Su Woong Jung

Clinicopathological features of diabetic and nondiabetic renal diseases in type 2 diabetic patients with nephrotic-range proteinuria

Abstract Heavy proteinuria with or without features of nephrotic syndrome is associated with many primary and systemic diseases. For diabetic patients, distinguishing nondiabetic renal disease (NDRD) from diabetic nephropathy (DN) is important in choosing treatment modalities and determining renal prognosis. However, clinical relevance of heavy proteinuria is inconsistent with clinical DN assessments. This study investigated the clinicopathological features and renal outcomes of DN and NDRD in type 2 diabetic patients with nephrotic-range proteinuria. We enrolled 220 cases of type 2 diabetic patients who underwent renal biopsy. They were grouped according to the presence of nephritic-range proteinuria and pathological features. Baseline characteristics, laboratory findings, types of pathological diagnosis, and renal outcomes were analyzed in patients with heavy proteinuria. Upon kidney biopsy, 129 patients (58.6%) showed nephritic-range proteinuria. Patients with heavy proteinuria (an average urine protein-to-creatinine ratio of 10,008 ± 7307 mg/gCr) showed lower serum albumin levels and higher total cholesterol levels, but did not show any difference in age, duration of diabetes, renal function, or the presence of retinopathy compared with those with mild-to-moderate proteinuria (an average urine protein-to-creatinine ratio of 1581 ± 979 mg/gCr). Renal biopsy revealed that the prevalence of NDRD was 37.2% in patients with heavy proteinuria, which was significantly lower than that in patients with mild-to-moderate proteinuria (63.7%). The most common pathological types of NDRD were membranous nephropathy (41.7%), IgA nephropathy (14.6%), and minimal change disease (10.4%). NDRD patients showed lower prevalence of diabetic retinopathy and better kidney function irrespective of proteinuria. Immunosuppressive treatment was administered more frequently in patients with heavy proteinuria (56.3%) compared with patients with mild-to-moderate proteinuria (20%) because of the pathological differences according to the amount of proteinuria. Renal outcomes were significantly worse in patients with DN than in patients with NDRD. DN patients with heavy proteinuria exhibited different prevalence of NDRD and worse prognosis. Renal biopsy in type 2 diabetic patients should be more extensively considered to accurately diagnose NDRD, guide further management, and predict renal outcomes, especially in patients with nephrotic-range proteinuria.

Syndrome of inappropriate antidiuretic hormone secretion associated with seronegative neuromyelitis optica spectrum disorder

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a potential cause of hyponatremia of the central nervous system (CNS). Although SIADH has been reported to be associated with many other central nervous disorders, its association with neuromyelitis optica (NMO) or NMO spectrum disorders are rare. NMO is a demyelinating disorder characterized by optic neuritis and transverse myelitis. Aquaporin-4 (AQP4), which is the target antigen for a NMO autoantibody, is the predominant CNS water channel. However, some NMO patients show seronegative AQP4 antibody results. The spectrum of NMO has been changed, and new findings about the disease have been reported. Here, we report a case of seronegative NMO spectrum disorder associated with SIADH.

Hypocomplementemic Urticarial Vasculitis Syndrome with Membranous Nephropathy: Case Report

Urticarial vasculitis is a rare disorder that principally manifests with recurrent urticarial, sometimes hemorrhagic, skin lesions and/or angioedema. Its clinical presentation is not always limited to cutaneous lesions and it can potentially affect other organs, such as the joints, lungs, kidneys, and eyes. Systemic involvement can either be present at the onset of disease or develop over time. In cases with systemic manifestations, urticarial vasculitis is more likely to be associated with a low complement level. We present the case of a teenage boy with hypocomplementemic urticarial vasculitis syndrome (HUVS) that occurred shortly following swine-origin influenza A virus infection in 2009. Afterwards, HUVS was systemically complicated with myositis and membranous nephropathy that developed several months and about 2 years after its onset, respectively. A combination of glucocorticoid and immunosuppressive agents has been used to effectively control disease activity.

Layer-specific analysis of dobutamine stress echocardiography for the evaluation of coronary artery disease.

AbstractAlthough dobutamine stress echocardiography (DSE) is a well-defined tool for the diagnosis of coronary artery disease (CAD), false-negative and false-positive results still occur. This study investigated the diagnostic role of layer-specific analysis using 2-dimensional speckle-tracking echocardiography (STE) during DSE.A total of 121 patients who underwent DSE and showed normal wall motion and ejection fraction during baseline echocardiography were enrolled. All patients underwent coronary angiography after DSE within 2 weeks. The patients were divided into the following 4 groups according to DSE results and CAD status: negative DSE with no significant CAD (n = 73), positive DSE with significant CAD (n = 16), negative DSE with significant CAD (n = 17), and positive DSE with no significant CAD (n = 15). Layer-specific global longitudinal strain (GLS) was assessed in the endocardium, mid-myocardium, and epicardium by STE techniques.Patients with significant CAD were older, more male and showed higher glucose level compared to patients without CAD. But coronary risk factors and previous medications were not different between patients with and without CAD. There were no significant differences in whole myocardium or layer-specific GLS found in the baseline echocardiography. During recovery echocardiography, endocardial GLS was significantly different between patients with and without CAD, regardless of the DSE results. A receiver-operating characteristic curve analysis showed that endocardial GLS (>−16%) was superior for identifying significant CAD during the DSE recovery stage. Diagnostic accuracy was improved by applying the results of endocardial GLS compared with visual estimation of DSE.The assessment of layer-specific strain by STE during DSE was feasible, and the evaluation of poststress endocardial function is a more sensitive tool for the detection of CAD.

[PP.17.04] BLOOD PRESSURE WAS ASSOCIATED WITH GLOMERULOMEGALY, INTERSTITIAL FIBROSIS AND RENAL PROGRESSION IN IGA NEPHROPATHY

Objective: Several factors contribute to the development of hypertension in patients with IgA nephropathy (IgAN). This study was conducted to find the relationships between baseline blood pressure and clinico-pathological findings in patients with IgAN and normal renal function. Design and method: Clinico-pathological findings were analyzed in a total of 163 patients with IgAN and normal serum creatinine levles from The Kyung-Hee Cohort of Glomerulonephritis. The glomerular surface area (GSA) was determined in the renal biopsy specimen using imaging analysis software. The serum and urine angiotensinogen (AGT) concentrations were measured using human ELISA kits. Results: Systolic BP was >130 mmHg in 72 patients (44%) and >140 mmHg in 42 (26%). Systolic BP was positively correlated with age, serum uric acid concentrations, IgM deposit and baseline and follow-up proteinuria, and negatively with follow-up glomerular filtration rate and the slope of change in 1/serum creatinine for 2 years, while it has no significant relationships with serum and urine AGT and 24 hour urinary sodium excretion. Patients with systolic BP >130 mmHg as compared with those <130 mmHg showed higher GSA, severer degree of interstitial fibrosis, larger amount of proteinuria after follow-up, and higher serum creatinine and lower glomerular filtration rate after follow-up. Conclusions: Baseline systolic BP was associated with renal progression and severe pathological findings, glomerulomegaly and interstitial fibrosis, in patients with IgAN.

Renal Tubular Acidosis in Patients with Primary Sjögren's Syndrome

Primary Sjögrens syndrome (pSS) is characterized by lymphocytic infiltration of the exocrine glands resulting in decreased saliva and tear production. It uncommonly involves the kidneys in various forms, including tubulointerstitial nephritis, renal tubular acidosis, Fanconi syndrome, and rarely glomerulonephritis. Its clinical symptoms include muscle weakness, periodic paralysis, and bone pain due to metabolic acidosis and electrolyte imbalance. Herein, we describe the cases of two women with pSS whose presenting symptoms involve the kidneys. They had hypokalemia and normal anion gap metabolic acidosis due to distal renal tubular acidosis and positive anti-SS-A and anti-SS-B autoantibodies. Since one of them experienced femoral fracture due to osteomalacia secondary to renal tubular acidosis, an earlier diagnosis of pSS is important in preventing serious complications.

Elevated serum immunoglobulin E level as a marker for progression of immunoglobulin A nephropathy.

Background Immunoglobulin E (IgE) has traditionally been associated with anaphylaxis and atopic disease. Previous studies reported that serum IgE levels are elevated in nephrotic syndrome and suggested IgE levels as a prognostic indicator in glomerular diseases. The aim of this study was to explore the association between serum IgE levels and renal outcome in patients with immunoglobulin A nephropathy (IgAN). Methods We included 117 patients with biopsy-proven IgAN. Renal progression was defined if a patient meets one of these criteria: (1) a negative value of delta estimated glomerular filtration rate (mL/min/1.73 m2/mo) or (2) a rise in serum creatinine to an absolute level of ≥ 1.3 mg/dL (male) or 1.2 mg/dL (female). We defined delta changes in serum creatinine, estimated glomerular filtration rate, and proteinuria as a difference of values during the follow-up period. Results A total of 117 patients with IgAN were included. The serum IgE level was significantly high in the renal progressive group compared with the nonprogressive group. Sex and history of gross hematuria were significantly different between the high-IgE group and the low-IgE group. Regression analysis showed that a male sex, initial proteinuria, and change of proteinuria were significantly associated with serum IgE levels. Conclusion The serum IgE level is potentially associated with disease progression and pathogenesis of IgAN.

ISH NIA PS 02-02 The different predictive role of serum triglyceride to high-density lipoprotein cholesterol ratio according to kidney function in patients with acute myocardial infarction (from the Korea Acute Myocardial Infarction Registry)

Objective: High serum triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio has been reported as an independent predictor for cardiovascular events in the general population. However, the prognostic effect of the TG/HDL-C ratio on patients with kidney dysfunction is unclear. We examined the association of TG/HDL-C ratio and major adverse cardiovascular events (MACEs) in patients with acute myocardial infarction (AMI) according to kidney function. Design and Method: This study was based on a retrospective cohort, the Korean Acute Myocardial Infarction Registry (KAMIR) database. Among 13,897 patients who diagnosed AMI from November 2005 to July 2008, we studied 8,225 patients who had baseline TG/HDL-C ratio. Patients were categorized into three groups by estimated glomerular filtration (eGFR) and the TG/HDL-C ratio was categorized into tertiles based on the quantity of the study population and the distribution of TG/HDL-C ratio. The primary end point was 12-month MACEs including cardiac death, MI, and repeated PCI or coronary artery bypass grafting. Results: During 12-month follow up period, 686 patients (8.3%) had MACEs. The log-rank test identified a significant association between the TG/HDL-C ratio and MACEs (p < 0.001) in the whole study cohort. In patients with normal kidney function (eGFR > 60 ml/min per 1.73 m2) and mildly reduced kidney function (eGFR = 60–89 ml/min per 1.73 m2), higher TG/HDL-C ratio was associated with increased risk of MACEs (hazard ratio [HR] 1.65, 95% confidence interval [CI] 1.01–2.69, p = 0.018; HR 1.46, 95% CI 1.06–1.99, p = 0.02, respectively). However, in patients with moderately reduced kidney function (eGFR < 60 ml/min per 1.73 m2), higher TG/HDL-C ratio did not associated with increased risk of MACEs (HR 1.42, 95% CI 0.93–2.17, p = 0.104). Conclusions: A higher serum TG/HDL-C ratio is associated with increased risk of MACEs in patients with normal and mildly reduced kidney function. However, in patients with moderately reduced kidney function, the TG/HDL-C ratio did not revealed significant association with MACEs.