Renal Failure Of Unknown Etiology Research Articles

Usefulness of Tolvaptan for the Postoperative Control After Kidney Transplantation in a Patient With Cardiac Hypofunction: A Case Report

Kidney transplantation in patients with cardiac hypofunction is challenging. Even if the surgery is successfully performed, these patients may suffer from low output cardiac function. We report the case of a patient with severe cardiac hypofunction who developed heart failure (HF) complicated with low output cardiac function, which markedly improved after the administration of tolvaptan, after successful living kidney transplantation. A 70-year-old man was diagnosed with chronic renal failure of unknown etiology 4 years previously, for which hemodialysis was initiated. Three years previously, percutaneous coronary intervention was performed because of acute myocardial infarction. Since then, he had been hospitalized for the control of HF. He was referred to our department because he wished to undergo kidney transplantation. We decided to perform the transplantation after determining that he could tolerate the operation. On postoperative day 6, however, his urine discharge volume suddenly declined, leading to an increase in his body weight despite administration of an adequate amount of furosemide, and he was diagnosed with acute HF. The patient's condition markedly improved after the introduction of tolvaptan. To our knowledge, this is the first report of improvement in postoperative HF after tolvaptan administration. Although numerous kidney transplantations have been performed at our institute, it is relatively rare that we decide to operate in a patient with severe cardiac hypofunction.

Unusual stomach and duodenum mucosal changes in a kidney transplant patient after long-term peritoneal dialysis

A 33-year-old man presented with a 2-month history of dyspepsia and nausea. He had undergone kidney transplantation (KT) 22 years ago due to renal failure of unknown aetiology. He underwent...

Massive Ascites of Unknown Origin: A Case Report

Ascites is the excessive accumulation of fluid in the peritoneal cavity and predominantly caused by liver cirrhosis, cancers, or heart failure. In this study, a 31-year-old woman with chronic renal failure of unknown etiology treated with hemodialysis and peritoneal dialysis was often hospitalized because of ascites, which appeared 4 years after the second kidney transplantation. The patient was regularly (every 2-3 weeks) treated with paracentesis. Peritoneal fluid tested negative for bacterial (including atypical) and fungal infections and tuberculosis. Doppler ultrasound and liver FibroScan did not show any irregularities. Computed tomography (CT) revealed an enlarged left ovary. A high level of CA 125 was found. The second diagnostic laparoscopy revealed no changes in the ovaries, and there were no tumor cells. Diagnostics were extended, but no deviations were revealed. Suspecting drug etiology, mycophenolic acid was discontinued, bringing no improvement. Diagnostic tests caused suspicion of Meigs’ syndrome; therefore, oophorectomy of left ovary was conducted, revealing numerous small cysts filled with serous fluid, without tumor cells in the ovary or peritoneal fluid. Despite the procedure performed, ascites was recurrent. Five month later, ascites spontaneously stopped growing. Paracentesis to decompress ascites was no longer required. There were 9 paracenteses performed from oophorectomy (the latest on May 23, 2019). The need for repetitive paracentesis, significantly reducing the patient’s quality of life, required diagnosis for casuistic diseases. The described case is atypical because of the confusing etiology of ascites and its spontaneous cessation. Despite numerous examinations and recession of ascites, the cause of the problem is not entirely clear.

Restoration of renal anemia following therapy with etelcalcetide for refractory secondary hyperparathyroidism: a case report with mini-review

The patient was a 72-year-old woman who had been under dialysis for a long time to chronic renal failure of unknown etiology. Her dialysis vintage was 22 years. She was under treatment with cinacalcet for secondary hyperparathyroidism (2HPT). However, cinacalcet was withdrawn because she presented digestive complications. In March 2017, treatment with etelcalcetide, a novel intravenous calcimimetic, became possible. On April 10, 2017, her intact parathyroid hormone (PTH) level was 1150 pg/mL, and etelcalcetide 5 mg was administrated three times per week after dialysis. After 6 months, her intact PTH (iPTH) level was 283 pg/mL and her hemoglobin (Hb) level was 12.9 g/dL though she was not administered erythropoietin-stimulating agent (ESA). She had three detectable parathyroid glands. Conventionally, her parathyroid glands should have been removed; however, as her parathyroid hormone level decreased, this procedure was not required. In this patient, etelcalcetide improved severe 2HPT and renal anemia.

Fetal Hypothyroidism

ABSTRACT This case report illustrates the prenatal diagnosis of fetal hypothyroidism in a nulliparous 31-year-old woman with a history of four previous cesarean sections. She was presented with chronic renal failure of unknown etiology and had been on dialysis for 3 years along with a subclinical hypothyroidism. At 21.4 weeks of gestation, color Doppler revealed a fetus with symmetrical solid mass in the anterior cervical region with little vascularization compatible with fetal goiter. Aminotic fluid was also increased for gestational age. At 25 weeks of gestation, due to maternal respiratory distress, an amniodrainage was performed. From the same sample, thyroid-stimulating hormone (TSH) was determined yielding 1.3 mIU/mL and 0.1 ng/dL for free T4. At 27 weeks of gestation, membrane rupture occurred. Chorioamniotis was suspected and cesarean section was performed extracting a live 1060 gm female newborn. The newborn was 29 weeks of age by Capurro test and Apgar score was 7/08. On physical examination, a 2 to 3 cm symmetrical tumor was found in cervical region. Admitted to neonatal intensive care unit for mechanical respiratory support, four ampoules of T4 were given, achieving complete regression of thyroid gland size at 15 days of life. At 34 days of age, nosocomial infection, Klepsiella neumonie, was confirmed and death occurred at 40 days of life. Isolated fetal hypothyroidism is rare. Ultrasound evaluation allows the identification of compensatory growth of the thyroid, showing a hypoechoic solid image. In extreme cases, it may cause esophageal obstruction and polyhydramnios as well as cervical hyperextension and dystocia during labor. How to cite this article Ruoti Cosp M, Gruhn E, Ontano M, Calabrese E, Mendoza L. Fetal Hypothyroidism. Donald School J Ultrasound Obstet Gynecol 2016;10(3):326-329.

Pelvic Lipomatosis Causing Renal Failure.

Observation A 34-year-old Cape Verdean male with terminal chronic renal failure of unknown etiology since two years was referred to the urology department for a second opinion after finding an infiltrative mass on routine renal ultrasound. The patient was nonobese and otherwise asymptomatic. Clinical examination revealed a large palpable mass in the pelvis. Laboratory examination showed highly elevated blood levels of creatinine (10.98 mg/dL (nl: 0.67– 1.17 mg/dL)) and urea (123 mg/dL (nl: 16.6–48.5 mg/dL)). We decided to perform a contrast-enhanced CT scan for further evaluation of the mass. The application of contrast agents in this patient with renal failure was permitted because these contrast agents were washed out by dialysis afterwards. The CT examination showed a large pelvic infiltration by fatty tissue with typical attenuation (–40 to –100 Hounsfield units) (Figure 1, arrows) and bilateral small kidneys with atrophy and hydroureteronephrosis. The fatty tissue caused extrinsic compression of the bladder (Figures 1, 2, and 3, white star) and rectum (Figure 2, black star) resulting in morphological deformity. The findings led to the diagnosis of pelvic lipomatosis with secondary chronic renal failure.

Biopsy-proven renal disease in Ile-Ife, Nigeria: A histopathologic review.

Although various patterns of renal diseases have been reported from different renal biopsy registries worldwide, data from Nigeria remain scanty. A 10-year retrospective review of renal biopsies was conducted in our tertiary health care facility. All cases were reclassified based on their light microscopic features after the application of standard histochemical stains. A total of 165 cases were reviewed with a male:female ratio of 1.8:1 and a mean age of 15.4 ± 12.0 years. About 69.7% of the cases were below the age of 16 years, while only 2.4% were older than 50 years. The most common indications for biopsy were nephrotic syndrome (72.1%) and acute renal failure of unknown etiology (11.5%). Overall, glomerulonephritis (80%) was the most common histologic category and occurred only in individuals younger than 50 years old. Minimal change disease (22.9%) and membranoproliferative glomerulonephritis (21.9%) were the most common varieties in children, while membranous glomerulonephritis (30.6%) and focal segmental glomerulosclerosis (27.8%) were the commonest among the adult population. The initial histologic diagnosis was revised in 18 cases while a diagnosis was arrived at in seven cases initially adjudged as inadequate for assessment. This study showed that renal biopsy was predominantly performed in children and adolescents. Although glomerulonephritis was the predominant disease, the predominant histologic patterns varied with the patient age. Despite the scarcity of advanced diagnostic tools in resource-poor environments, routine use of histochemical stains is helpful in the evaluation of renal biopsies.

Kidney biopsy in the Military Hospital of Morocco: Complications and histopathological findings.

Epidemiological studies on renal biopsies are necessary to establish the pattern and trends of renal diseases in a particular geographic area. In this retrospective study, we reviewed the medical records, histopathology findings and complications of renal biopsy in a region of Morocco. We studied a total of 130 native kidney biopsies taken between January 2008 and January 2012. All biopsies were examined by light microscopy and immunofluorescence microscopy. There were 86 males (66.2%) and 44 females (33.8%), with a mean patient age of 44.82 ± 17.86 (range 8-86) years. The most common indications of renal biopsy was nephritic syndrome (61.5%), followed by renal failure of unknown etiology (30.8%) and asymptomatic urinary abnormalities (5.4%). Primary glomerulonephritis (PGN) was found in 60 (46.2%) of the patients. Among the PGN cases, the most common one was membranous nephropathy (MN) (12.3%). Secondary glomerular disease (SGN) accounted for 48 (36.9%) of the cases. The most common SGN was lupus nephritis (LN) (10%). Tubulointerstitial disease [13 (10%)] and vascular disease [9 (6.9%)] were less common. The most common complications of the procedure were pain at the biopsy site in 12.3%, gross hematuria in 12.3%, perirenal hematoma in 7.7% and hematuria requiring nephrectomy in 0.8% of the patients. The most common indication for renal biopsy was nephrotic syndrome, MN was the most frequent PGN and LN was the most frequent SGN in our report.

Uncovering a Covert Enemy: Systemic AL Amyloidosis Associated With Intravascular Diffuse Large B-Cell Lymphoma

IntroductionAL amyloidosis, precipitated by the deposition of immunoglobulin light chains in various organs, is generally secondary to the benign or malignant proliferation of clonal plasma cells. Reviews from large amyloid centers show that approximately 2-3% of AL amyloidosis is associated with an underlying non-Hodgkin lymphoma (NHL). Of the non-Hodgkin lymphomas, lymphoplasmacytic lymphoma (LPL) is most commonly associated with systemic AL amyloidosis. Systemic NHL-associated AL amyloidosis tends to feature a high level of IgM paraproteinemia and a predilection for several different organ tropisms. Here we report the unique case of a 71-year-old male with an insidious course of hypotension and worsening renal failure of unknown etiology, who was ultimately diagnosed post-mortem with AL amyloidosis associated with an intravascular large B-cell lymphoma (IVLBCL). Case DescriptionA 71-year-old white male presented to the hospital after a fall. His medical history included type II diabetes, spinal stenosis, and a 30-pack-year smoking history. Over the past few months, he noticed a steady decline in functional status. On admission, he was hypotensive with bilateral 2+ pitting lower extremity edema. Laboratory evaluation revealed leukocytosis, anemia, and acute kidney injury with elevated creatinine and blood urea nitrogen. Urinalysis showed 30 mg/dL of protein, along with the presence of white and red blood cells and moderate bacteria. Enterococcus was subsequently cultured from the urine. A chest X-ray revealed small bilateral effusions. The patient was treated for urosepsis with antibiotics and vasopressor support in the intensive care unit. His hypotension improved initially, but over the next 3 weeks his course was complicated by recurrent episodes of hypotension, altered mental status, and worsening renal function. An exhaustive laboratory workup was negative for infection, and a transthoracic echocardiogram showed no significant findings. Further evaluation included a normal cortisol stimulation test and TSH level, but a serum protein electrophoresis showed 0.13 g/dL of monoclonal IgM lambda immunoglobulin (Figure A) with a urine protein electrophoresis showing a low level of lambda free light chains. Abdominal fat pad biopsy was negative for amyloid. The patient's condition continued to deteriorate, and he died on hospital day 29 with no clear diagnosis. Post-mortem examination revealed a CD20+, lambda restricted intravascular diffuse large B-cell lymphoma involving the kidneys, prostate, a cecal polyp, and lungs (Figure B). Sections of lung tissue revealed scattered areas of extracellular eosinophilic material that stained brick red with Congo red staining (Figure C) and displayed apple green birefringence under polarized light (Figure D). Similar findings in the heart and kidneys were consistent with systemic amyloidosis. Bone marrow analysis showed normal trilineage hematopoiesis with no evidence for involvement by lymphoma or plasma cell neoplasm. [Display omitted] DiscussionThis case exhibits the first reported association of two rare and diagnostically challenging disorders: intravascular large B-cell lymphoma (IVLBCL) and systemic AL amyloidosis. Patients with IVLBCL often present with nonspecific symptoms secondary to small vessel occlusion and subacute deterioration in performance status, as was the case with our patient. Our patient's underlying intravascular NHL with systemic AL amyloidosis proved difficult to diagnose with his low-level IgM paraproteinemia serving as the only clue to the cause of his illness. The negative fat pad biopsy added to the diagnostic difficulty, but was not surprising due to the low sensitivity of the test in detecting systemic amyloidosis. In addition, diagnosing intravascular lymphoma is difficult as patients present with nonspecific findings and often without lymphadenopathy, making post-mortem diagnosis common. Thus, this case sets a precedent for intravascular diffuse large B-cell lymphoma provoking the onset of systemic AL amyloidosis – a covert, morbid, and diagnostically challenging combination. Disclosures:No relevant conflicts of interest to declare.

LEARNING FROM IMAGES Perinephric Lymphoma

Renal imaging plays a valuable role in determining the etiology of renal failure due to intrinsic or extrinsic obstruction of the urinary tract. We report an interesting finding encountered on routine renal imaging in an asymptomatic elderly man who presented with renal failure of unknown etiology. Routine renal ultrasound imaging revealed a large mass around the kidney, which on magnetic resonance imaging of the abdomen was characterized as a retroperitoneal mass that was soft and pliable that surrounded but did not compress or obstruct the retroperitoneal vessels (Fig. 1). However, it caused partial

Primary Amyloid Goiter and Review of Imaging Characteristics

Clinically symptomatic amyloid goiter is extremely rare. We report the case of a 76-year-old male patient under the care of the nephrologists with end stage renal failure of unknown aetiology. Concurrent investigation for a dysphagia causing goiter allowed primary diagnosis of amyloid by targeted fine needle aspiration (FNA) under ultrasound guidance. The imaging features are reviewed across multimodalities. This report highlights the usefulness of FNA in establishing diagnosis and the importance of maintaining clinical suspicion in patients with a concomitant history of a chronic inflammatory process.

Glomerular diseases in the Military Hospital of Morocco: Review of a single centre renal biopsy database on adults

Epidemiological studies provide useful information for clinical practice and investigations. This report aimed to determine glomerular diseases frequencies in a region of Morocco. All native renal biopsies (January 2000 to December 2007) on adults were reviewed, but only glomerular diseases were analyzed. The diagnosis of each case was based on histological, immunopathological and clinical features. We have performed 171 renal biopsies in 161 patients (101 males and 60 females), the mean age was (range) 40.4 ±15 years (16–72). Clinical indications that lead to renal biopsy were: nephrotic syndrome (60.3%), renal failure of unknown aetiology (31.6%), asymptomatic urinary abnormalities (6.2%) and nephritic syndrome(1.9%). Primary glomerular diseases were reported in 84 patients (52%). The most common histological lesion was minimal change disease (26%). Idiopathic membranous glomerulopathy was the second most common lesion (23%) followed by membranoproliferative glomerulonephritis (17%), IgA nephropathy (12%), focal and segmental glomerulosclerosis (9.4%) and crescentic glomerulonephritis (6%). Secondary glomerular diseases were reported in 53 patients (33%). Lupus nephritis was the secondary glomerular disease most frequent (45%) followed by amyloïdosis (19%), diabetic nephropathy (15%), and Good pasture's syndrome (7.6%). The most common complications of the procedure were pain at biopsy site in 4%, gross hematuria in 11.1%, perirenal hematoma in 5% and hematuria requiring nephrectomy in 0.6% patients. Minimal change disease was the most frequent primary glomerulopathy and lupus nephritis was the most frequent secondary glomerulopathy in our group. The reasons for these findings are unclear. This information is an important contribution to the understanding the prevalence of renal diseases in North Africa.

Forgotten indwelling stent in a transplanted kidney: a case report

• IntroductionForgotten or retained ureteric stents are a well-recognised phenomenon with the potential to cause a range of complications, the most dangerous of which is obstructive nephropathy. These risks are potentially devastating when the patient has a single functioning transplanted kidney. Here we describe the case of a renal transplantation patient with a forgotten ureteric stent of 10 years, who presented with irritative bladder symptoms and was successfully managed using a multimodal urological approach with specialist advice on antibiotic prophylaxis. To the best of our knowledge this is the longest documented time period for a forgotten ureteric stent in a transplantation patient and is unusual in that obstructive nephropathy did not occur.• Case presentationA 32-year-old man with a history of end stage renal failure of unknown aetiology received a cadaveric renal transplant in 1995. An indwelling JJ stent was placed at the time of transplant to protect the vesicoureteric anastomosis. The patient made an unremarkable recovery and initially attended regular follow up in the renal transplant clinic. He was subsequently lost to transplant clinic follow up. In 2005 at the age of 42 he was referred to a nephrologist with irritative bladder symptoms. Renal tract imaging with ultrasound and a plain film demonstrated a retained encrusted ureteric stent.• ConclusionThe removal of a retained encrusted ureteric stent always provides a urological challenge. This case demonstrates that multimodal treatment involving a combination of endourological and percutaneous techniques can be employed with success even when the patient has a heavily encrusted stent for a single functioning transplanted kidney. Involvement of a microbiologist to advise on prophylactic antibiotics is deemed especially useful, as the immunosuppressed transplant patient is at particular risk of sepsis secondary to bacteraemia as a result of the endoscopic manipulation of the colonised encrusted stent. This case also provides further evidence to highlight the potential benefits of a stent registry.

Kidney biopsy in west of Iran: Complications and histopathological findings.

In this retrospective study, we reviewed the medical records and histopathology findings of 135 patients who underwent renal biopsies at two special hospitals affiliated to Kermanshah medical university during a six-year period (2003-2007). All were performed using Tru-Cut needle under ultrasound guidance. Twenty four specimens were unsatisfactory. There were 38 males (34.2%) and 73 females (65.7%) in 111 patients with adequate specimens (each specimen has more than 5 glomeruli); the mean age was 16.5 years (range 2-64 years). Side effects of the renal biopsies included pain at the site of biopsy in 2 (2.7%), gross hematuria in 1 (0.9%). Nephrotic syndrome was the most common indication for biopsy followed by acute renal failure of unknown etiology and nephritic syndrome. Primary glomerular disease was reported in 78 patients (70.2%) and also secondary glomerular disease in 33 patients (29.7%). Among the primary glomerulonephritis disease, minimal change disease and membranous glomerulonephritis were the commonest findings in children below the age of 16 years. Minimal change disease ranked first in adults whole membranous glomerular disease and focal segmental glomerulosclerosis were more common in the elderly. In all patients lupus glomerular disease was the commonest secondary glomerular disease. We conclude that study on renal biopsy makes final diagnosis which is associated with an acceptably low rate of complications in our practice, and in all, the patterns of renal histology in our study vary slightly from those reported from other countries.

Outbreak of acute renal failure in Panama in 2006: a case-control study

In September 2006, a Panamanian physician reported an unusual number of patients with unexplained acute renal failure frequently accompanied by severe neurological dysfunction. Twelve (57%) of 21 patients had died of the illness. This paper describes the investigation into the cause of the illness and the source of the outbreak. Case-control and laboratory investigations were implemented. Case patients (with acute renal failure of unknown etiology and serum creatinine > 2 mg/dl) were individually matched to hospitalized controls for age (+/- 5 years), sex and admission date (< 2 days before the case patient). Questionnaire and biological data were collected. The main outcome measure was the odds of ingesting prescription cough syrup in cases and controls. Forty-two case patients and 140 control patients participated. The median age of cases was 68 years (range: 25-91 years); 64% were male. After controlling for pre-existing hypertension and renal disease and the use of angiotensin-converting enzyme inhibitors, a significant association was found between ingestion of prescription cough syrup and illness onset (adjusted odds ratio: 31.0, 95% confidence interval: 6.93-138). Laboratory analyses confirmed the presence of diethylene glycol (DEG) in biological samples from case patients, 8% DEG contamination in cough syrup samples and 22% contamination in the glycerin used to prepare the cough syrup. The source of the outbreak was DEG-contaminated cough syrup. This investigation led to the recall of approximately 60 000 bottles of contaminated cough syrup, widespread screening of potentially exposed consumers and treatment of over 100 affected patients.

Leukoerythroblastic anemia due to oxalosis with extensive bone marrow involvement

A 27-year-old North African immigrant man was admitted because of bone pain and discomfort. Since he arrived to Spain, 2 years before, he presented bilateral nephrocalcinosis in an abdomen X-ray, and a progressive renal failure of unknown etiology that required hemodialysis and a renal transplant. The post-transplant course was complicated and required transplantectomy and hemodyalisis. The histological study revealed plenty of oxalate crystal deposition and the diagnosis of oxalosis was made. Amount of oxalate was determined to be 306 lmol/L and glycolate was 73.6 lmol/L in hemodialytic filtrate, consistent with diagnosis of primary hyperoxaluria. Two years after transplantectomy, leukopenia and anemia were detected. The physical examination was normal. The main hematological parameters were: hemoglobin 73 g/L, reticulocytes 71.2 3 10/L, white blood cell count 3.3 3 10/L (59% neutrophils, 34% lymphocytes, 6% monocytes, 1% eosinophils), and platelet count 194 3 10/L. The serum levels of sodium was 139 mmol/L, potassium 6 mmol/L, urea 25.9 mmol/L, and creatinine 731 lmol/L. A peripheralblood smear showed anisocytosis with numerous teardrop forms and a leucoerythroblastic anemia, that led to a bone marrow aspirate and trephine biopsy. The bone marrow aspirate resulted dry tap and only scarce material was obtained from the needle, showing some giant cells and few crystals (Image 1). The trephine biopsy showed an extensive deposition of polarizable oxalate crystals with moderate fibrosis and abundant foreign body giant cells without recognizable residual hematopoiesis (Image 2). The patient underwent a combined liver and kidney transplantation. He presented a hyperacute renal rejection and died 2months later because of splenic and portal vein thrombosis. Primary hiperoxaluria is a very infrequent metabolic disorder secondary to the lack of alanineglioxylate aminotransferase, which rapidly develops to renal failure. However, it has been reported to be more frequent among people from Canary Islands and north of Africa.

Hemorrhagic fever with renal syndrome (HFRS, Korean hemorrhagic fever)

Sirs, Recently we experienced a case of hemorrhagic fever with renal syndrome (HFRS) and normal findings of kidney magnetic resonance imaging (MRI). A Korean girl aged 14 years 9 months was referred to Gyeongsang National University Children’s Hospital with symptoms of fever and hypotension. Three days prior to referral she had developed fever. These symptoms continued for 2 days and were then followed by abdominal pain, nausea, vomiting, diarrhoea and back pain. At this time, an abrupt decrease of blood pressure (80/40 mmHg) occurred. On presentation, she looked acutely ill. Her blood pressure was 120/ 90 mmHg and temperature 39°C. Except for diffuse tenderness and suspicious rebound tenderness on the abdomen, other findings on physical examination were normal. Initial laboratory values were: haemoglobin level 12.9 g/dl, white blood cell count (WBC) 18.1×10/l, platelet count 250×10/l blood urea nitrogen 17 mg/dl and serum creatinine 1.5 mg/dl. The blood urea nitrogen/ creatinine (BUN/Cr) slowly rose to 47/5.1 for 5 days without decrease of urine output. Fever declined slowly to 36.5°C for 5 days. On the sixth hospital day, urinary output was over 5,000 ml/day and MRI was checked, which was normal. At discharge on the 12th hospital day, serum Cr was 0.8 mg/dl and urinary output was normalised. The indirect immunofluorescent test for Hantaan virus performed on the second and 12th hospital days was at 1:2,560 and 1:1280 dilutions, respectively. Discrimination between Hantaan and Seoul viruses was done by plaque reduction neutralisation tests. She was diagnosed with HFRS caused by Hantaan virus [1]. Hemorrhagic fever by Hantaan virus accounts for 75% of Korean hemorrhagic fever, and compared with that caused by the Seoul virus has more severe clinical symptoms. It can cause complications, including hypopituitarism, and has a recorded death rate of up to 2∼7%. Infection by Seoul virus accounts for 10∼25% of all hemorrhagic fever and is mild in severity, often completely cured without complications and less than a 1% death rate. With Seoul virus infection, there is a tendency for the bleeding trait or the main symptom, kidney disorder, is milder than with Hantaan virus infection while liver function disorder is more severe. Haemoglobin counts suddenly increase in the hypotension stage, more than a half of which are above 50% in hematocrit [2]. Characteristic mucocutaneous manifestations and usual findings of hemoconcentration, thrombocytopenia, elevated liver enzymes and lactic acid dehydrogenase (LDH) of Korean hemorrhagic fever were not found in this patient. Kim et al. reported a low signal intensity along the outer renal medulla on the T2-weighted MRI image in all patients in oliguric or diuretic phase [3]. What is truly related with this form of Korean hemorrhagic fever due to Hantaan virus? I am not sure, but the economic growth, good health hygiene and strong host defence could be the answer. Patients with acute renal failure of unknown aetiology with ill-defined febrile or gastrointestinal disease need specific serological tests for Korean hemorrhagic fever. Pediatr Nephrol (2007) 22:156–157 DOI 10.1007/s00467-006-0234-z

Successful Use of Rituximab for Cutaneous Vasculitis

A 23-year-old woman presented with recalcitrant purpuric macules and papules on her forearms, legs, and abdomen. At the age of 13 years, she presented to an outside facility with renal failure of unknown etiology requiring hemodialysis followed by living-related kidney transplantation at the age of 14 years. Renal biopsies had not been performed. The patient did well until 1 year later, when she experienced an upper respiratory illness followed by a new petechial rash on her bilateral lower extremities that was thought to be clinically consistent with HenochSchonlein purpura. Although her initial rash resolved without additional therapy, she continued to experience intermittent purpuric eruptions that were associated with abdominal pain, arthritis, and arthralgia. Over the next several years, her rash became persistent, progressed to involve her forearms and abdomen, and was accompanied by hematuria and increases in serum creatinine levels. She had no pulmonary or neurologic symptoms. Her condition did not respond to trials of prednisone (up to 40 mg/d), cyclosporine (100 mg twice daily), azathioprine (100 mg/d), and etanercept (50 mg twice weekly). Mycophenolate mofetil was not tolerated owing to angioedema. When the patient first presented to our clinic in February 2004, she had purpuric macules and papules over her forearms, thighs (Figure1), legs, and abdomen. Medications at that time included prednisone (10 mg/d), cyclosporine (100 mg twice daily), azathioprine (100 mg/d), lisinopril, atenolol, and erythropoietin. A skin biopsy specimen showed leukocytoclastic vasculitis with perivascular C3 deposition but without detectable IgG or IgA on direct immunofluorescence. Subsequent biopsy of her renal allograft showed no evidence of vasculitis or deposition of immunoreactants (data not shown). Significant laboratory test results included the following values: hematocrit, 29% (reference range, 35%-47%); C4, 10.4 mg/dL (reference range, 20-59 mg/dL); C3, 88 mg/dL (reference range, 86-184 mg/dL); rheumatoid factor, 48 IU/mL (reference value, 20 IU/mL); erythrocyte sedimentation rate, 60 mm/h (reference value, 20 mm/h); and creatinine, 1.4 mg/dL (124 μmol/L) (reference value, 1.2 mg/dL [ 106 μmol/L]). Urinalysis revealed microscopic hematuria but no casts. The results of the following laboratory investigations were normal or negative: determination of serum cryoglobulin levels, protein immunofixation electrophoresis, antinuclear antibody and antineutrophil cytoplasmic antibody tests, serologic tests for hepatitis B and C, urinary protein electrophoresis, and stool guaiac tests.

RETROPERITONEAL EFFUSION IN DOGS AND CATS

Although cases of retroperitoneal effusion associated with adrenal gland neoplasia have been reported in the veterinary literature, these clinical reports have been largely anecdotal. To our knowledge, no comprehensive evaluation of the causes or clinical indications of effusion (RPE) in the retroperitoneal space exists. In this retrospective study, we evaluated the causes, presenting signs, clinical findings and outcomes associated with RPE. The records of 23 cats and 44 dogs presenting to the Tufts University School of Veterinary Medicine between 1996 and 2003 and having been identified with RPE were reviewed. The presence of RPE was identified using abdominal ultrasonography. All of the cats and 84% (n=38) of dogs in this study presented through the Emergency Service. Diagnoses for RPE were categorized as follows: (Group 1) 14 dogs and 3 cats with acute renal failure associated with infection; (Group 2) 5 dogs and 6 cats with acute renal failure of unknown etiology; (Group 3) 3 cats with acute renal failure due to urinary tract obstruction; (Group 4) 8 dogs with adrenal gland neoplasia; (Group 5) 7 dogs and 1 cat with non‐adrenal gland neoplasia; (Group 6) 5 dogs and 4 cats with other renal disease, and (Group 7) 5 dogs and 6 cats with RPF due to other causes. The most frequent presenting complaints in all categories except for those in Group 4 included anorexia, lethargy and vomiting. Physical examination findings were very similar for all categories except for those in Group 4 and included abdominal pain, dehydration, mental depression, lethargy and weakness. For those in Group 4, the most common complaints were collapse or marked weakness, anorexia, lethargy, and discomfort. The physical examination findings for dogs in Group 4 also included collapse or marked weakness, and abdominal distension. Percent mortality for dogs was 39% and, for cats, 43%. In each category, the percent mortalities are as follows (euthanized=e, died=d): Group 1: dogs: 14% (e n=1, d n=1), and cats: 33% (e n=1); Group 2: dogs: 100% (e n=4, d n=1) and cats 67% (e n=4).; Group 3: cats: 100% (e n=2, d n=1); Group 4: dogs: 32% (e n=3); Group 5: dogs: 71% (e n=5) and cats: 0%;. Group 6: dogs: 0% and cats: 25% (e n=1), and Group 7: dogs: 40% (e n=2) and cats: 17% (e n=1). Retroperitoneal effusion, regardless of cause, is associated with significant disease. In people, another category of disease associated with RPE is trauma. Although this category is not included in this study, abdominal ultrasonography of trauma victims may identify a veterinary population with RPE.

Ischemic nephropathy: an important cause of renal disease in the elderly.

RAOD is an important cause of progressive renal failure in the elderly population. We can expect to see an increasing incidence of this disease as the population ages. A non-invasive test for detecting this condition with a high degree of sensitivity and specificity has been developed, although the technique is sufficiently difficult that it is currently available in only a few specialized centers. Indications for intervention to preserve renal function are not clear. Application of stenting to renal artery lesions has lead some to advocate treatment of these lesions empirically when they are detected much as is done with coronary artery lesions in patients with ischemic heart disease. Given the present state of knowledge, this is not an unreasonable approach. However, not all lesions progress and their role in causing renal failure is not clear in all cases. Furthermore, intervention can cause worsening of renal failure in some cases and actually precipitate the need for dialysis. Several recommendations are reasonable based on this review. Patients over 50 starting dialysis with renal failure of unknown etiology should be screened for RAOD. Those with bilateral lesions should be offered an intervention. Patients with mild or moderate renal failure of unknown etiology over age 50 should also be screened. Those with bilateral lesions should be offered an intervention with conservative management for those with unilateral lesions. The later group should be monitored on a yearly basis for the development of contralateral lesions or significant bilateral renal atrophy. If either of these eventualities develop, intervention should be offered. These recommendations would have to be considered in the light of the possible need to perform an intervention for the treatment of hypertension.