Mari Okada

Primary care physicians' own exercise habits influence exercise counseling for patients with chronic kidney disease: a cross-sectional study

BackgroundThe appropriate exercise counseling for chronic kidney disease (CKD) patients is crucial to improve their prognosis. There have been few studies about exercise counseling by primary care physicians for CKD patients. We investigated primary care physicians’ exercise counseling practices for CKD patients, and the association of these physicians’ own exercise habits with exercise counseling.MethodsThe population of this cross-sectional study was 3310 medical doctors who graduated from Jichi Medical University from 1978 to 2012. The study instrument was a self-administered questionnaire that was mailed in August 2012 to investigate their age class, specialty, workplace, exercise habits, and practices of exercise counseling for CKD.Results581 (64.8%) medical doctors practiced the management of CKD among a total of 933 responses. These 581 medical doctors were defined as CKD primary care physicians and their answers were analyzed. CKD primary care physicians’ own exercise habits (frequencies and intensities) were as follows: frequencies: daily, 71 (12.1%); ≥2–3 times/week, 154 (26.5%); ≥1 time/week, 146 (25.1%); and ≤1 time/month, 176 (30.2%); intensities: high (≥6 Mets), 175 (30.1%); moderate (4–6 Mets), 132 (22.7%); mild (3–4 Mets), 188 (32.3%); very mild (<3 Mets), 47 (8.1%); and none, 37 (6.4%). The CKD primary care physicians’ exercise recommendation levels for CKD patients were as follows: high, 31 (5.3%); moderate, 176 (29.7%); low, 256 (44.0%); and none, 92 (15.8%). The CKD primary care physicians’ exercise recommendations for CKD patients were significantly related to their own exercise frequency (p < 0.001), but they were not related to their age, specialty, workplace, or exercise intensity.ConclusionsCKD primary care physicians’ exercise recommendation level for CKD patients was limited. In addition, CKD primary care physicians’ own exercise habits influenced the exercise counseling for CKD patients. The establishment of guidelines for exercise by CKD patients and their dissemination among primary care physicians are needed.(University Hospital Medical Information Network Clinical Trial Registry. number, UMIN000011803. Registration date, Sep/19/2013)

Antineutrophil Cytoplasmic Antibody–associated Glomerulonephritis Complicated by Pneumatosis Intestinalis

Pneumatosis intestinalis is a characteristic imaging phenomenon indicating the presence of gas in the bowel wall. The link between pneumatosis intestinalis and various kinds of autoimmune diseases has been reported anecdotally, while information regarding the cases with antineutrophil cytoplasmic antibodies (ANCA)–associated vasculitis complicated by concurrent pneumatosis intestinalis is lacking. In this report, we describe our serendipitous experience with one such case of pneumatosis intestinalis in a patient with ANCA-associated glomerulonephritis. We also discuss several therapeutic concerns that arose in the current case, which had an impact on the pathogenesis of the disease.

Posterior ischemic optic neuropathy in a patient with granulomatosis with polyangiitis (Wegener’s)

Ocular involvement is common in granulomatosis with polyangiitis (GPA), with the main manifestations including scleritis, ulcerative keratitis, conjunctivitis, optic neuritis, and compression symptoms due to periorbital pseudotumor [1]. Here, we present a patient with GPA who complained of the sudden onset of blurred vision bilaterally and was finally diagnosed as having posterior ischemic optic neuropathy (PION). A 60-year-old woman who had GPA presented with blurred vision in the left eye for 1 week. The diagnosis of GPA had been established 3 months earlier, based on the presence of destructive sinusitis, perforation of the nasal septum, scleritis, multiple pulmonary granulomas, and positive anti-neutrophil cytoplasmic antibody for proteinase 3 (PR3-ANCA). Pathologic examination of a lung nodule revealed a typical palisading granuloma with geographic necrosis. She had been treated with oral prednisolone (1 mg/kg/day) plus intravenous cyclophosphamide pulse therapy (750 mg). Warfarin was also started for deep venous thrombosis. On admission, she was taking prednisolone at 25 mg/ day. She had no fever or headache, and her general condition was good. The sclera was hyperemic, but she had no pain. Her visual acuity (VA) was 16/20 in the right eye and hand movement in the left eye. A relative afferent pupillary defect was present. Funduscopic examination was unremarkable, with the optic disc appearing normal. Laboratory findings were as follows: C-reactive protein (CRP) was 0.06 mg/dl (normal \ 0.06), erythrocyte sedimentation rate (ESR) was 18 mm/h, and PR3-ANCA was negative. Urinalysis was normal. A chest radiograph revealed no recurrence of granulomas. Gadolinium-enhanced magnetic resonance imaging (MRI) of the orbit was normal, including the optic nerve. She also had mild diabetes (HbA1c: 6.9 %) and hypertension. Because of these conditions together with no evidence of exacerbation of GPA and the normal-appearing optic disc, she was diagnosed as having nonarteritic PION. Treatment was started with warfarin, aspirin, and vitamins. On the next day, the VA of the right eye decreased to 40/200. Although there was no evidence of active vasculitis, this rapid decrease of VA was treated with intravenous methylprednisolone pulse therapy (500 mg/day) for 3 days. Subsequently, VA improved to 10/20 in the right eye and 40/200 in the left eye. However, VA deteriorated again in both eyes 3 days later. Because of the marked response to glucocorticoid pulse therapy, it was considered that she had active local vasculitis, so the dose of prednisolone was increased from 25 mg/day to 60 mg/ day (1 mg/kg). Two weeks later, her VA had almost recovered to baseline (20/20 in the right eye and 16/20 in the left eye). A diagnosis of PION is only made after excluding other causes of retrobulbar optic neuropathy [2]. If MRI is not performed, distinguishing between optic neuritis and PION can be difficult [3]. MRI can also detect other causes of retrobulbar optic neuropathy by showing enhancement of the optic nerve sheath or apical infiltration of the orbit [4, 5]. PION has rarely been reported in GPA [4, 6, 7]. The visual prognosis was poor in most cases, and only one T. Nagashima (&) K. Matsumoto T. Murosaki M. Okada M. Iwamoto S. Minota Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke, Tochigi 329-0498, Japan e-mail: naga4ma@jichi.ac.jp

Valacyclovir Neurotoxicity and Nephrotoxicity in an Elderly Patient Complicated by Hyponatremia

A 66-year-old women with no history of renal disease was admitted due to a coma and acute kidney injury with a serum creatinine level of 7.44 mg/dL which were ascribed to valacyclovir neurotoxicity and nephrotoxicity, respectively. She had received valacyclovir at a standard dosage for the treatment of herpes zoster and was finally discharged, having fully returned to her normal baseline mental status with a recovered serum creatinine level of 0.68 mg/dL. We feel that awareness of this pathology remains a challenge for physicians and therefore strongly recommend the further accumulation of experiences similar to our own. Our experience underscores the pitfalls of administering valacyclovir to elderly patients who barely appear to have a favorable renal function. Several concerns regarding the therapeutic management, including blood purification strategies, that emerged in this case are also discussed.

Hemolytic Uremic Syndrome: An Increasingly Recognized Public Health Problem:

A 28-year-old man was referred and admitted to our hospital due to Escherichia coli O157–mediated hemorrhagic colitis with severe thrombocytopenia. A systemic workup concluded that the patient had acute pancreatitis as well as hemolytic uremic syndrome. The patient was ultimately discharged, with his platelet count having recovered. Our case serves an illustrative example of potentially serious complications of an increasingly recognized public health problem. Systemic studies on this topic are insufficient, and we strongly recommend the further accumulation of more experiences like ours. Several diagnostic and management concerns that emerged in this case are also discussed.

Retroperitoneal Bleeding: An Experience During Prophylactic Anticoagulation in a Patient With Nephrotic Syndrome

The association between nephrotic syndrome (NS) and a hypercoagulable state has been demonstrated. Controlling the blood clotting activity may therefore be attractive for patients with nephrosis in terms of thromboembolism prophylaxis. We herein report a 75-year-old woman with minimal change disease who developed pains in the right back, groin, and thigh because of retroperitoneal bleeding during prophylactic anticoagulation with unfractionated heparin. Although this procedure has not been accepted as the standard of care for patients with nephrosis, pharmacologic prophylaxis may already be practiced empirically, as in the present patient. We believe that our experience highlights the pitfalls of such a management in patients with nephrosis, implying the need for a diagnostic strategy for identifying those patients with NS who can benefit from prophylactic anticoagulation. Several concerns that emerged in this case are also discussed.

Delayed Development of Primary Biliary Cirrhosis in a Patient with Acute Glomerulonephritis: A Possible Pitfall of a Self-limiting Disease

Acute poststreptococcal glomerulonephritis (APSGN) is a well-established disease. Although various immune responses are thought to be involved in the pathogenesis of APSGN, the disease has a self-limiting nature in clinical practice, despite the presence of severe acute symptoms. We herein report the case of a 78-year-old woman with APSGN who developed primary biliary cirrhosis (PBC) after achieving remission of renal manifestations, including anasarca and elevation of serum creatinine, indicating that persistent alterations in the immune system can cause extrarenal disorders. This case provides insights into the appropriate clinical management of ASPGN and pathogenesis of PBC.