Chih-Hsiung Lee

Bilateral Moderate Hydroureteronephrosis Due to Uterine Prolapse: Two Case Reports and Review of the Literature

Uterine prolapse resulting in hydronephrosis was uncommon. We report two cases of complete uterine prolapse and bilateral moderate hydronephrosis. Case 1, she was admitted due to fever with pyuria. Uterine prolapse was noted by incidental finding. Urine culture showed Escherichia coli. She received total vaginal hysterectomy, which corrected the obstruction and bladder dysfunction. Case 2, she had a history of liver cirrhosis and was denied further operation due to bleeding tendency. Renal echo and intravenous pyelography showed bilateral moderate hydronephrosis with hydroureter in the two cases. Normal renal function was found in the two cases. We suggest early diagnosis and management are necessary in order to prevent renal failure and urinary tract infection.

Comparison of Iodixanol and Iohexol in Patients Undergoing Intravenous Pyelography: A Prospective Controlled Study

Background. Nephropathy associated with contrast medium exposure is a well-known complication of IVP. However, it is uncertain whether iso-osmolar non-iodinated contrast medium (iodixanol) is less nephrotoxic than low-osmolar contrast medium (iohexol). Materials and Methods. In this single-center, double-blind, prospective study, 50 patients undergoing IVP were randomized into two groups receiving different contrast medium: iodixanol and iohexol. Patients in high risk for contrast nephropathy were included, 28 with renal insufficiency and 19 with diabetes mellitus. We compared the nephrotoxic effect (contrast nephropathy), complement and cytokines profile between the iodixanol and iohexol groups. The mean volume of contrast medium in each IVP procedure was 0.8 mL/kg. Results. The incidence of contrast nephropathy was 4 percent among all patients (one iodixanol and one iohexol). We found no significant differences in contrast nephropathy and allergic reactions between the two groups. There was no significant difference in cytokine profiles in both groups (p > 0.05).The incidence of allergic reaction was 16 percent among all patients. Twelve percent (3/25) had late reaction after iohexol exposure compared to four percent (2/25) with iodixanol (p = 1.0). One patient had severe skin rash due to late adverse reaction after iodixanol. No mortality was found. Conclusions. New iodixanol and iohexol contrast medium for routine IVP examination are safe and have low nephrotoxicity profile, especially in elderly or high-risk patients. Iodixanol contrast medium has an increased risk to induce severe late adverse reaction compared to iohexol. Allergic reaction may be the main adverse effect after contrast medium infusion.

Extrapulmonary tuberculosis in chronic hemodialysis patients

Background. The incidence of extrapulmonary tuberculosis is higher in dialysis than general population. The aim of the study was to characterize clinical picture in dialysis patients, who developed extrapulmonary tuberculosis. Methods. We retrospectively investigated the hemodialysis patients with extrapulmonary tuberculosis. 2208 hemodialysis patients were reviewed for extrapulmonary tuberculosis from 10 1986 to 01 2001. Results. Seventeen patients (10 male, 7 female) were enrolled. The mean age was 57.4 ± 12.4 years. The sites for extrapulmonary tuberculosis were peritoneum (35.3%, 6/17), cervical lymph node (17.6%, 3/17), bone marrow (5.9%, 1/17), spine (5.9%, 1/17), knee (5.9%, 1/17), brain (5.9%, 1/17), pericardium (5.9%, 1/17), cutaneous tissue (5.9%, 1/17) and genitourinary system (5.9%, 1/17). Fourteen of 15 tissue-biopsy specimens from suspicious sites revealed granulomatous inflammation. There were low yield in mycobacteria culture (11.1%, 1/9) and PCR (33.3%, 2/6). Three patients died during the treatment of the disease. Conclusion. Extrapulmonary tuberculosis constitutes a major part of tuberculosis in dialysis patients. Tissue biopsy with invasive procedures, such as laparoscopy or laparotomy, may be necessary if clinical presentations are suspicious.

Hypercalcaemia and haemophagocytic syndrome : rare concurrent presentations of disseminated tuberculosis in a dialysis patient

Tuberculosis remains an important cause of infection in chronic haemodialysis patients. Frequent extrapulmonary involvement, non‐specific presentation and limited diagnostic tools usually make early diagnosis difficult. Herein, we report on an 83‐year‐old female patient who had been on regular heamodialysis therapy for 15 years, who presented with asymptomatic hypercalcaemia and pancytopenia. Haemophagocytic syndrome was documented during the admission period. Mycobacterium tuberculosis was cultured from bone marrow 1 month after her demise. This case report highlights the non‐specific manifestations of extrapulmonary tuberculosis in dialysis patients and the limited value of conventional diagnostic methods. We would like to recommend aggressive intervention and early tissue aspiration from possible infectious sites when tuberculosis cannot be completely ruled out. Disseminated tuberculosis should be considered as an indication of hypercalcaemia where haemophagocytic syndrome occurs simultaneously.

Risk factors influencing the outcome of peptic ulcer bleeding in end stage renal diseases after initial endoscopic haemostasis

Background and Aims:  Patients suffering from peptic ulcer (PU) bleeding who have end‐stage renal disease (ESRD) may encounter more adverse outcomes. The primary objective is to investigate the risk factors that influence the outcomes of ESRD and chronic kidney disease (CKD) patients with PU bleeding after successful initial endoscopic haemostasis.

Discrepancy between effects of carbapenems and flomoxef in treating nosocomial hemodialysis access-related bacteremia secondary to extended spectrum beta-lactamase producing Klebsiella pneumoniae in patients on maintenance hemodialysis.

BackgroundHemodialysis (HD) patients are susceptible to extended spectrum beta-lactamase (ESBL)-producing bacterial infections. Because the optimal treatment and clinical significance of ESBL-producing Klebsiella pneumoniae (ESBL-Kp) HD access-related bacteremia remain unclear, we conducted this retrospective study to determine the clinical outcomes of patients treated with either flomoxef or a carbapenem.MethodsThe eligibility criterion was fistula or graft- or catheter- related ESBL-Kp bacteremia in patients on maintenance HD. The clinical characteristics and antibiotic management were analyzed. Outcome was determined by mortality resulting from bacteremia during the 14‐day period after the first positive blood culture for flomoxef-susceptible ESBL-Kp.ResultsThe 57 patients studied were predominantly elderly, malnourished, with a history of severe illnesses and broad-spectrum antibiotic use before the onset of bacteremia, and with severe septicemia as determined by the Pitt bacteremia score (PBS). The study population comprised 7 fistula, 8 graft, and 42 HD catheter-related bacteremia (CRB) cases, and the mortality rate was high (36/57, 63.2%) in these 57 patients. Of 42 patients with CRB, those in the deceased group (27/42, 64.3%) had significantly lower levels of serum albumin, longer prior hospital stay and duration of catheter-dependent HD, and higher PBS than patients in the survived group. Failure to receive effective antibiotics (flomoxef or a carbapenem) within 5 days after onset of bacteremia and treatment with flomoxef both significantly contributed to higher mortality. Multivariate analyses revealed that flomoxef use, PBS, and catheter-dependent HD >30 days were independently associated with increased mortality (OR, 3.52; 95% CI, 1.19–58.17, OR, 2.92; 95% CI, 1.36–6.26 and OR, 5.73; 95% CI, 1.21–63.2, respectively).ConclusionsConsidering the high mortality rate, ESBL-Kp should be recognized as a possible pathogen in patients on maintenance HD at high risk of acquiring HD access infections associated with ESBL-producing bacteria. Carbapenems rather than flomoxef should be the therapy of choice in these critically vulnerable patients.

Successful management of acute renal artery thromboembolism by intra-arterial thrombolytic therapy with recombinant tissue plasminogen activator.

Acute renal artery thromboembolism (ARAT), a rare event in native kidneys, potentially result in severe renal injury if it is not appropriately managed. The optimal therapy still remains controversial today even though various methods of managements for ARTA were applied in these decades including surgical intervention and medical approach such as thrombolytic therapy. Recombinant tissue plasminogen activator (rt-PA) reveals a better bioavailability and lower incidence of adverse effects and it has been widely used to treat a number of clinical conditions but only very few cases have been reported where rt-PA was used to treat ARAT. We described a case of ARAT, which was successfully treated by the administration of rt-PA via intra-arterial infusion within a period of 60 min without residual renal impairment. It may be a useful choice for ARAT and renal infarction sufferers.

Chronic Hypercalcemia as the Presenting Feature of Tuberculous Peritonitis in a Hemodialysis Patient

Hypercalcemia is a common electrolyte disturbance in chronic dialysis patients. Although most causes are easily identified, some are obscure. Tuberculosis, a granulomatous disease associated with hypercalcemia, can appear at anytime while the infection is active. Dialysis-associated tuberculosis is characterized by a higher risk than that in the general population, with a greater chance of extrapulmonary involvement and a high mortality rate. If the presentation of tuberculosis is atypical and its manifestation nonspecific, diagnosis can be delayed, leading to poor patient outcome. Herein, we report a case of tuberculous peritonitis in a hemodialysis patient. Asymptomatic hypercalcemia was noted 8 months before ascites became detectable. Nevertheless, the patient responded well to antituberculous therapy. We conclude that hypercalcemia can be an early sign of tuberculous peritonitis in the absence of other signs and symptoms. Remaining aware of the possibility of tuberculosis and testing for it, physicians can identify tuberculous infection earlier and initiate appropriate therapy in a timely manner.

Nephrogenic systemic fibrosis in advanced chronic kidney disease: A single hospital’s experience in Taiwan

Nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD) clinically resembles scleromyxedema which develops in the setting of advanced chronic kidney diseases. Limited data exist about its epidemiology in Asian countries. A total of 153 magnetic resonance imaging (MRI) examinations, including 81 contrast-enhancement, were identified in 127 patients with advanced chronic kidney disease at stage five undergoing MRI or angiography examination between January 2005 and July 2007, in our hospital. The diagnosis of NFD/NSF was established based on clinical manifestation and histopathology. NFD/NSF was diagnosed in none of the 105 patients on haemodialysis but in one of the 22 patients on peritoneal dialysis. This 24-year-old woman was a case of systemic lupus erythematosus since age 15 and who developed skin lesions two months before the initiation of peritoneal dialysis but nine months after four exposures to gadodiamide during MRI study. The skin condition had significantly improved within three months under a combination regimen of systemic pentoxifylline and topical clobetasol propionate ointment, with further amelioration during subsequent treatment with colchicine. Our results lend support to the predisposition of gadolinium-containing contrast agents to the development of NFD/NSF in patients with advanced renal failure, even before the initiation of dialysis. The cause of a lower incidence rate in our series remains to be determined.

A Quality and Cost-Benefit Analysis of Dialyzer Reuse in Hemodialysis Patients

Background. To evaluate the benefits of dialyzer reuse for hemodialysis (HD) patients, including the cost of HD treatment and patients survival, a comparison was made regarding the standard practice of single-use dialysis. Methods. From January 1, 2005, to December 31, 2005, a total of 128,232 successive HD treatments in 822 patients in Chang Gung Memorial Hospital-Kaohsiung Medical Center were included in this study. Results. Approximately 54.25% (446/822) of patients reused dialyzers. The average times of dialyzer reuse was 2.54. The annual hollow fiber cost is reduced by