[Show abstract][Hide abstract] ABSTRACT: Previous studies suggested that intravenous methylprednisolone possibly accelerates remission of proteinuria in adult-onset minimal change disease; its impact on relapse of proteinuria is unknown.
This multicenter retrospective cohort study included 125 adult-onset minimal change disease patients diagnosed by kidney biopsy between 2000 and 2009 and treated initially with corticosteroid in five nephrology centers in Japan participating in the Study of Outcomes and Practice Patterns of Minimal Change Disease. Times to first remission and first relapse of proteinuria after initiating the first immunosuppressive therapy were compared between 65 patients with initial use of intravenous methylprednisolone followed by prednisolone and 60 patients with initial use of prednisolone alone using multivariate Cox proportional hazards models. After calculating the probability of receiving methylprednisolone and prednisolone using a logistic regression model (propensity score), the results were ascertained using propensity score-matched and -stratified models.
During the median 3.6 years of observation (interquartile range=2.0-6.9), all 65 patients in the methylprednisolone and prednisolone group achieved remission within 11 (8-20) days of the corticosteroid initiation, whereas in the prednisolone group, 58 of 60 patients (96.7%) achieved remission within 19 (12-37) days (P<0.001). After achieving first remission, 32 (49.2%) patients in the methylprednisolone and prednisolone group and 43 (74.1%) patients in the prednisolone group developed at least one relapse. Multivariate Cox proportional hazards models revealed that methylprednisolone and prednisolone use was significantly associated with early remission (multivariate-adjusted hazard ratio, 1.56; 95% confidence interval, 1.06 to 2.30) and lower incidence of relapse (0.50; 95% confidence interval, 0.29 to 0.85) compared with prednisolone use alone. These results were ascertained in propensity score-based models. No significant difference was observed in incidence of adverse events, including infection, aseptic osteonecrosis, cataract, diabetes, and gastrointestinal bleeding.
Initial use of methylprednisolone was associated with earlier remission and lower incidence of relapse in adult-onset minimal change disease patients. Efficacy of methylprednisolone should be evaluated in randomized controlled trials.
Preview · Article · Apr 2014 · Clinical Journal of the American Society of Nephrology
[Show abstract][Hide abstract] ABSTRACT: Little is known about genetic predictors that modify the renoprotective effect of renin-angiotensin system (RAS) blockade in IgA nephropathy (IgAN).
The present multicenter retrospective observational study examined effect modification between RAS blockade and three RAS-related gene polymorphisms in 237 IgAN patients, including ACE I/D (rs1799752), AT1R A1166C (rs5186) and AGT T704C (rs699).
During 9.9 ± 4.2 years of observation, 63 patients progressed to a 50% increase in serum creatinine level. Only ACE I/D predicted the outcome (ACE DD vs ID/II, hazard ratio 1.86 (95% confidence interval 1.03, 3.33)) and modified the renoprotective effect of RAS blockade (p for interaction between ACE DD and RAS blockade = 0.087). RAS blockade suppressed progression in ACE DD patients but not in ID/II patients (ACE ID/II with RAS blockade as a reference; ID/II without RAS blockade 1.45 (0.72, 2.92); DD without RAS blockade 3.06 (1.39, 6.73); DD with RAS blockade 1.51 (0.54, 4.19)), which was ascertained in a model with the outcome of slope of estimated glomerular filtration rate (p = 0.045 for interaction).
ACE I/D predicted the IgAN progression and the renoprotective effect of RAS blockade in IgAN patients whereas neither AT1R A1166C nor AGT T704C did.
No preview · Article · Jan 2014 · Journal of Renin-Angiotensin-Aldosterone System
[Show abstract][Hide abstract] ABSTRACT: In 2010, a 71-year-old man was referred to our hospital because of mild proteinuria and hematuria. At that time, he had been asymptomatic. Three months later he noticed macroscopic hematuria, followed by general malaise, and then anorexia. He was admitted for acute kidney injury (serum creatinine 2.7 mg/dL), marked proteinuria (4.35 g/gCr), and elevated C-reactive protein (7.21 mg/dL). Some vesicles were noted on the soft palate, and a throat culture yielded a growth of group A beta-hemolytic streptococci. Antistreptolysin O and antistreptokinase titers were elevated, but serum complement levels were within normal limits. Antineutrophil cytoplasmic antibodies (ANCA) directed against elastase and bactericidal permeability increasing protein (BPI)were positive. The renal function and inflammation did not improve despite oral antibiotic therapy. Pathological examination of a renal biopsy specimen revealed diffuse crescent formation, numerous subepithelial dome-shaped deposits (humps), and prominent endocapillary proliferation. Furthermore, a focal and segmental spike appearance was seen, with deposits smaller than humps. There was a striking clinical improvement after steroid pulse therapy followed by oral prednisolone. The features of this case strongly suggest crescentic PSAGN accompanied by pre-existing membranous nephropathy.
No preview · Article · Jul 2013 · Nippon Jinzo Gakkai shi
[Show abstract][Hide abstract] ABSTRACT: A 33-year-old man was diagnosed with Crohn's disease in 2001, and treated with mesalazine and ranitidine. Administration of infliximab was started in 2007 and led to a decrease in the activity of the Crohn's disease. He was referred to our department in the summer of 2011 following rapid progression of renal insufficiency, with serum creatinine levels increasing from 1.5 mg/dL to 4.3 mg/dL within 2 months. On admission, laboratory findings showed signs of inflammation, anemia, proteinuria, and hematuria. Renal biopsy results indicated the diagnosis of granulomatous interstitial nephritis. Neither clinical manifestations nor laboratory findings were suggestive of infectious disease, sarcoidosis, Wegener's granulomatosis or tubulointerstitial nephritis and uveitis. Mesalazine and ranitidine were discontinued in view of reports of drug-induced granulomatous interstitial nephritis. Levels of C-reactive protein immediately decreased, but renal function remained unimproved. Treatment with steroid pulse therapy was then initiated, followed by oral prednisolone at 40 mg/day, and his serum creatinine recovered to 2.3 mg/dL. Mesalazine and/or ranitidine appear to have been responsible for the granulomatous interstitial nephritis. In cases of Crohn's disease showing rapid deterioration of renal function, drug-induced renal disease should be considered, even if the drugs have been taken without apparent problems for a long duration.
No preview · Article · May 2013 · Nippon Jinzo Gakkai shi
[Show abstract][Hide abstract] ABSTRACT: A 63-year-old man was diagnosed with periodontitis and underwent tooth extraction. Several days later, he suffered a high fever, ischuria, a change in personality, and disorientation. A urologist examined him and found severe hyponatremia (117 mEq/L), and he was then transferred to our hospital. On admission, physical findings revealed dysfunction of the bladder and bowel, altered mental status, and hypovolemia. Blood chemistry showed serum sodium of 120 mEq/L, a serum urate of 1.4 mg/dL, urinary Na of 61 mEq/L, and fractional urate excretion of 16 %. Examination of the cerebrospinal fluid (CSF) showed monocytosis. Magnetic resonance imaging (MRI) of the brain and spinal cord showed multiple lesions characterized by hyperintensity on T2-weighted sequences, suggesting demyelinating disease. His sodium concentration normalized 3 days after volume replacement therapy, and his altered mental status along with the dysfunction of the bladder and bowel were promptly improved after the initiation of high-dose glucocorticoids. Additionally, the abnormal lesions on MRI markedly decreased. This clinical course led to the likely diagnosis of acute disseminated encephalomyelitis (ADEM). Hyponatremia in neurologically injured patients is usually attributed to the syndrome of inappropriate antidiuretic hormone (SIADH) or cerebral salt-wasting syndrome (CSWS). In the present patient, the uric acid level remained low and uric acid excretion remained elevated despite correction of the hyponatremia, which suggested CSWS. The differentiation of CSWS from SIADH is difficult but critically important due to the fact that the disorders are managed differently. Coexistence of ADEM and CSWS has rarely been reported.
[Show abstract][Hide abstract] ABSTRACT: Background:
In adult-onset minimal-change disease (MCD) the predictors of remission and relapse of proteinuria and corticosteroid-related adverse events remain unknown.
The multicenter retrospective cohort study, the STudy of Outcomes and Practice patterns of Minimal-Change Disease (STOP-MCD), included 142 adult-onset MCD patients in 5 nephrology centers in Japan. Primary outcomes were first remission of proteinuria defined by urinary protein (UP) <0.3 g/day, UP/creatinine ratio (UPCR) <0.3, and/or negative/trace by dipstick test and first relapse of proteinuria defined by UP ≥1.0 g/day, UPCR ≥1.0, and/or dipstick test ≥1+ followed by immunosuppressive therapy. Secondary outcomes were corticosteroid-related adverse events.
During the median 3.6 (interquartile range, 2.0-6.9) years of the entire observational period, 136 (95.8 %) and 79 (58.1 %) patients developed at least 1 remission and 1 recurrence within a median of 15 (10-34) days and 0.90 (0.55-1.57) years, respectively. Compared with younger patients aged 15-29 years at kidney biopsy, elderly patients aged ≥60 years developed remission significantly later [hazard ratio 0.53 (95 % confidence interval 0.32-0.88)], while older patients aged ≥45 years were at a significantly lower risk of relapse [45-59 years, 0.46 (0.22-0.96); 60-83 years, 0.39 (0.21-0.74)]. However, older patients were significantly more vulnerable to severe infection, diabetes, and cataract as compared with younger patients.
Younger patients had a higher risk of relapse while older patients had a lower risk of relapse but a higher risk of corticosteroid-related adverse events.
No preview · Article · Mar 2013 · Clinical and Experimental Nephrology
[Show abstract][Hide abstract] ABSTRACT: Few findings are available regarding adult-onset minimal change nephrotic syndrome (MCNS) with respect to the disease course and complications, such as acute kidney injury (AKI). We therefore performed a retrospective review to characterize the clinical presentations, steroid responsiveness and complications of adult-onset MCNS patients in our hospital.
We retrospectively reviewed 40 cases of idiopathic adult-onset MCNS who had been investigated and treated at a single center. Patients between 18 and 50 years of age (Younger group) at the time of biopsy were compared with those older than 50 years (Older group) with regard to demographic data, clinical features and treatment outcome.
Baseline characteristics of the 40 patients were: median age, 42 years (interquartile range: 28-63 years); male, 70%; mean (+/- standard deviation) systolic and diastolic blood pressures, 125 +/- 17 mmHg and 78 +/- 12 mmHg, respectively; estimated glomerular filtration rate (eGFR), 74 mL/min/1.73 m2 (range: 64-94 mL/min/1.73 m2); serum albumin, 1.8 +/- 0.3 g/dL; and urinary protein, 7.8 g/day (range: 3.9-10.4 g/day). All except for one patient received steroid pulse therapy. Time to complete response (CR) was 12 days (range: 8-21 days). Time to CR was significantly longer in the Older group (p = 0.011). The Late-responder group (time to CR > 2 weeks)was significantly older (p < 0.01), with a low eGFR (p < 0.001) and a higher prevalence of interstitial fibrosis in renal biopsy before the initiation of corticosteroid therapy (p < 0.05), compared with the Early-responder group. AKI was observed in 14 patients. Patients with an episode of AKI were significantly older (p = 0.005), with a lower eGFR (p < 0.002) and a higher prevalence of cellular casts (p < 0.05). At the follow-up, 19 patients (51%) had experienced relapses. The relapse rate was significantly lower in the Older group than in the Younger group (p < 0.05).
The present study revealed that older patients had a longer period to CR and a higher risk of AKI at follow-up.
No preview · Article · Dec 2012 · Nippon Jinzo Gakkai shi
[Show abstract][Hide abstract] ABSTRACT: There is little evidence regarding the target blood pressure level in patients with type 2 diabetes mellitus without overt proteinuria.
We followed 608 Japanese patients with type 2 diabetes without apparent cardiovascular disease and overt proteinuria who underwent cerebral magnetic resonance imaging for a mean of 7.5 years. The patients were categorized according to their mean systolic blood pressure during the follow-up period (strict: <130 mm Hg, moderate: ≥130 and <140 mm Hg, poor: ≥ 140 mm Hg). The risks for the primary composite outcome of death or end-stage renal disease were not different among the three groups. The renal risk of the doubling of serum creatinine for the poor group was significantly higher than those in other groups. In addition, among the patients without silent cerebral infarction (SCI), the renal risk was significantly lower in the strict group than in the moderate group. Further, in both the SCI and non-SCI groups, strict blood pressure control slowed the progression of albuminuria.
In nonproteinuric diabetic patients without SCI, strict blood pressure control was associated with improved renal outcomes. There may be different effects of intensive blood pressure control on the renoprotection of diabetic patients according to their complications.
Full-text · Article · Dec 2011 · Journal of the American Society of Hypertension (JASH)
[Show abstract][Hide abstract] ABSTRACT: Hypertension, which is affected by genetic and environmental factors, is one of the major risk factors for chronic kidney disease. Identification of the genetic factor contributing to hypertension in patients with chronic kidney disease may potentially refine a therapeutic strategy.
In the present multicenter cross-sectional study, 240 patients were eligible (aged 15-50 years with urinary protein ≥0.25 g/day) out of 429 patients who were diagnosed as having immunoglobulin (Ig) A nephropathy (IgAN) by renal biopsy between 1990 and 2005 and enrolled in our previous study, PREDICT-IgAN. The outcome was hypertension defined as ≥140 and/or ≥90 mmHg of systolic and diastolic blood pressure and/or use of antihypertensives at renal biopsy. We assessed associations between hypertension and 28 polymorphisms with the frequency of minor genotype ≥10% among 100 atherosclerosis-related polymorphisms using the Chi-squared test in dominant and recessive models. We identified polymorphisms associated with hypertension in multivariate logistic regression models.
Baseline characteristics: hypertension 36.3%. Among 28 polymorphisms, the Chi-squared test revealed that CD14 (-159CC vs CT/TT, P = 0.03) and ACE (DD vs DI/II, P = 0.03) were significantly associated with hypertension after Bonferroni correction. Multivariate logistic regression models revealed that CD14 -159CC [vs CT/TT, odds ratio (OR) 3.58 (95% confidence interval (CI) 1.66-7.63)] and ACE DD [vs DI/II, OR 4.41 (95% CI 1.80-10.8), P = 0.001] were independently associated with hypertension.
CD14 C-159T and ACE I/D contributed to hypertension in patients with IgAN.
No preview · Article · Nov 2011 · Clinical and Experimental Nephrology
[Show abstract][Hide abstract] ABSTRACT: Genetic factors contributing to the development of IgA nephropathy remain to be elucidated.
The present multicenter cross-sectional case-control study measured genotype frequencies of 65 atherosclerotic disease-related gene polymorphisms in 230 Japanese patients with IgA nephropathy and 262 apparently healthy volunteers with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m(2) and negative or trace proteinuria and hematuria by dipstick test [non-chronic kidney disease (CKD) participants]. Clinical characteristics at kidney biopsy of patients with IgA nephropathy and those at the study recruitment of non-CKD participants were included as covariates in multivariate logistic regression models.
Among 31 gene polymorphisms with ≥5% of minor genotype in non-CKD participants, methionine synthase MTR A2756G (D919G) was significantly associated with IgA nephropathy using χ(2) test even after controlling for family-wise error rate by the method of Bonferroni (P = 0.044). A multivariate nonconditional logistic regression model identified MTR A2756G as a significant contributor of IgA nephropathy [2756AG and GG versus AA, odds ratio 0.42 (95% confidence interval 0.25-0.69) and 0.21 (95% confidence interval 0.06-0.68), P(trend) < 0.001]. After each patient with IgA nephropathy was randomly matched to a non-CKD participant on age (±5 years), gender, mean arterial pressure (±5 mmHg) and eGFR (±5 mL/min/1.73 m(2)), a multivariate conditional logistic regression model also verified their significant association [odds ratio 0.42 (95% confidence interval 0.18-1.00) and odds ratio 0.09 (95% confidence interval 0.01-0.73), P(trend) = 0.004]. MTR A2756G was not associated with slope of eGFR (mL/min/1.73 m(2)/year) in 230 patients with IgA nephropathy.
MTR A2756G was associated with the development, but not progression, of IgA nephropathy.
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION AND AIMS: Recent studies have highlighted that podocyte injury and decrease in glomerular podocyte number leads to proteinuria (PU)
and glomerulosclerosis. Urinary detection of podocyte injury by measurement of podocyturia and podocyte-specific protein has
been used to estimate ongoing glomerular damage. These urinary tests are widely discussed as a more sensitive indicators of
CGN activity and prognosis than PU.
The aim of study: was to define urinary levels of slit membrane protein - nephrin as a feature of podocyte dysfunction and
to clarify its significance for the CGN prognosis and therapy efficiency.
METHODS: Nephrinuria (NU) levels were measured by ELISA in 74 CGN pts:18 - without clinical activity (I group), 18- with PU 1-3g/d
(II group), 38 - with nephrotic syndrome (NS) (III group). 10 healthy subjects were evaluated as control. Response to immunosuppressive
therapy was evaluated in 23 pts with the different NU levels.
RESULTS: We revealed significantly increased NU in pts with active CGN (II and III group) compared to I group and control. Furthermore,
NU in NS was greatly higher than in pts with lower PU and depends on persistent NS duration (Rs =0,5 p<0,01).
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No preview · Article · Jun 2011 · CKJ: Clinical Kidney Journal
[Show abstract][Hide abstract] ABSTRACT: In December 2008, a 69-year-old Japanese woman was admitted to the Department of Otorhinolaryngology because of hearing impairment due to bilateral exudative otitis media, and was discharged without complete recovery despite conventional treatment. Two weeks later, she was readmitted for worsened deafness, numbness, gait disturbance, and general fatigue. She was referred to our department for general investigation. On admission, laboratory examination revealed severe inflammatory signs and active nephritic urinary sediments. Cranial computed tomography (CT) revealed progressive exudative otitis media and sinusitis. Initially, Wegener's granulomatosis was suspected. Nasal cavity biopsy, however, showed no granuloma formation or vasculitis. Serology revealed high titer of myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA), suggestive of microscopic polyangitis (MPA). However, contrast CT identified stenosis of a celiac artery, and renal biopsy showed tubulointerstitial changes with minor glomerular abnormalities. Therefore, polyarteritis nodosa (PAN) was suspected and treatment with intravenous methylprednisolone was initiated. However, a lacunar infarct developed followed by cerebral hemorrhage, and the patient died 19 days after readmission. Autopsy revealed fibrinoid necrosis, neutrophilic infiltration, and giant cell reaction in small to medium-sized arteries in multiple organs. These findings led to diagnosis of systemic vasculitis anatomically compatible with PAN. This was a rare case of a patient with MPO-ANCA-positive PAN who may have developed bilateral exudative otitis media and hearing loss as the initial manifestation of PAN.
No preview · Article · May 2011 · Clinical and Experimental Nephrology
[Show abstract][Hide abstract] ABSTRACT: Background: C. E. R. A. (Continuous Erythropoietin Receptor Activator) is an innovative erythropoiesis stimulating agent (ESA) with unique activity against erythropoietin receptor, and shows a significantly prolonged half-life after the administration. In the present study we evaluated the efficacy and safety profiles of subcutaneous (SC) or intravenous (IV) C. E. R. A. dosing once every 4 weeks (Q4W) in Japanese patients chronic kidney disease (CKD) not on dialysis previously treated with recombinant human erythropoietin (rHuEPO). Methods: CKD patients (n = 101) not on dialysis were assigned to 100 μg (n = 78) or 150 μg (n = 23) of C. E. R. A. by depending on previous rHuEPO doses of under 4500 IU/wk or over 4500 IU/wk, respectively. C. E. R. A. was administered Q4W via either SC (n = 70) or IV (n = 31) routes based on doctor's decision. After 8 weeks in switching period, the doses of C. E. R. A. Q4W were adjusted from 25 to 400 μg to maintain Hb levels of 11-13 g/dL (10-12 g/dL, in the patients with any histories or complications of cardiovascular diseases) as a maintenance period for the following 40 weeks. Primary endpoint was the percentage of patients whose mean Hb levels were within the 11-13 g/dL during 18-24 weeks. Results: The percentages of patients whose mean Hb levels maintain within each target Hb of 11-13 g/dL and 10-12 g/dL during 18-24 weeks were 79.2% and 100%, respectively. No significant differences in the maintenance rate were found between SC and IV route for 48 weeks. The mean (SD) slope of regression line of Hb levels were 0.116 (0.148) g/dL/week after switching from rHuEPO to C. E. R. A. administration. This parameter was also similar between both routes. Adverse event profiles were similar to those reported in rHuEPO and no antibodies against C. E. R. A. were detected in any patients examined. Conclusions: C. E. R. A. could safely switch from rHuEPO by dosing Q4W, successfully maintain target Hb levels of 11-13 g/dL by dose adjustment and is generally well tolerated in Japanese patients with CKD not on dialysis.
[Show abstract][Hide abstract] ABSTRACT: Background: C. E. R. A. (Continuous Erythropoietin Receptor Activator) is an innovative erythropoiesis stimulating agent (ESA) with unique activity toward erythropoietin receptor, and results in showing significantly prolonged half-life. These studies were planned to evaluate the appropriate dose of C. E. R. A. administered either SC or IV once every 2 weeks (Q2W) to correct renal anemia in Japanese CKD patients not on dialysis. Methods: C. E. R. A. was administered SC (77 patients) or IV (57 patients) at three dose levels of 25, 50 or 75 μg Q2W to attain the Hb level of 12 g/dL (correction period) for patients with Hb levels of < 10 g/dL. Once this Hb level had been attained, C. E. R. A. was administered Q4W at the dose levels ranging from 15 to 300 μg (SC) or 25 to 300 μg (IV) to maintain Hb levels within 11-13g/dL (maintenance period). The total observation period in these studies was 48-50 weeks. Primary endpoint is the slope of the Hb level/time curve (g/dL/week). Secondary endpoints are the percentage of patients who achieved the target Hb level of 12 g/dL and the time taken to reach target level in correction period, and the percentage of patients to maintain the target Hb levels of 11-13 g/dL in maintenance period. Results: Mean (SD) slopes of the Hb/time curves with SC administration of Q2W C. E. R. A. at each of 25, 50 or 75 μg were 0.100 (0.108), 0.227 (0.137) or 0.303 (0.159) g/dL/week, and those with IV were 0.129 (0.118), 0.352 (0.219) or 0.412 (0.174) g/dL/week (IV), respectively, which were similar between SC and IV route at the same dose. At each dose of 25, 50 or 75 μg, the percentages of patients achieving the Hb level of 12 g/dL were 75.0, 92.0 or 84.6% (SC), 84.2, 95.0 or 100% (IV), respectively, and the time to achieve Hb target was 140, 112 or 84 days (SC) and 112, 70 or 55.5 days (IV), in which both endpoints found to be dose-related. The percentages of the patients maintained Hb target levels (11-13 g/dL) after 24 week and 48 weeks were 81.1% and 72.7% (SC) and 73.3% and 85.0% (IV), respectively. Conclusions: These studies have demonstrated that a dose of C. E. R. A. Q2W as low as 25 μg, provides a smooth and steady increase in Hb levels in Japanese patients with CKD not on dialysis, regardless of administration route. Furthermore, administration of C. E. R. A. Q4W successfully maintained target Hb levels in this patient population.
[Show abstract][Hide abstract] ABSTRACT: In 2003, a 64-year-old woman was diagnosed with mixed connective tissue disease and treated with oral prednisolone (30 mg/day). The prednisolone dose was gradually decreased, and a dose of 5 mg/day had been maintained since 2004. In 2009, she gradually developed vision loss, malaise, anorexia, and throat pain due to hydrodipsia. She was noted to have iritis and vitreous opacity by an ophthalmologist, and was referred for further evaluation. Fine rales were audible throughout the entire lung field, and chest CT showed diffuse small nodules that were more prominent on the upper and middle lobes, and swelling of the mediastinal and hilar lymph nodes. Transbronchial lung biopsy showed many epithelioid granulomas with multinuclear giant cells, compatible with sarcoidosis. Polyuria was identified as a cause of hydrodipsia and a diagnosis of partial central diabetes insipidus was made. High-dose prednisolone (40 mg/day) together with intranasal administration of desmopressin resulted in improvement of all of her clinical symptoms. MCTD followed by sarcoidosis is rare. Furthermore, this is the first reported case of MCTD complicated by sarcoidosis and central diabetes insipidus.
No preview · Article · Jan 2011 · Nippon Jinzo Gakkai shi
[Show abstract][Hide abstract] ABSTRACT: A 76-year-old man developed fever and appetite loss, and then was referred to our hospital because of rapidly progressive renal insufficiency; his serum creatinine increased from 1.2 to 5.9 mg/dl within 1 month. On admission, his blood pressure was 166/92 mmHg, and laboratory findings showed signs of inflammation, anemia, proteinuria, and hematuria. Chest computed tomography (CT) suggested interstitial pneumonia, while a renal biopsy revealed that small arteries and arterioles were affected, and there was pauci-immune glomerulonephritis with cellular and fibrocellular crescents. In addition, an increased myeloperoxidase antineutrophil cytoplasmic antibody titer confirmed microscopic polyangiitis. Treatment with oral prednisolone was initiated and seemed to successfully resolve the vasculitis activity. On the 11th day of admission, a calcium channel blocker, azelnidipine, was added to treat hypertension. Two days later, the patient developed abdominal distension, and abdominal CT showed massive ascites. The ascitic fluid was a milky white transudate with a normal leukocyte count. Neither clinical manifestations nor laboratory findings suggestive of liver cirrhosis, malignancy, infectious peritonitis, or bowel perforation were observed. On the 18th day of admission, azelnidipine was discontinued in view of reports of calcium channel blocker-induced chyloperitoneum in patients undergoing peritoneal dialysis. Immediately, the abdominal distension disappeared, and the ascites appeared to decrease. Azelnidipine appears to have been responsible for the chyloperitoneum. Since a few cases of secondary vasculitis developing chyloperitoneum have been previously reported, vasculitis may have played a role in the development of chyloperitoneum.
No preview · Article · Oct 2010 · Clinical and Experimental Nephrology
[Show abstract][Hide abstract] ABSTRACT: Multiple community-based cohort studies of mainly middle-aged and elderly populations have shown that cigarette smoking is a risk factor for chronic kidney disease. However, little information is available about an effect of cigarette smoking on progression of primary kidney diseases, including immunoglobulin A (IgA) nephropathy.
Retrospective cohort study.
971 of 1,001 patients with a diagnosis of IgA nephropathy in 3 major nephrology centers in Osaka, Japan, between 1992 and 2005 who enrolled in the Study of Outcome and Practice Pattern of IgA Nephropathy (STOP-IgAN).
Smoking status and number of cigarettes smoked at the time of diagnosis using kidney biopsy. Dose-dependent associations between cigarette smoking and outcomes were assessed in multivariate Cox proportional hazards models. Significantly different clinical characteristics between non-/past and current smokers were controlled for using propensity score-based adjustment, stratification, and matching.
50% increase in serum creatinine level as primary outcome. A composite outcome of a 100% increase in serum creatinine level or end-stage renal disease (ESRD) and ESRD alone as secondary outcomes.
During the median 5.8 years (interquartile range, 2.6-10.2) of the observational period, 117 participants progressed to a 50% increase in serum creatinine level and 47 advanced to ESRD. Multivariate Cox proportional hazards models identified current smokers (HR, 2.03 [95% CI, 1.33-3.10] for primary outcome) and number of cigarettes at kidney biopsy (HR, 1.21 [95% CI, 1.06-1.39] per 10 cigarettes per day) as significant predictors of outcomes. Propensity score-based models confirmed these results. Tests for interaction showed that the association of current smoking with adverse outcomes was stronger in those with lower compared with higher estimated glomerular filtration rates.
Baseline smoking status was not verified using biochemical tests. Smoking status during the observational period was unavailable.
Cigarette smoking, in a dose-dependent manner, was identified as a key prognostic factor in IgA nephropathy. Smoking cessation should be encouraged as part of the treatment for IgA nephropathy.
No preview · Article · Aug 2010 · American Journal of Kidney Diseases