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CALCIFIC UREMIC ARTERIOLOPATHY SUCCESSFULLY TREATED WITH SODIUM THIOSULFATE
NKF 2015 Spring Clinical Meetings Abstracts
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AN UNUSUAL CASE OF IGA NEPHROPATHY Ruby Appiah, Osei Whyte, Anil Ghimire, SUNY Upstate Medical University, Syracuse, NY, USA IgA nephropathy is a common cause of glomerulonephritis and frequently presents with asymptomatic hematuria. It can be associated with pulmonary capillaritis but rarely presents with pulmonary hemorrhage, which is often fatal. Of the patients presenting with asymptomatic hematuria, less than 10% develop renal insufficiency and even fewer present with pulmonary hemorrhage. We describe a case of severe hemoptysis and respiratory failure as the initial presentation of IgA nephropathy. A 23 year-old male with a past medical history of hypertension, vitiligo, and right-sided hearing loss, presented with a 2-week history of cough and hemoptysis. Physical examination was significant for pale mucus membranes; heart rate was 110, blood pressure 92/63, oxygen saturation 92% on a nonrebreather. On admission, hemoglobin was 6.7, hematocrit 20.0, BUN 126 and creatinine 13.6. Urinalysis was positive for blood with 1045 red blood cells. A chest CT scan showed bilateral patchy opacities, and bronchoscopy confirmed diffuse alveolar hemorrhage. The patient was transfused 2 units of packed red blood cells, and underwent urgent dialysis. He was empirically started on steroids and a renal biopsy was performed. Biopsy revealed mesangial proliferation with prominent IgA deposition, consistent with IgA nephropathy. Repeat chest CT scan post dialysis showed resolution of the bilateral infiltrates originally seen. Lab work after dialysis and steroids showed: BUN 46, creatinine 7.3, hemoglobin 9.1, and hematocrit 26.8. IgA nephropathy (IGAN) is often diagnosed in its early stages. Its presenting symptoms are often hematuria after a recent gastrointestinal or respiratory tract illness, rarely resulting in a high acuity presentation. When IGAN presents with pulmonary hemorrhage and renal failure, it is associated with a high mortality rate. Pulmonary hemorrhage in the setting of renal failure is often reserved for diagnoses such as Wegener’s granulomatosis or Goodpasture’s syndrome. This case report represents an exception, and the importance of IGAN in the differential diagnosis. Early consideration is crucial in the acutely ill patient to allow for swift intervention. This case represents a common illness with an uncommon presentation and successful treatment.
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Am J Kidney Dis. 2015;65(4):A1-A93
20 HYDROTHORAX AS A COMPLICATION OF PERITONEAL DIALYSIS: STILL A CAUSE FOR TREATMENT FAILURE Ziad Arabi, Melanie Porter, Dona Spaeth, Richard Solomon, Dana Negoi. University of Vermont Medical Ctr, Burlington, VT, USA Hydrothorax due to pleuro-peritoneal leak is a rare peritoneal dialysis (PD) complication. Despite being easy to diagnose, adequate treatment is not readily available and commonly results in technique failure and switch to HD. We reviewed our recent experience with hydrothorax in PD and compared it with other centers’ experience by means of a short survey. 45 new patients were initiated on PD in our program from 2012 to 2014. Three women between the ages of 36 to 54, were diagnosed with pleuro-peritoneal leak and large, symptomatic hydrothorax after initiating PD. Our 1st patient was referred to cardiothoracic surgery and underwent video-assisted thoracoscopy (VATS) with talc pleurodesis. Case reports describe it as being a successful treatment. Low fill volume dialysis (1500 CC) was attempted 6 weeks post VATS but releak recurred after only 4 treatments. Patient was referred for a second surgical opinion at two other tertiary medical centers in New England, but only one center agreed to see the patient. Their imaging studies showed no anatomical defects. Another trial of PD was attempted but failed after one fill. The other two women, who developed right-sided pneumothorax, were not referred for surgical repair due to socioeconomic and medical reasons. None of these patients returned to PD. We were able to survey 5 other PD programs (3 academic and 2 private) in different geographic locations. They had a total of 129 new patients from 2012 to 2014. Only one case of hydrothorax related to PD was reported during this period of time in the 5 surveyed programs. This patient was treated with VATS but treatment failed and the patient had to be switched to HD. Our experience shows a much higher incidence of pleuro-peritoneal leak than other centers. Currently there are no guidelines and standards of care for this condition. We propose the creation of a disease registry for PD patients with hydrothorax. Data collection from multiple centers on this rare condition will help identify risk factors, rapid diagnosis and best course of action in order to allow them to continue PD.
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AN UNUSUAL CASE OF IGA NEPHROPATHY Ruby Appiah, Osei Whyte, Anil Ghimire, SUNY Upstate Medical University, Syracuse, NY, USA IgA nephropathy is a common cause of glomerulonephritis and frequently presents with asymptomatic hematuria. It can be associated with pulmonary capillaritis but rarely presents with pulmonary hemorrhage, which is often fatal. Of the patients presenting with asymptomatic hematuria, less than 10% develop renal insufficiency and even fewer present with pulmonary hemorrhage. We describe a case of severe hemoptysis and respiratory failure as the initial presentation of IgA nephropathy. A 23 year-old male with a past medical history of hypertension, vitiligo, and right-sided hearing loss, presented with a 2-week history of cough and hemoptysis. Physical examination was significant for pale mucus membranes; heart rate was 110, blood pressure 92/63, oxygen saturation 92% on a nonrebreather. On admission, hemoglobin was 6.7, hematocrit 20.0, BUN 126 and creatinine 13.6. Urinalysis was positive for blood with 1045 red blood cells. A chest CT scan showed bilateral patchy opacities, and bronchoscopy confirmed diffuse alveolar hemorrhage. The patient was transfused 2 units of packed red blood cells, and underwent urgent dialysis. He was empirically started on steroids and a renal biopsy was performed. Biopsy revealed mesangial proliferation with prominent IgA deposition, consistent with IgA nephropathy. Repeat chest CT scan post dialysis showed resolution of the bilateral infiltrates originally seen. Lab work after dialysis and steroids showed: BUN 46, creatinine 7.3, hemoglobin 9.1, and hematocrit 26.8. IgA nephropathy (IGAN) is often diagnosed in its early stages. Its presenting symptoms are often hematuria after a recent gastrointestinal or respiratory tract illness, rarely resulting in a high acuity presentation. When IGAN presents with pulmonary hemorrhage and renal failure, it is associated with a high mortality rate. Pulmonary hemorrhage in the setting of renal failure is often reserved for diagnoses such as Wegener’s granulomatosis or Goodpasture’s syndrome. This case report represents an exception, and the importance of IGAN in the differential diagnosis. Early consideration is crucial in the acutely ill patient to allow for swift intervention. This case represents a common illness with an uncommon presentation and successful treatment.
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Am J Kidney Dis. 2015;65(4):A1-A93
20 HYDROTHORAX AS A COMPLICATION OF PERITONEAL DIALYSIS: STILL A CAUSE FOR TREATMENT FAILURE Ziad Arabi, Melanie Porter, Dona Spaeth, Richard Solomon, Dana Negoi. University of Vermont Medical Ctr, Burlington, VT, USA Hydrothorax due to pleuro-peritoneal leak is a rare peritoneal dialysis (PD) complication. Despite being easy to diagnose, adequate treatment is not readily available and commonly results in technique failure and switch to HD. We reviewed our recent experience with hydrothorax in PD and compared it with other centers’ experience by means of a short survey. 45 new patients were initiated on PD in our program from 2012 to 2014. Three women between the ages of 36 to 54, were diagnosed with pleuro-peritoneal leak and large, symptomatic hydrothorax after initiating PD. Our 1st patient was referred to cardiothoracic surgery and underwent video-assisted thoracoscopy (VATS) with talc pleurodesis. Case reports describe it as being a successful treatment. Low fill volume dialysis (1500 CC) was attempted 6 weeks post VATS but releak recurred after only 4 treatments. Patient was referred for a second surgical opinion at two other tertiary medical centers in New England, but only one center agreed to see the patient. Their imaging studies showed no anatomical defects. Another trial of PD was attempted but failed after one fill. The other two women, who developed right-sided pneumothorax, were not referred for surgical repair due to socioeconomic and medical reasons. None of these patients returned to PD. We were able to survey 5 other PD programs (3 academic and 2 private) in different geographic locations. They had a total of 129 new patients from 2012 to 2014. Only one case of hydrothorax related to PD was reported during this period of time in the 5 surveyed programs. This patient was treated with VATS but treatment failed and the patient had to be switched to HD. Our experience shows a much higher incidence of pleuro-peritoneal leak than other centers. Currently there are no guidelines and standards of care for this condition. We propose the creation of a disease registry for PD patients with hydrothorax. Data collection from multiple centers on this rare condition will help identify risk factors, rapid diagnosis and best course of action in order to allow them to continue PD.
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