SummaryChronic kidney disease (CKD) is a major and serious risk factor for cardiovascular disease (CVD). Continuous hypoxia due to hypoperfusion in peritubular capillaries is one of the factors aggravating CKD, but evaluation of perfusion in this region is difficult using clinically available imaging methods. Since the second-generation ultrasound contrast agent Sonazoid TM has a stable shell, it enables visualization of the renal vasculature for a long period of time. We therefore evaluated changes in contrast-enhanced ultrasound (CEUS) imaging with Sonazoid TM in CKD patients.Sonazoid TM was used in 85 CKD patients and 5 control subjects, and images were recorded for 10 minutes. Time-intensity curves were generated from the images of 62 time points in both cortex and medulla.In control samples, contrast enhancement spread from the hilar portion to the periphery along the direction of arterial flow, and renal cortex and medulla were then enhanced in sequence. Enhancement was maximal soon after, then gradually decreased, but was still visible at 600 seconds. In CKD patients, renal contrast enhancement was attenuated in both cortex and medulla. On time-intensity curves, the attenuation of enhancement was composed of delayed rising, reduction of peak, and acceleration of decay in both cortex and medulla with progression of renal dysfunction. No side effects of the contrast agent were observed in any subjects.The attenuation of renal contrast enhancement observed in CKD patients appears to reflect disturbance of perfusion in peritubular capillaries. CEUS with Sonazoid TM is a useful and safe means of visualizing the renal microvasculature. (Int Heart J 2010; 51: 176-182)

Background: Therapeutic plasma exchange (TPE) is an important treatment modality for various diseases, but its use can be restricted by allergic reactions (AR). The aim of our study was to elucidate the frequency of and risk factors for AR at initial TPE using fresh frozen plasma (FFP).Methods: Presences of AR were extracted from the medical records of consecutive patients receiving TPE from 2002 to 2012. The following data at initial TPE were retrieved: age, gender, history of allergy, steroid use, timing of steroid use, mean steroid dose, immunosuppressant use, indication for TPE, and laboratory data.Results: Eighty-eight patients (median age 57 years) underwent TPE, and 28% had an episode of AR. Younger age (odds ratio (OR), 1.04 (95% CI, 1.01-1.08)) and indications other than hepatic insufficiency (OR, 17.8 (95% CI, 1.95-429.4)) were associated with higher incidence of AR.Conclusions: Close observation for AR may be warranted at initial TPE for these conditions.

Arteriovenous fistula (AVF) is the most important vascular access method for hemodialysis (HD). However, ischemic steal syndrome occasionally develops. This study evaluated the change in skin perfusion pressure (SPP) after the creation of upper limb AVF and analyzed the relationship between blood flow measurements and the change in SPP. The subjects included 21 patients who underwent radiocephalic AVF creation for the first time between November 2012 and September 2013. We measured SPP on the palm side of the third finger of both hands and assessed blood flow measurements using ultrasound examination before and after the creation of AVF. The subjects consisted of 15 men and 6 women (average age: 65.3 ± 12.7 years, including 12 diabetic patients). Observational period between before and after surgery was 4.9 ± 5.2 days. None of the patients had ischemic steal syndrome after the creation of AVF. Skin perfusion pressure tended to decrease after creation of AVF on the finger of AVF side (100.0 ± 20.9 vs. 87.9 ± 26.5 mmHg, P = 0.063). In contrast, SPP did not change in the limb without AVF (97.9 ± 20.7 vs. 101.0 ± 19.4 mmHg, P = 0.615). The rate of change in SPP was significantly decreased on the finger of AVF side compared with that of limb without AVF (0.055% vs. -0.112%, P = 0.014). There was no correlation between the change in SPP and blood flow measurements. Skin perfusion pressure is possible to detect ischemic steal syndrome after the creation of upper limb AVF.

Tumor lysis syndrome (TLS) is a metabolic disorder that is generally associated with a malignancy leading to hyperuricemia, hyperphosphatemia, and acute kidney injury. On the other hand, we sometimes encounter these phenomena in nonmalignant disease, which has been referred to as tumor lysis-like syndrome in some studies. We herein experienced a case in which tumor lysis-like syndrome occurred in the course of therapy for eosinophilic disease of the lung, a nonmalignant disease. Even in nonmalignant disease, massive cell lysis induced by therapy can cause phenomena such as TLS or tumor lysis-like syndrome.

BACKGROUND The number of elderly patients with kidney disease is increasing rapidly, and we often encounter situations in which we need to weigh the benefits and risks of kidney biopsy (KBx). The decision is often difficult because reports addressing the safety and utility of KBx in the elderly are scarce. METHODS This observational study included 548 consecutive adult patients who underwent native KBx. We divided the patients into an E group, elderly patients 65 years or older, and an NE group, the remaining nonelderly patients. Baseline characteristics and complications of KBx were compared between the two groups. We also investigated the proportions of patients in whom steroid and/or immunosuppressive treatment was started after KBx. RESULTS There were 112 patients in the E group and 436 in the NE group. The baseline values differed significantly between the groups for age (71.5 ± 4.7 vs. 39.6 ± 13.9 years), estimated glomerular filtration rate (eGFR) (41.4 ± 27.1 vs. 72.0 ± 33.7 ml/min/1.73 m 2 ), proportion of patients with diabetes (25.0% vs. 4.8%), and proportion of those who underwent surgical KBx (11.6% vs 3.0%), There was no significant difference in terms of sex.The E group experienced slightly more major complications (4.0% vs. 1.2%, p=0.05) but fewer minor complications (2.0% vs. 6.0%, p=0.10) with percutaneous KBx than the NE group did, although neither major nor minor complications occurred in patients who underwent surgical KBx. Final diagnoses after KBx, such as IgA nephropathy, IgA vasculitis, and ANCA-associated glomerulonephritis, were associated with various clinical diagnoses, indicating that the final diagnoses could not have been obtained without KBx. Treatment with steroid and/or immunosuppressant was required to a high degree in patients with ANCA-associated glomerulonephritis and minimal change disease after histologic evaluation by KBx. CONCLUSIONS The risk of KBx in the elderly patients was significantly higher than that in the non-elderly, and some diagnoses could not have been obtained without KBx. Thus, as long as nephrologists perform KBx cautiously according to strict indications, KBx can be a safe and useful option in the management of kidney disease in the elderly.