Edward Kingdon

Hepatitis B virus related membranous glomerulonephritis and proteinuria treated with lamivudine and tenofovir

Membranous glomerulonephritis is the most common histological renal lesion associated with hepatitis B virus (HBV) infection. The authors describe here a case of a patient presenting with the nephrotic syndrome and HBV infection but without progressive liver disease. The use of lamivudine and tenofovir resulted in arrest of proteinuria and stabilisation of renal function.

Membrane and centrifugal therapeutic plasma exchange: practical difficulties in anticoagulating the extracorporeal circuit

Therapeutic plasma exchange (TPE) is a well-established treatment modality for nephrology patients, using two conventional methods: membrane (mTPE) or centrifugal TPE (cTPE). Although the efficacy of both treatments has been described, there are few reports that compare these methodologies. Here we describe three nephrology patients who were treated with both mTPE and cTPE. The mTPE method, but not the cTPE method, was associated with persistent difficulty anticoagulating the extracorporeal circuit in all three patients. In mTPE procedures, the doses of heparin bolus and infusion rate were important determinants of whether the circuit clotted. With a heparin bolus at or below 2000 IU, clotting occurred in 67% of treatments, dropping to 25% with a bolus of >2000 IU. Likewise, a heparin infusion rate during the procedure was indicative of clotting. With a maintenance infusion of <2000 IU/h, most circuits clotted. No clotting was observed during cTPE procedures using acid citrate dextrose formula A solution as an anticoagulant of the extracorporeal circuit. Overall, difficulties maintaining the extracorporeal circuit in mTPE required the use of additional disposable sets, high doses of heparin and nursing time. In addition, mTPE procedures took longer to perform than cTPE.

Intravascular large B-cell lymphoma diagnosed at renal biopsy

A 77-year-old woman was referred with renal impairment—serum creatinine 230 mmol/L (2.61 mg/dL) and proteinuria 2.14 g/day. The past medical history included hypertension, sicca symptoms and osteoarthritis. Her medications included amlodipine 5 mg od, omeprazole 20 mg od and prednisolone 10 mg od. Systematic enquiry revealed lethargy and 6 kg weight loss over 6 months. Examination was unremarkable. Laboratory investigations revealed normocytic normochromic anaemia with reactive thrombocytosis. Serum lactate dehydrogenase was elevated. Bone biochemistry, liver function tests, serum protein electrophoresis, immunoglobulins, anti-nuclear antibodies, anti-neutrophil cytoplasmic antibodies and complements were all negative or normal. Ultrasound showed normal-sized unobstructed kidneys of normal echogenicity.

Assessment of the Renal Patient

Nephrologists encounter patients with a spectrum of renal disease, from asymptomatic incidental findings to severe renal impairment or electrolyte disturbance in a critically ill patient. Many of these patients will have significant comorbidity, often alongside previously diagnosed chronic renal disease. These factors mean the assessment of the ‘renal patient’ can be a challenging proposition to the less. There are numerous approaches to the assessment of patients with kidney disease, and practitioners will develop their own style with time. The ‘practical’ strategy we outline here is only one of many but one that we find successful in day-to-day practice.

Renal involvement in an Anderson-Fabry heterozygote

A 34 year old Algerian woman with no history of consanguinity was referred to the nephrology service in 1998 with oedema, proteinuria (3.5 g/24 hours), and hypoalbuminaemia (28 g/l). These abnormalities were identified immediately before pre-eclampsia precipitated the delivery of a healthy boy by caesarean section. Previously, a healthy girl had been delivered by caesarean section because of failure to progress in the second stage of labour in 1993. The patients past medical history included four earlier miscarriages, a deep venous thrombosis, homozygosity for the factor V Leiden mutation, antinuclear antibodies, and a patent …