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  • ISSN: 2573-1637
    Volume 2, Issue 1
    Case Report
    Robert Murphy*, Evelyn Murphy, and Janusz Krawczyk
    We describe a female patient in her 70s with haemophagocytic lymphohistiocytosis who developed an acute kidney injury secondary to cyclosporine use. Haemophagocytic lymphohistiocytosis (HLH) is a rare and severe immunologic disorder characterized by multiorgan system involvement, fever, rash, hepatosplenomegaly, cytopenias, and a range of neurologic manifestations. It is usually present in a paediatric population.
    The patient was treated according to the 2004 HLH protocol which included cyclosporine. The patient had been established on a stable on a dose of 125mg PO BD, with target trough levels of between 100 - 200 ng/L within range for the preceding four weeks. Her weight had plummeted due to HLH, losing up to 40% of her body weight from symptom onset. Her baseline serum creatinine was low at 46 μ mol/l, decreasing throughout her hospitalisation. As we had not checked her body weight on a regular basis, dose adjustments of cyclosporine had not been made periodically.
    She developed AKI, in conjunction with a doubling of her cyclosporine level. Her creatinine had tended to increase but there was a delay in the diagnosis of AKI because the significant rise in her serum creatinine level was masked due to excessively low level of serum creatinine. After cyclosporine was withheld, and the dose adjusted, the patient recovered fully.
    This case highlights the importance of appreciating the absolute rise in creatinine as a marker of the severity of renal impairment, especially in patients with low baseline serum creatinine and the importance of regular monitoring of weight in conditions where patients have a propensity to rapid weight loss.
    Maja Vuckovic, Gordana Cavric*, Anita Skrtic, Ingrid Prkacin, Martina Zeljko, and Darko Blaskovic
    In this report we will present a case on a seventy-six-year-old female patient with bilateral hydronephrosis, sepsis, and insulinoma that died due to septic shock. Necropsy findings showed that the cause of bilateral hydronephrosis was the swelling of the urinary bladder mucosa that occurred due to purulent cystitis which is rare. Interestingly, no obvious predisposing factor in the patient was found. Diabetes mellitus, which is a risk factor for the development of an infection, was not found in our patient, but on the contrary, insulinoma.
    Larissa Kruger Gomes*, Erin Little, Hassan Attique, and Ruchir Trivedi
    Emphysematous pyelonephritis (EPN) is a rare gas producing necrotizing infection of renal parenchyma, which overlooked can lead to a mortality rate as high as 80%. A 54-year-old female with a history of diabetes presented to the emergency department with dull left sided flank pain. She computed tomographic (CT) scan showed air in the renal collecting system in addition to an obstructing stone, confirming the diagnosis of EPN. She was admitted, received intravenous (IV) antibiotics, and underwent a procedure to place aureteralstent to help relieve the obstructing stone. She improved clinically and was able to be discharged home. EPN is most common in the diabetic and female populations. Most notably, Escherichia coli, Klebsiella and Proteus speciesare the most common bacteria found in blood and urinary cultures in these cases. Management depends on radiological staging of EPN by CT scan. Class 1 can be managed with antibiotics alone; classes 2 and 3 need percutaneous drainage in addition to antibiotics. High risk class 3 is indicated by the presence of thrombocytopenia, renal failure, altered mental status or shock on presentation in which case a nephrectomy could be required. Regardless of class, all patients with EPN and an obstructing stone should surgical intervention. Additionally, if the initial intervention fails, nephrectomy should be pursued given the high mortality of this disease. Diagnosis of EPN requires a high degree of suspicion. After diagnosis, patients should be monitored closely and managed with IV antibiotics as well as an individualized surgical approach, depending on radiological staging and risk factors.
    Mini Review
    Garcia-Pedraza JA, Moran A, Martin ML, and Monica García Domingo*
    The renal vasculature contributes to the cardiovascular homeostasis, regulating its vascular tone, blood flow as well as systemic blood pressure. The renovascular tone can be modulated by many vasoactive substances, highlighting 5-hydroxytryptamine (5-HT) which could exert totally opposite vascular effects in the kidney. This mini-review aims to determine if 5-HT predominantly acts as vasoconstrictor or vasodilator agent in the kidney.
    To study modifications in the renal vasculature, one of the best experimental techniques in vivo is the in situ autoperfused rat kidney, which allows continuous measurement of rat renovascular resistance, permitting to evaluate rapid change in renal blood flow induced by i.e. drug administration. 5-HT directly exerts vasoconstrictor responses in the kidney of healthy rats, involving 5-HT2C receptor activation. The induction of a pathological situation, such as hypertension or diabetes (where the kidney is predominantly at risk of injury), increases the serotonergic vasoconstrictor effect, but the receptor implicated is 5-HT2A. This fact places 5-HT as an ‘enemy’ in the kidney, especially in renal disorders. Surprisingly, chronically blocking 5-HT2 receptor with sarpogrelate makes 5-HT behave as a renal vasodilator agent by 5-HT1/7 receptor activation. The modulation of the serotonergic system, leading to 5-HT renal vasodilation, opens new perspectives in the pharmacological approach to prevent/treat renal and cardiovascular pathologies.
    Research Article
    Amin Roshdy Soliman, Ahmed Abdalla Hassan*, Mahmoud Amin Soliman, Manal Mohamed Eldeeb, Dalia Ahmed Roshd, and Tarek Elsayed Aboelregal
    Hypertension with rapid worsening of renal function is a rare presentation of lupus nephritis. The aim of this work is to ascertain the prevalence and prognostic importance of malignant hypertension at the onset of LN. We also searched for a correlation between malignant hypertension and LN histological class. We have retrospectively assessed 15 cases of malignant hypertension and SLE with LN. Eleven were males (73.3%). Mean age was 36 years. Mean interval between diagnosis of SLE and the appearance of renal complications was 110 months. Clinical presentation consisted of malignant hypertension (DBP> 115 mm Hg with hypertensive retinopathy grades III-IV). At presentation, 12/15 (80%) showed renal insufficiency (mean creatinine was 3.8 mg/dl). Mean proteinuria level was 4.2 g/24h and microhematuria was observed in 73.3% of cases. Immunologic studies showed decreased C3 (66.6%) and circulating cryoglobulins in 13.3%. Renal biopsies showed class IV (10/15, 66.7%), III (1/15, 6.6%) and V GN (4/15, 26.7%). Of the 15 patients, crescentic transformation occurred in 7 (46.6 %) and TMA occurred in one patient (6.6 %) on top of class IV-S. After a mean follow up of 24 months, 5 patients (33%) had recovered normal renal function, and 6 (40%) had started chronic dialysis.
    Conclusion: Malignant hypertension associated with LN was a high risk clinical presentation with rapid worsening of renal function.
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