki, Chikayuki Morimoto, Risa Iino, Kei Taniguchi, Yosuke Kawamorita, Shinichiro Asakawa, Daigo Toyoki, Shinako Miyano, Wataru Fujii, Tatsuru Ota, Shigeru Shibata, and Shunya Uchida Copyright © 2017 Yoshihide Fujigaki et al. All rights reserved. Rhabdomyolysis Induced by Coadministration of Fusidic Acid and Atorvastatin: A Case Report and Comprehensive Review of the Literature Sun, 08 Oct 2017 00:00:00 +0000 http://www.hindawi.com/journals/crin/2017/2187264/ Statins are among the most widely prescribed medications worldwide. Acute rhabdomyolysis constitutes a potentially life-threatening side effect regardless of whether statins are administered alone or in combination. The potentially fatal combination of a statin and fusidic acid has been well described in the literature. Acute renal failure can be a direct consequence of this drug-drug interaction. We present a case of a 79-year-old woman who presented to our Emergency Department with a one-week history of limb weakness, myalgia, and inability to stand and walk. The patient had been given fusidic acid to treat Methicillin-Sensitive Staphylococcus Aureus (MSSA) positive dermatitis in the 3 weeks prior to admission, while she continued to take her complete therapeutic regimen, which included atorvastatin. Thus, she developed rhabdomyolysis due to the interaction between fusidic acid and atorvastatin. Herein, we report a life-threatening complication of coadministration of fusidic acid and a statin, which is preventable and predictable. The exact mechanism of the interaction is not fully understood, but coadministration of these two medications must be avoided in clinical practice. Dimitrios Patoulias, Theodoros Michailidis, Thomas Papatolios, Rafael Papadopoulos, and Petros Keryttopoulos Copyright © 2017 Dimitrios Patoulias et al. All rights reserved. Early Renal Involvement in a Girl with Classic Fabry Disease Sun, 01 Oct 2017 08:10:54 +0000 http://www.hindawi.com/journals/crin/2017/9543079/ Fabry disease is an X-linked lysosomal storage disorder resulting from the deficiency or absence of the enzyme alpha galactosidase A; this defect leads to the systemic accumulation of globotriaosylceramide and its metabolites. Organic involvement in men is well known, but in women it is controversial, mainly due to the random X-chromosome inactivation in each of their cells (Lyon hypothesis). This would explain why women (heterozygotes) present a wide variability in the severity of their phenotype. The manifestations are multisystemic and begin in early childhood, reaching a severe compromise in adulthood. Typical acroparesthesia in hands and feet, gastrointestinal symptoms, angiokeratomas, dyshidrosis, hearing loss, arrhythmias, hypertrophic cardiomyopathy, cerebrovascular accidents, and renal failure can be observed. Nephropathy is one of the major complications of Fabry disease. Glomerular and vascular changes are present before progression to overt proteinuria and decreased glomerular filtration rate, even in pediatric patients. A case of incipient renal involvement in a girl with classic Fabry disease is reported. Fernando Perretta, Norberto Antongiovanni, and Sebastián Jaurretche Copyright © 2017 Fernando Perretta et al. All rights reserved. Unusual Complication of Multidrug Resistant Tuberculosis Mon, 18 Sep 2017 09:23:57 +0000 http://www.hindawi.com/journals/crin/2017/6835813/ Introduction. Capreomycin is a second-line drug often used for multidrug-resistant tuberculosis which can result in nephrotoxic effects similar to other aminoglycosides. We describe a case of capreomycin induced Bartter-like syndrome with hypocalcemic tetany. Case Report. 23-year-old female patient presented with carpopedal spasms and tingling sensations in hands. Patient was being treated with capreomycin for two months for tuberculosis. On further investigation, hypocalcemia, hyponatremia, hypomagnesemia, hypokalemia, and hypochloremic metabolic alkalosis were noted. Vitamin D and serum PTH levels were within normal limits. Hypercalciuria was confirmed by urine calcium/creatinine ratio. Calcium, potassium, and magnesium supplementation was given and capreomycin was discontinued. Electrolytes normalized in two days after cessation of capreomycin with no further abnormalities on repeat investigations. Discussion. Aminoglycosides can result in renal tubular dysfunction leading to Fanconi syndrome, Bartter syndrome, and distal tubular acidosis. Impaired mitochondrial function in the tubular cells has been hypothesized as the possible cause of these tubulopathies. Acquired Bartter-like syndrome phenotypically resembles autosomal dominant type 5 Bartter syndrome. Treatment consists of correction of electrolyte abnormalities, indomethacin, and potassium-sparing diuretics. Prompt diagnosis and treatment of severe dyselectrolytemia are warranted in patients on aminoglycoside therapy. Prerna Sharma and Ravindra Nath Sahay Copyright © 2017 Prerna Sharma and Ravindra Nath Sahay. All rights reserved. Snakebite Induced Thrombotic Microangiopathy Leading to Renal Cortical Necrosis Sun, 13 Aug 2017 06:23:09 +0000 http://www.hindawi.com/journals/crin/2017/1348749/ Renal complications from snakebite result in high mortality and morbidity. Acute kidney injury (AKI) occurs in 5–30% of cases. Renal manifestation could include acute tubular necrosis, cortical necrosis, interstitial nephritis, glomerulonephritis, and vasculitis. We present a case of thrombotic microangiopathy (TMA) resulting in renal cortical necrosis. Renal biopsy showed fibrin thrombi in glomeruli and arterioles with cortical necrosis. Our patient progressed to end-stage renal disease. Ying Mao Gn, Arvind Ponnusamy, and Vikram Thimma Copyright © 2017 Ying Mao Gn et al. All rights reserved. Acute Hypocalcemia and Metabolic Alkalosis in Children on Cation-Exchange Resin Therapy Tue, 01 Aug 2017 07:01:17 +0000 http://www.hindawi.com/journals/crin/2017/6582613/ Background. Sodium polystyrene sulfonate (SPS) is a chelating agent used for the treatment of hyperkalemia. SPS has a wide range of exchange capacity requiring close monitoring of serum electrolytes. We observed two patients who developed acute hypocalcemia and increased metabolic alkalosis after initiating SPS therapy. We report these cases to draw attention to the potential risk of this medication in pediatric patients. Case Diagnosis/Treatment. Two children with chronic kidney disease on dialysis were started on SPS for hyperkalemia. Within a week after initiation of the medication, both patients developed hypocalcemia on routine labs without overt clinical manifestations. The hypocalcemia was rapidly corrected with oral supplementation and discontinuation of SPS. Conclusions. Severe hypocalcemia can develop after SPS therapy. The metabolic alkalosis in these patients associated with the hypocalcemia put them at increased risk for complications. Hence, careful attention must be paid to the state of calcium metabolism in all patients receiving SPS. Often calcium supplementation is required to maintain normal calcium levels. Aadil Kakajiwala, Kevin T. Barton, Elisha Rampolla, Christine Breen, and Madhura Pradhan Copyright © 2017 Aadil Kakajiwala et al. All rights reserved. Therapeutic Approach to the Management of Severe Asymptomatic Hyponatremia Thu, 27 Jul 2017 00:00:00 +0000 http://www.hindawi.com/journals/crin/2017/1371804/ Hyponatremia is an electrolyte imbalance encountered commonly in the hospital and ambulatory settings. It can be seen in isolation or present as a complication of other medical conditions. It is therefore a challenge to determine the appropriate therapeutic intervention. An understanding of the etiology is key in instituting the right treatment. Clinicians must not be too hasty to correct a random laboratory value without first understanding the physiologic principle. We present such a case of a patient who presented with sodium of 98 mmol/L, the lowest recorded in the current literature, and yet was asymptomatic. Following appropriate management driven by an understanding of the underlying pathophysiologic mechanism, the patient was managed to full recovery without any clinically significant neurological sequelae. Thaofiq Ijaiya, Sandhya Manohar, and Kameswari Lakshmi Copyright © 2017 Thaofiq Ijaiya et al. All rights reserved. Acinetobacter lwoffii Peritonitis in a Patient on Automated Peritoneal Dialysis: A Case Report and Review of the Literature Wed, 26 Jul 2017 00:00:00 +0000 http://www.hindawi.com/journals/crin/2017/5760254/ Acinetobacter lwoffii, a nonfermentative gram-negative aerobic bacillus, which presents in the normal flora of the oropharynx and skin, has recently been reported as a cause of human infection. Herein, the authors present a case report of peritonitis related to automated peritoneal dialysis caused by A. lwoffii. Murat Yasar Tas, Meral Merve Oguz, and Mevlut Ceri Copyright © 2017 Murat Yasar Tas et al. All rights reserved. Successful Resuscitation of a Patient with Life-Threatening Metabolic Acidosis by Hemodialysis: A Case of Ethylene Glycol Intoxication Tue, 25 Jul 2017 10:42:27 +0000 http://www.hindawi.com/journals/crin/2017/9529028/ Background. Ethylene glycol intoxication causes severe metabolic acidosis and acute kidney injury. Fomepizole has become available as its antidote. Nevertheless, a prompt diagnosis is not easy because patients are often unconscious. Here we present a case of ethylene glycol intoxication who successfully recovered with prompt hemodialysis. Case Presentation. A 52-year-old Japanese male was admitted to a local hospital due to suspected food poisoning. The patient presented with nausea and vomiting, but his condition rapidly deteriorated, with worsening conscious level, respiratory distress requiring mechanical ventilation, hypotension, and severe acute kidney injury. He was transferred to the university hospital; hemodialysis was initiated because of hyperkalemia and severe metabolic acidosis. On recovering consciousness, he admitted having ingested antifreeze solution. Thirty-seven days after admission, the patient was discharged without requiring HD. Conclusions. We reported a case of ethylene glycol intoxication who presented with a life-threatening metabolic acidosis. In a state of severe circulatory shock requiring catecholamines, hemodialysis should be avoided, and continuous hemodiafiltration may be a preferred approach. However, one should be aware of the possibility of intoxication by unknown causes, and hemodialysis could be life-saving with its superior ability to remove toxic materials in such cases. Ikuyo Narita, Michiko Shimada, Norio Nakamura, Reiichi Murakami, Takeshi Fujita, Wakako Fukuda, and Hirofumi Tomita Copyright © 2017 Ikuyo Narita et al. All rights reserved. An Intact Dopamine Sensitivity in the Brain: A Necessity to Recover Hyperprolactinemia and Galactorrhea in a Female Hemodialysis Patient? Sun, 16 Jul 2017 00:00:00 +0000 http://www.hindawi.com/journals/crin/2017/3729629/ A female hemodialysis patient with galactorrhea due to hyperprolactinemia was treated with different dialysis modalities to assess the effect on prolactin levels. A single session of both high-flux hemodialysis and hemodiafiltration resulted in decreased prolactin levels (16,6% and 77,2%, resp.). However, baseline prolactin levels measured immediately before the next dialysis session did not change markedly. After cabergoline treatment was started, prolactin levels normalized and galactorrhea disappeared. Thus, dopaminergic inhibition of prolactin secretion might be reduced in patients with end-stage renal disease. This dopaminergic resistance could be an important mechanism of hyperprolactinemia in hemodialysis patients and its subsequent treatment strategies. Eva Philipse, Ester Philipse, Theodorus Twickler, Amaryllis Van Craenenbroeck, Marie Madeleine Couttenye, and Luc Van Gaal Copyright © 2017 Eva Philipse et al. All rights reserved. Cisplatin-Induced Nephrotoxicity and HIV Associated Nephropathy: Mimickers of Myeloma-Like Cast Nephropathy Mon, 10 Jul 2017 00:00:00 +0000 http://www.hindawi.com/journals/crin/2017/6258430/ Myeloma cast nephropathy is an obstructing disorder of renal tubules, caused by precipitation of Bence Jones proteins. Myeloma-like cast nephropathy (MLCN) has been reported in the literature to occur in various primary renal and nonrenal diseases. We present a series of three rare cases of cast nephropathy, two of which are HIV patients, and the third patient is receiving cisplatin-based chemotherapy. However, in all three patients plasma cell dyscrasia has been ruled out. A 30-year-old male was admitted to the hospital with facial cellulitis. The second patient is a 31-year-old male who presented with Pneumocystis jiroveci pneumonia. The third patient was treated with cisplatin-based chemotherapy for carcinoma. First two cases revealed foci of diffuse tubular dilatation containing hyaline casts and interstitial inflammatory infiltrate, in addition to globally sclerotic glomeruli with ultrastructural foot process fusion and mesangium expansion. The third case showed acute tubular injury and cast formation of irregular casts composed of amorphous or granular material of low density admixed with scattered high electron-dense globules. Myeloma-like cast nephropathy and true myeloma cast nephropathy pose similar destructive effects on renal parenchyma. This new pattern of HIV-related nephropathy should be considered in HIV patients with MLCN, once monoclonal gammopathy is ruled out. Muhammad Siddique Khurram, Ahmed Alrajjal, Warda Ibrar, Jacob Edens, Umer Sheikh, Ameer Hamza, and Hong Qu Copyright © 2017 Muhammad Siddique Khurram et al. All rights reserved. Extended Peritoneal Dialysis and Renal Recovery in HIV-Infected Patients with Prolonged AKI: A Report of 2 Cases Thu, 06 Jul 2017 00:00:00 +0000 http://www.hindawi.com/journals/crin/2017/8620832/ Peritoneal dialysis (PD) has recently been established as a treatment option for renal replacement therapy (RRT) in patients with acute kidney injury (AKI). Its efficacy in providing fluid and small solute removal has also been demonstrated in clinical trials and is equivalent to hemodialysis (HD). However, effect of RRT modality on renal recovery after AKI remains a controversy. Moreover, the setting of human immunodeficiency virus- (HIV-) infected patients with AKI requiring RRT makes the decision on RRT initiation and modality selection more complicated. The authors report here 2 cases of HIV-infected patients presenting with severe AKI requiring protracted course of acute RRT. PD had been performed uneventfully in both cases for 4–9 months before partial renal recovery occurred. Both patients eventually became dialysis independent but were left in chronic kidney disease (CKD) stage 4. These cases highlight the example of renal recovery even after a prolonged course of dialysis dependence. Thus, PD might be a suitable option for HIV patients with protracted AKI. Donlawat Saengpanit, Pongpratch Puapatanakul, Piyaporn Towannang, and Talerngsak Kanjanabuch Copyright © 2017 Donlawat Saengpanit et al. All rights reserved. Transient Central Diabetes Insipidus and Marked Hypernatremia following Cardiorespiratory Arrest Mon, 03 Jul 2017 06:46:40 +0000 http://www.hindawi.com/journals/crin/2017/1574625/ Central Diabetes Insipidus is often an overlooked complication of cardiopulmonary arrest and anoxic brain injury. We report a case of transient Central Diabetes Insipidus (CDI) following cardiopulmonary arrest. It developed 4 days after the arrest resulting in polyuria and marked hypernatremia of 199 mM. The latter was exacerbated by replacing the hypotonic urine by isotonic saline. Sahar H. Koubar and Eliane Younes Copyright © 2017 Sahar H. Koubar and Eliane Younes. All rights reserved. Acute Pancreatitis and Rhabdomyolysis with Acute Kidney Injury following Multiple Wasp Stings Mon, 19 Jun 2017 00:00:00 +0000 http://www.hindawi.com/journals/crin/2017/8596981/ Multiple wasp stings can induce multiple organ dysfunction by toxic reactions. However, acute pancreatitis is a rare manifestation in wasp sting injury. A 74-year-old woman visited the emergency department by anaphylactic shock because of multiple wasp stings. Acute kidney injury, rhabdomyolysis, hepatotoxicity, and coagulopathy were developed next day. Serum amylase and lipase were elevated and an abdominal computed tomography revealed an acute pancreatitis. Urine output was recovered after 16 days of oliguria (below 500 ml/day). Her kidney, liver, and pancreas injury gradually improved after sessions of renal replacement therapy. Seo Hee Yang, Yeon Han Song, Tae Hoon Kim, Su Bin Kim, Sang Youb Han, Han-Seong Kim, and Se Won Oh Copyright © 2017 Seo Hee Yang et al. All rights reserved. The Cushing Reflex: Oliguria as a Reflection of an Elevated Intracranial Pressure Mon, 15 May 2017 08:11:37 +0000 http://www.hindawi.com/journals/crin/2017/2582509/ Oliguria is one of the clinical hallmarks of renal failure. The broad differential diagnosis is well known, but a rare cause of oliguria is intracranial hypertension (ICH). The actual knowledge to explain this relationship is scarce. Almost all literature is about animals where authors describe the Cushing reflex in response to ICH. We hypothesize that the Cushing reflex is translated towards the sympathetic nervous system and renin-angiotensin-aldosterone system with a subsequent reduction in medullary blood flow and oliguria. Recently, we were confronted with a patient who had complicated pituitary surgery and displayed multiple times an oliguria while he developed ICH. K. Leyssens, T. Mortelmans, T. Menovsky, D. Abramowicz, Marcel Th. B. Twickler, and L. Van Gaal Copyright © 2017 K. Leyssens et al. All rights reserved. Cisplatin-Induced Renal Salt Wasting Requiring over 12 Liters of 3% Saline Replacement Wed, 10 May 2017 07:25:54 +0000 http://www.hindawi.com/journals/crin/2017/8137078/ Cisplatin is known to induce Fanconi syndrome and renal salt wasting (RSW). RSW typically only requires transient normal saline (NS) support. We report a severe RSW case that required 12 liters of 3% saline. A 57-year-old woman with limited stage small cell cancer was admitted for cisplatin (80 mg/m2) and etoposide (100 mg/m2) therapy. Patient’s serum sodium (SNa) decreased from 138 to 133 and 125 mEq/L within 24 and 48 hours of cisplatin therapy, respectively. A diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) was initially made. Despite free water restriction, patient’s SNa continued to decrease in association with acute onset of headaches, nausea, and dizziness. Three percent saline (3%S) infusion with rates up to 1400 mL/day was required to correct and maintain SNa at 135 mEq/L. Studies to evaluate Fanconi syndrome revealed hypophosphatemia and glucosuria in the absence of serum hyperglycemia. The natriuresis slowed down by 2.5 weeks, but 3%S support was continued for a total volume of 12 liters over 3.5 weeks. Attempts of questionable benefits to slow down glomerular filtration included the administration of ibuprofen and benazepril. To our knowledge, this is the most severe case of RSW ever reported with cisplatin. Phuong-Chi Pham, Pavani Reddy, Shaker Qaqish, Ashvin Kamath, Johana Rodriguez, David Bolos, Martina Zalom, and Phuong-Thu Pham Copyright © 2017 Phuong-Chi Pham et al. All rights reserved. Antiglomerular Basement Membrane Disease in a Pediatric Patient: A Case Report and Review of the Literature Tue, 09 May 2017 07:27:36 +0000 http://www.hindawi.com/journals/crin/2017/1256142/ Goodpasture’s syndrome (GPS) remains a very rare disease entity in the pediatric population characterized by the presence of pulmonary hemorrhage and rapidly evolving glomerulonephritis. We hereby describe the case of a 2-year-old girl who presented with renal failure and was diagnosed with GPS. A brief review of the literature in regard to data on demographics, pathogenesis, clinical features, diagnosis, treatment, and prognosis for renal recovery is also provided. Vimal Master Sankar Raj, Diana Warnecke, Julia Roberts, and Sarah Elhadi Copyright © 2017 Vimal Master Sankar Raj et al. All rights reserved. Diabetic Muscle Infarction Masquerading as Necrotizing Fasciitis Wed, 26 Apr 2017 00:00:00 +0000 http://www.hindawi.com/journals/crin/2017/7240156/ A 43-year-old male patient with past medical history of diabetes mellitus (DM), end stage renal disease (ESRD) on hemodialysis (HD), congestive heart failure (CHF), obstructive sleep apnea (OSA), and chronic anemia presented with complaints of left thigh pain. A computerized tomogram (CT) of the thigh revealed evidence of edema with no evidence of a focal collection or gas formation noted. The patient’s clinical symptoms persisted and he underwent magnetic resonance imaging (MRI) of his thigh which was reported to show small areas of muscle necrosis with fluid collection. These findings in the acute setting concerned necrotizing fasciitis. After careful discussion following a multidisciplinary approach, a decision was made to perform a fasciotomy with tissue debridement. The patient was treated with IV antibiotics and discharged with a vacuum assisted wound drain. The surgical pathology revealed evidence of muscle edema with necrosis. Seven weeks later the patient presented with similar complaints on the other thigh (right thigh). MRI of the thighs revealed worsening edema with features suggestive of myositis and possible muscle infarction. A CT guided biopsy of the right quadriceps muscle revealed fibrotic interstitial connective tissue and no evidence of necrosis. This favored a diagnosis of diabetic muscle infarction. The disease was managed with pain control, strict diabetes management, and aggressive dialysis. Kalyana C. Janga, Ankur Sinha, Perry Wengrofsky, Phone Oo, Sheldon Greenberg, Regina Tarkovsky, and Kavita Sharma Copyright © 2017 Kalyana C. Janga et al. All rights reserved. Delayed Manifestation of Shunt Nephritis: A Case Report and Review of the Literature Sun, 09 Apr 2017 10:54:52 +0000 http://www.hindawi.com/journals/crin/2017/1867349/ We present an unusual case of shunt nephritis in a 39-year-old male who presented 21 years after placement of a ventriculoperitoneal (VP) shunt. He complained of fevers, headaches, dizziness, and urticarial plaques on arms, trunks, and legs and was found to have anemia, low complement levels, elevated serum creatinine, proteinuria, and new onset microhematuria. Blood and urine cultures were negative. Renal biopsy showed features of acute tubulointerstitial nephritis attributed to vancomycin use. Glomeruli showed increased mesangial hypercellularity and segmental endocapillary proliferation. Immunofluorescence showed focal IgM and C3 staining. Electron microscopy revealed small subendothelial electron-dense deposits. Symptoms and renal insufficiency appeared to improve with antibiotic therapy. He was discharged and readmitted 2 months later with similar presentation. CSF grew Propionibacterium acnes and shunt hardware grew coagulase-negative Staphylococcus. He completed an intravenous antibiotic course and was discharged. On 1-month follow-up, skin lesions persisted but he was otherwise asymptomatic. Follow-up labs showed significant improvement. We did a brief systematic review of the literature on shunt nephritis and report our findings on 79 individual cases. In this review, we comment on the presentation, lab findings, pathological features, and management of this rare, potentially fatal, but curable disease entity. Michael Babigumira, Benjamin Huang, Sherry Werner, and Wajeh Qunibi Copyright © 2017 Michael Babigumira et al. All rights reserved. In Acute IgA Nephropathy, Proteinuria and Creatinine Are in the Spot, but Podocyturia Operates in Silence: Any Place for Amiloride? Mon, 03 Apr 2017 07:27:49 +0000 http://www.hindawi.com/journals/crin/2017/1292531/ IgA nephropathy is the most frequent cause of primary glomerulonephritis, portends erratic patterns of clinical presentation, and lacks specific treatment. In general, it slowly progresses to end-stage renal disease. The clinical course and the response to therapy are usually assessed with proteinuria and serum creatinine. Validated biomarkers have not been identified yet. In this report, we present a case of acute renal injury with proteinuria and microscopic hematuria in a young male. A kidney biopsy disclosed IgA nephropathy. Podocyturia was significantly elevated compared to normal subjects. Proteinuria, renal function, and podocyturia improved promptly after steroids and these variables remained normal after one year of follow-up, when steroids had already been discontinued and patient continued on valsartan and amiloride. Our report demonstrates that podocyturia is critically elevated during an acute episode of IgA nephropathy, and its occurrence may explain the grim long-term prognosis of this entity. Whether podocyturia could be employed in IgA nephropathy as a trustable biomarker for treatment assessment or even for early diagnosis of IgA nephropathy relapses should be further investigated. H. Trimarchi, M. Paulero, R. Canzonieri, A. Schiel, A. Iotti, C. Costales-Collaguazo, A. Stern, M. Forrester, F. Lombi, V. Pomeranz, R. Iriarte, T. Rengel, I. Gonzalez-Hoyos, A. Muryan, and E. Zotta Copyright © 2017 H. Trimarchi et al. All rights reserved. Nephrologists Hate the Dialysis Catheters: A Systemic Review of Dialysis Catheter Associated Infective Endocarditis Mon, 20 Mar 2017 10:41:57 +0000 http://www.hindawi.com/journals/crin/2017/9460671/ A 53-year-old Egyptian female with end stage renal disease, one month after start of hemodialysis via an internal jugular catheter, presented with fever and shortness of breath. She developed desquamating vesiculobullous lesions, widespread on her body. She was in profound septic shock and broad spectrum antibiotics were started with appropriate fluid replenishment. An echocardiogram revealed bulky leaflets of the mitral valve with a highly mobile vegetation about 2.3 cm long attached to the anterior leaflet. CT scan of the chest, abdomen, and pelvis showed bilateral pleural effusions in the chest, with triangular opacities in the lungs suggestive of infarcts. There was splenomegaly with triangular hypodensities consistent with splenic infarcts. Blood cultures repeatedly grew Candida albicans. Despite parenteral antifungal therapy, the patient deteriorated over the course of 5 days. She died due to a subsequent cardiac arrest. Systemic review of literature revealed that the rate of infection varies amongst the various types of accesses, and it is well documented that AV fistulas have a much less rate of infection in comparison to temporary catheters. All dialysis units should strive to make a multidisciplinary effort to have a referral process early on, for access creation, and to avoid catheters associated morbidity. Kalyana C. Janga, Ankur Sinha, Sheldon Greenberg, and Kavita Sharma Copyright © 2017 Kalyana C. Janga et al. All rights reserved. Multiple Electrolyte and Metabolic Emergencies in a Single Patient Tue, 31 Jan 2017 09:33:11 +0000 http://www.hindawi.com/journals/crin/2017/4521319/ While some electrolyte disturbances are immediately life-threatening and must be emergently treated, others may be delayed without immediate adverse consequences. We discuss a patient with alcoholism and diabetes mellitus type 2 who presented with volume depletion and multiple life-threatening electrolyte and metabolic derangements including severe hyponatremia (serum sodium concentration [] 107 mEq/L), hypophosphatemia (“undetectable,” <1.0 mg/dL), and hypokalemia (2.2 mEq/L), moderate diabetic ketoacidosis ([DKA], pH 7.21, serum anion gap [] 37) and hypocalcemia (ionized calcium 4.0 mg/dL), mild hypomagnesemia (1.6 mg/dL), and electrocardiogram with prolonged QTc. Following two liters of normal saline and associated increase in by 4 mEq/L and serum osmolality by 2.4 mosm/Kg, renal service was consulted. We were challenged with minimizing the correction of (or effective serum osmolality) to avoid the osmotic demyelinating syndrome while replacing volume, potassium, phosphorus, calcium, and magnesium and concurrently treating DKA. Our management plan was further complicated by an episode of significant aquaresis. A stepwise approach was strategized to prioritize and correct all disturbances with considerations that the treatment of one condition could affect or directly worsen another. The current case demonstrates that a thorough understanding of electrolyte physiology is required in managing complex electrolyte disturbances to avoid disastrous outcomes. Caprice Cadacio, Phuong-Thu Pham, Ruchika Bhasin, Anita Kamarzarian, and Phuong-Chi Pham Copyright © 2017 Caprice Cadacio et al. All rights reserved. Kinetics of Rituximab Excretion into Urine and Peritoneal Fluid in Two Patients with Nephrotic Syndrome Tue, 24 Jan 2017 00:00:00 +0000 http://www.hindawi.com/journals/crin/2017/1372859/ Clinical observations suggest that treatment of Rituximab might be less effective in patients with nephrotic range proteinuria when compared to nonnephrotic patients. It is conceivable that the reason for this is that significant amounts of Rituximab might be lost in the urine in a nephrotic patient and that these patients require a repeated or higher dosage. However, this has not been systematically studied. In this case report we describe two different patients with nephrotic range proteinuria receiving Rituximab. The first patient received Rituximab for therapy resistant cryoglobulinemic membranoproliferative glomerulonephritis and the other for second line treatment of Felty’s syndrome. We employed flow cytometry to determine the amount of Rituximab excretion in both urine and peritoneal fluid specimens in these patients following administration of Rituximab. We found that a significant amount of Rituximab is lost from the circulation by excretion into the urine. Furthermore we saw a close correlation of the excretion of Rituximab to the excretion of IgG molecules suggesting selectivity of proteinuria as the determining factor of Rituximab excretion. Further larger scale clinical studies could have the potential to evaluate an optimal cut-off value of IgG urinary loss before a possible administration of Rituximab therefore contributing to a more individualized treatment approach in patients with nonselective and nephrotic range proteinuria. Klaus Stahl, Michelle Duong, Anke Schwarz, A. D. Wagner, Hermann Haller, Mario Schiffer, and Roland Jacobs Copyright © 2017 Klaus Stahl et al. All rights reserved. Porphyria Cutanea Tarda in a Patient with End-Stage Renal Disease: A Case of Successful Treatment with Deferoxamine and Ferric Carboxymaltose Sun, 22 Jan 2017 00:00:00 +0000 http://www.hindawi.com/journals/crin/2017/4591871/ Porphyria cutanea tarda (PCT) is a rare disease, with a strong association with hepatitis C virus. PCT is particularly problematic in end-stage renal disease patients as they have no renal excretion of porphyrins and these are poorly dialyzed. Also, conventional treatment of PCT is compromised in these patients as hydroxychloroquine is contraindicated, phlebotomies with the stipulated frequency are poorly tolerated in already anaemia-prone patients, and iron-chelating agents are less efficient in removing iron and contribute to worsening anaemia. The authors report a patient on haemodialysis, with hepatitis C infection, that is diagnosed with PCT. Despite the good clinical results with deferoxamine, she became dependent on blood transfusions because of her ferropenic state. Every time oxide iron was started, the patient developed clinical features of the disease, resolving after the suspension of the drug. A decision was made to start the patient on ferric carboxymaltose, which was well tolerated without disease symptoms and need of further blood transfusions. This case suggests that deferoxamine is efficient in treatment of porphyria cutanea tarda. Also, ferric carboxymaltose may be a valuable option for refractory anaemia in patients with this disease and end-stage renal disease, as it seems to provide iron without clinical relapse of the disease. Natacha Rodrigues, Fernando Caeiro, Alice Santana, Teresa Mendes, and Leonor Lopes Copyright © 2017 Natacha Rodrigues et al. All rights reserved. Successful Management of Refractory Type 1 Renal Tubular Acidosis with Amiloride Tue, 03 Jan 2017 06:52:56 +0000 http://www.hindawi.com/journals/crin/2017/8596169/ A 28-year-old female with history of hypothyroidism, Sjögren’s Syndrome, and Systemic Lupus Erythematosus (SLE) presented with complaints of severe generalized weakness, muscle pain, nausea, vomiting, and anorexia. Physical examination was unremarkable. Laboratory test showed hypokalemia at 1.6 mmol/l, nonanion metabolic acidosis with HCO3 of 11 mmol/l, random urine pH of 7.0, and urine anion gap of 8 mmol/l. CT scan of the abdomen revealed bilateral nephrocalcinosis. A diagnosis of type 1 RTA likely secondary to Sjögren’s Syndrome was made. She was started on citric acid potassium citrate with escalating dosages to a maximum dose of 60 mEq daily and potassium chloride over 5 years without significant improvement in serum K+ and HCO3 levels. She had multiple emergency room visits for persistent muscle pain, generalized weakness, and cardiac arrhythmias. Citric acid potassium citrate was then replaced with sodium bicarbonate at 15.5 mEq every 6 hours which was continued for 2 years without significant improvement in her symptoms and electrolytes. Amiloride 5 mg daily was added to her regimen as a potassium sparing treatment with dramatic improvement in her symptoms and electrolyte levels (as shown in the figures). Amiloride was increased to 10 mg daily and potassium supplementation was discontinued without affecting her electrolytes. Her sodium bicarbonate was weaned to 7.7 mEq daily. Patrick Oguejiofor, Robert Chow, Kenneth Yim, and Bernard G. Jaar Copyright © 2017 Patrick Oguejiofor et al. All rights reserved. Treatment of Light Chain Deposition Disease Using Bortezomib-Based Regimen Followed by Thalidomide-Based Regimen in a Saudi Male Mon, 19 Dec 2016 09:48:38 +0000 http://www.hindawi.com/journals/crin/2016/7485695/ Light chain deposition disease (LCDD) is a rare illness with, as yet, no clear evidence-based guidelines for its treatment. To the best of our knowledge, LCDD has not been previously reported from Saudi Arabia. We present in this report, a 38-year-old Saudi male who presented with clinical features suggestive of hypertensive nephropathy but kidney biopsy later revealed the diagnosis of LCDD. His serum creatinine at presentation was 297 μmol/L which came down to 194 μmol/L on treatment with Bortezomib, Cyclophosphamide and Dexamethasone. His 24-hour protein excretion at presentation was 6 g/L which also came down to less than 1 g/day. He was later placed on Cyclophosphamide, Thalidomide, and Dexamethasone regimen because of persistent high titres of serum free light chains. He went into remission with undetectable serum free light chains and remained so for three years at the time of writing this report. We conclude that LCDD, though rare, does occur in Saudi population. The treatment of LCDD is challenging but the use of Bortezomib, a proteosome inhibitor, is promising. However, suboptimal response may require further treatment with other therapeutic options such as chemotherapy with alkylating agents or high-dose Melphalan with autologous stem cell transplant. Bappa Adamu, Mushabab Al-Ghamdi, Mustafa Ahmad, and Khaled O. Alsaad Copyright © 2016 Bappa Adamu et al. All rights reserved. Acute Kidney Injury, Recurrent Seizures, and Thrombocytopenia in a Young Patient with Lupus Nephritis: A Diagnostic Dilemma Sun, 04 Dec 2016 09:27:48 +0000 http://www.hindawi.com/journals/crin/2016/7104098/ Introduction. Posterior reversible encephalopathy syndrome (PRES) is a constellation of clinical and radiologic findings. Fluctuations in blood pressure, seizures, and reversible brain MRI findings mainly in posterior cerebral white matter are the main manifestations. PRES has been associated with multiple conditions such as autoimmune disorders, pregnancy, organ transplant, and thrombotic microangiopathy (TMA). Case Presentation. A 22-year-old woman with history of Systemic Lupus Erythematous complicated with chronic kidney disease secondary to lupus nephritis class IV presented with recurrent seizures and uncontrolled hypertension. She was found to have acute kidney injury and thrombocytopenia. Repeat kidney biopsy showed diffuse endocapillary and extracapillary proliferative and membranous lupus nephritis (ISN-RPS class IV-G+V) and endothelial swelling secondary to severe hypertension but no evidence of TMA. Brain MRI showed reversible left frontal and parietal lesions that resolved after controlling the blood pressure, making PRES the diagnosis. Conclusion. PRES is an important entity that must be recognized and treated early due to the potential reversibility in the early stages. Physicians must have high suspicion for these unusual presentations. We present a case where performing kidney biopsy clinched the diagnosis in our patient with multiple confounding factors. Hector Alvarado Verduzco and Anjali Acharya Copyright © 2016 Hector Alvarado Verduzco and Anjali Acharya. All rights reserved. Adjustment of Eculizumab Dosage Pattern in Patients with Atypical Hemolytic Uremic Syndrome with Suboptimal Response to Standard Treatment Pattern Tue, 29 Nov 2016 11:01:49 +0000 http://www.hindawi.com/journals/crin/2016/7471082/ In patients with atypical hemolytic uremic syndrome (aHUS), complement blocking by eculizumab rapidly halts the process of thrombotic microangiopathy and it is associated with clear long-term hematologic and renal improvements. Eculizumab treatment consists of a 4-week initial phase with weekly IV administration of 900 mg doses, followed by a maintenance phase with a 1,200 mg dose in the fifth week and every days thereafter. We present three patients with aHUS and suboptimal response to eculizumab treatment at the usual administration dosage who showed hematologic and renal improvements after an adjustment in the eculizumab treatment protocol. Camino García Monteavaro, Carmen Peralta Roselló, Borja Quiroga, José María Baltar Martín, Lorena Castillo Eraso, Fernando de Álvaro Moreno, Alberto Martínez Vea, and María Teresa Visus-Fernández de Manzanos Copyright © 2016 Camino García Monteavaro et al. All rights reserved.