BackgroundAcute tubulointerstitial nephritis (ATIN) has been increasingly recognized as an important manifestation of kidney injury associated with the use of immune checkpoint inhibitors (anti-PD-1 and anti-CTLA-4). While the exact pathophysiology remains unknown, corticosteroids are the mainstay of management.Case presentationWe describe a 67-year-old man with stage IV non-small-cell lung cancer who developed kidney injury during treatment with the anti-PD-1 antibody nivolumab. A kidney biopsy showed ATIN without granuloma formation. Considering their mechanism of action, immune checkpoint inhibitors can alter immunological tolerance to concomitant drugs that have been safely used for a long time. For more than 4 years before the initiation of nivolumab therapy, the patient had been receiving the proton pump inhibitor lansoprazole, known to cause drug-induced ATIN, without significant adverse events including kidney injury. He showed rapid improvement in kidney function in 3 days (creatinine decreased from 2.74 to 1.82 mg/dl) on discontinuation of lansoprazole. He then received 500 mg intravenous methylprednisolone for 3 days followed by 1 mg/kg/day oral prednisolone and his creatinine levels eventually stabilized around 1.7 mg/dl. Drug-induced lymphocyte stimulation test (DLST) for lansoprazole was positive.ConclusionsThe rapid improvement of kidney function after discontinuation and DLST positivity indicate that lansoprazole contributed to the development of ATIN during nivolumab therapy. Considering the time course, it is plausible that nivolumab altered the long-lasting immunological tolerance against lansoprazole in this patient. To the best of our knowledge, this is the first case report of DLST positivity for a drug that had been used safely before the initiation of an immune checkpoint inhibitor. Although corticosteroid therapy is recommended, the recognition and discontinuation of concomitant drugs, especially those known to induce ATIN, is necessary for the management of kidney injury associated with anti-PD-1 therapy.
We administered 2.5 g of Shakuyaku-kanzo-to granule to 61 patients who had muscle cramp during hemodialysis (HD) sessions and examined its immediate effects. We selected 10 patients who wanted to take the drug at home, out of cases, for whom the drug was effective on the study described above and had them take the drug in the same way at the beginning of muscle cramp at home examined the effects. In the study during HD sessions, muscle cramp and its associated pain disappeared in 5.3 ± 3.9 min on average in 54 out of 61 cases. In the study of patients who took the drug at home, muscle cramp disappeared within 10 min in all cases. Shakuyaku-kanzo-to is thought to be very useful for muscle cramp during HD sessions of hemodialized patients because it has immediate effects by its oral administration on the occasion of cramp. With regard to the muscle cramp, which appears at home after HD sessions, the patients can cope with it by taking the drug by themselves. This is an epoch-making therapy, for it was impossible to cope with muscle cramp except in hospitals because the therapy of muscle cramp was limited to intravenous infusion of hypertonic solutions of dextrose, mannitol, and saline during HD sessions.
BackgroundPhysiological abnormalities are often observed in patients prior to cardiac arrest. A modified early warning score (MEWS) system was introduced, which aims to detect early abnormalities by grading vital signs, and the present study investigated its usefulness.MethodsBased on previous reports, the Chubu Tokushukai Hospital-customized MEWS was developed in Okinawa, Japan. The MEWS was calculated among all inpatients, and the rates of in-hospital cardiac arrests (IHCAs) were compared according to the score. The warning zone (WZ) was set as 7 or more because of the high possibility of acute deterioration. The MEWS system was introduced to provide immediate interventions for patients who reached the WZ in accordance with the callout algorithm. The numbers of IHCAs were compared between the 18 months before and after introduction of the MEWS system.ResultsThe numbers of patients who experienced IHCA with each score were as follows: score of 6, 1 of 556 patients (0.18 %); score of 7, 4 of 289 (1.40 %); score of 8, 2 of 114 (1.75 %); and score of 9 or more, 2 of 56 (3.57 %). There was no significant difference in the mean age or sex between before and after the introduction of the MEWS system. The rate of IHCAs per 1000 admissions decreased significantly from 5.21 (79/15,170) to 2.05 (43/17,961) (p < 0.01).ConclusionsThe Chubu Tokushukai Hospital-customized MEWS was applied to all inpatients, and the rate of IHCA decreased owing to the introduction of the system, as the system enables early interventions for patients who have the possibility of acute deterioration.
Similar patterns of bacteria are present in tonsillar crypts of both IgAN and RT patients, suggesting that the host response to these bacteria might be important in the development of IgAN.
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