Cholesterol atheromatous embolism: an increasingly recognized cause of acute renal failure

BACKGROUND.: Cholesterol atheromatous embolism is a systemic disease resultingfrom cholesterol crystal embolization to many organs, includingthe kidney. Vascular surgery, vascular radiology investigationsand anticoagulation have been identified as inciting factors. METHODS.: Fifteen patients with extensive atherosclerosis, presentingwith simultaneous occurrence of acute renal failure and peripheralischaemic changes were diagnosed as having acute renal failuredue to cholesterol atheromatous embolism. RESULTS.: The patients, 12 men and three women, had an average age of65 years. In one patient, spontaneous occurrence of the diseasewas observed. An inciting factor was identified in 14 patients:aortography in 10, aortic surgery in two, and thrombolysis intwo. Clinical course of acute renal failure was quite variable.Four patients required dialysis; 11 were conservatively managed.All patients had concomitant skin lesions, including digitalmottling, cyanosis and gangrene of the toes, and livedo reticularisof the lower limb and abdomen. Eosinophilia was the most commonlaboratory abnormality. The diagnosis of cholesterol atheromatousembolism was confirmed by tissue examination in eight; in threeit was based on the finding of retinal cholesterol emboli; infourpatients it was made on clinical grounds. Seven patientsdied within 36 months. Death was most commonly from cardiaccauses. CONCLUSIONS.: Since the population at risk for cholesterol embolism is growingand the disease is iatrogenic in origin, we should expect todetect cholesterol embolism with greater frequency as causeof acute renal failure in the future.     

Automated assessment of cervical dystonia.

We developed an automated and objective method to measure posture and voluntary movements in patients with cervical dystonia using Fastrack, an electromagnetic system consisting of a stationary transmitter station and four sensors. The junction lines between the sensors attached to the head produced geometrical figures on which the corresponding aspects of the head were superimposed. The head position in the space was reconstructed and observed from axial, sagittal, and coronal planes. Four patients with cervical dystonia and 6 healthy subjects were studied. Each patient was representative of one of the typical patterns of cervical dystonia. The study allowed the authors to collect quantitative data on posture and range of motion of the head. This pilot study demonstrates the efficacy of the Fastrack system to objectively measure the head position in cervical dystonia patients.     

Primary hypothyroidism due to leukemic infiltration of the thyroid gland

We describe a patient with acute B-lymphocyte lymphoblastic leukemia who developed laboratory changes (not detectable free thyroxine, TSH 66 microIU/ml) suggesting severe primary hypothyroidism. Histological examination at autopsy showed massive leukemic infiltration of the thyroid gland: the progressive reduction of thyroid hormone levels with concomitant increase in TSH levels observed over a three-month period from the onset of the hemopathy suggests a cause-effect relationship between leukemic infiltration of the thyroid gland and hypothyroidism.     

Rituximab or Cyclophosphamide in the Treatment of Membranous Nephropathy: The RI-CYCLO Randomized Trial

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A Binational Study of Patient-Initiated Changes to Antiretroviral Therapy Regimen Among HIV-positive Latinos Living in the Mexico–U.S. Border Region

Research is lacking on factors associated with antiretroviral therapy (ART) sub-optimal adherence among U.S. Latinos, who are disproportionately affected by HIV and face substantial health care barriers. We examined self-reported, patient-initiated changes to ART (i.e., made small/major changes from the antiretroviral drugs prescribed) among HIV-positive Latinos. Trained interviewers administered surveys to 230 participants currently on ART in San Diego, U.S. and Tijuana, Mexico. We identified factors independently associated with ART changes. Participants were Spanish-language dominant (86%), mean age of 41 years, male (77%), and born in Mexico (93%). Patient-initiated changes to ART were reported in 43% of participants. Being female, having ≥1 sexual partner (past 3 months), ≤6 years since HIV diagnosis and poor health were associated with increased odds of ART changes. Findings raise concern about sub-optimal adherence among this binational population. Longitudinal studies are needed to further explore adherence barriers and avenues for intervention.     

Evaluation of the resistive index (RI) for the diagnosis of acute renal rejection in renal allografts from the same donor

PURPOSE: To investigate the importance of the resistive index (RI) in the diagnosis of acute renal rejection, compared with the RI of the twin kidney from the same donor, transplanted in two different patients. MATERIAL AND METHODS: From January to December 2000, we studied retrospectively 25 pairs (50 patients) of renal allografts from the same donor considering the RI obtained with by eco color-Doppler ultrasound, daily diuresis and renal function (serum creatinine level) in the first six days following surgery. Improvement of diuresis and renal function after corticosteroid therapy was considered the gold standard for the diagnosis of acute rejection. RESULTS: Medical complications (acute renal rejection) in the first six days were occurred in three cases, two in the first transplanted kidney as first and one in the second; all three cases showed disappearance of the diastolic waveform component. Considering a RI variation >0.15 with respect to the initial value, the sensitivity, specificity and diagnostic accuracy in the Doppler diagnosis of acute rejection were 100%, 97.1% and 97.3% respectively, with a prevalence of 7.8%. There were no statistically significant correlations between the RI variation of the renal transplant and the twin kidney from the same donor. DISCUSSION AND CONCLUSIONS: Doppler ultrasound is an important diagnostic tool in the detection of medical complications in the immediate postoperative period and during renal transplant follow-up. RI analysis, when studied serially and in the right clinical settings, allows an early diagnosis of renal rejection with high sensibility and specificity.     

Direct effect of the correction of acidosis on plasma parathyroid hormone concentrations, calcium and phosphate in hemodialysis patients: a prospective study

BACKGROUND: Metabolic acidosis contributes to renal osteodystrophy and together with hyperphosphatemia, hypocalcemia and altered vitamin D metabolism may result in increased levels of intact parathyroid hormone (iPTH) and metastatic calcifications. However, the impact of the correction of metabolic acidosis on iPTH levels and calcium-phosphate metabolism is still controversial. STUDY DESIGN: The effects of the correction of metabolic acidosis on serum concentrations of iPTH, calcium (Ca), phosphate (PO(4)) and alkaline phosphatase were prospectively studied. Twelve uremic patients on maintenance hemodialysis (HD) for 49 months (median; range 6-243 months) with serum bicarbonate levels < or =20 mmol/l were studied before and after 3 months of oral sodium bicarbonate supplementation. Predialysis serum bicarbonate, arterial pH, ionized calcium, plasma sodium, plasma potassium, serum creatinine, hemoglobin, K(t)/V, postdialysis body weight, predialysis systolic and diastolic blood pressure were also evaluated before and after correction. RESULTS: Serum bicarbonate levels and arterial pH increased respectively from 19.3 +/- 0.6 to 24.4 +/- 1.2 mmol/l (p < 0.0001) and 7.34 +/- 0.03 to 7.40 +/- 0.02 (p < 0.001). iPTH levels decreased significantly from 399 +/- 475 to 305 +/- 353 pg/ml (p = 0.026). No changes in total serum Ca, plasma PO(4), serum akaline phosphatase, K(t)/V, serum creatinine, hemoglobin, body weight, predialysis systolic and diastolic blood pressures were observed. iCa decreased significantly. CONCLUSIONS: Our study demonstrates that the correction of metabolic acidosis in chronic HD patients reduces iPTH concentrations in HD patients with secondary hyperparathyroidism possibly by a direct effect on iPTH secretion.