We investigated the effect of weight reduction on blood pressure, microalbuminuria and renal function in hypertensive patients with obesity for over 12 months.Twenty-five patients with a body mass index (BMI) of over 25 were prescribed low calorie diet (25 kcal/kg).All patients had mild hypertension and microalbuminuria.They were classified into 2 groups after 12 months.Group A consisted of 10 patients who had a weight loss of at least 5 %.Group B consisted of 15 patients who did not have any weight loss. The following results were obtained.(1) The percentage of patients with hyperfiltration (GFR;more than 140 ml/min) was 20%.(2) Blood pressure, fasting plasma insulin level, urinary sodium and albumin excretion rate were significantly decreased in Group A.On the other hand, these changes were not observed in Group B.(3) Reduction in mean arterial blood pressure significantly correlated with the fall in body weight.(4) Renal function did not change during the study period in both groups.(5) Urinary albumin excretion rate significantly correlated with weight reduction, decrease in blood pressure and fasting insulin levels. Blood pressure and urinary albumin excretion rate in hypertensive patients with obesity significantly decreased with weight reduction.Probably, weight loss improves insulin resistance and decrease in the plasma insulin level causes a reduction in blood pressure and urinary albumin excretion rate.

View full abstract

Some outpatients with only mild urinary abnormalities have histologically active lesions. To prevent the progression of these lesions, they should not be overlooked at the initial diagnosis. For this purpose, I propose a new system of diagnostic cooperation between physicians in private practice and hospitals. A 50-year-old male showed proteinuria (_??_), occult blood (_??_), and one granular and red cell cast in the total fields in spot urine samples, a 24 hr urinary protein of 0.17 g, a serum creatinine of 1.2 mg/dl and a mean blood pressure of 112 mmHg at the first examination. Four months after the administration of an ACE-inhibitor, the urinary protein decreased to 0.04 g while the serum creatinine level increased to 1.5mg/dl. Therefore, a biopsy was performed at Kyoto University Hospital. Twenty-one glomeruli were obtained revealing 6 with global sclerosis and 13 proliferative glomeruli, including 3 with crescentic and 4 with adhesive lesions. In addition, interstitial cell infiltration was observed. After treatment for active blomeruli lesions using prednisolone and warfarin, the 24 hr urinary protein decreased to 0 g and serum creatinine to 1.2 mg/dl, Since a correlation between the relative volume of the renal cortical interstitial involvement and the serum creatinine concentration has been reported, the possibility of glomerularinterstitial interaction was considered. Thus, to prevent the neglect of patients with apparently mild disease associated with a poor prognosis, I propose the establishment of a system of diagnostic cooperation consisting of physicians in private practice, general hospitals and central hospitals that can provide appropriate treatment principles and give instructions for patients with mild urinary abnormalities encountered in daily practice.

View full abstract

A 76-year-old woman, who had received hemodialysis due to chronic renal failure of unknown cause for two months, was admitted to our hospital. She was suffering from severe pain in the left thigh, rapidly progressive anemia and thrombocytopenia after receiving a contusion on her left thigh. Soon after admission, the patient died of shock. Autopsy revealed multiple myeloma (lamda type) with extramedullary plasmacytoma and systemic amyloidosis. In the kidney, there were typical tubular casts with multinucleated giant cells and interstitial fibrosis. More specific findings included an extramedullary plasmacytoma in the left iliopsoas muscle surrounded by a huge hematoma. Internal hemorrhage resulting from indirect contusion at this site was likely to have caused her shock. Since typical clinical findings of multiple myeloma, such as serum M protein and hypercalcemia, were not found in this case, it was difficult to make a diagnosis of multiple myeloma. In cases of multiple myeloma, micro-or macroscopic extramedullary tumor formation is not rare, but there has been no report of a case with macroscopic tumor formed in skeletal muscle, exhibiting massive hemorrhage. We report here a case of multiple myeloma with an unusual clinical course

View full abstract

A 63-year-old man was referred to our hospital for rapid deterioration of his renal function. He had worked as a metal founder for more than 40 years, and had been diagnosed as having silicosis. Laboratory data on admission showed severe anemia, thrombocytopenia, and end-stage renal failure (BUN 88.8 mg/ dl, serum creatinine 9.0mg/dl). Myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) was also detected in his sera. On the next day after admission, he complained of sudden dyspnea and hemoptysis. Mechanical ventilation with pure oxygen was insufficient to improve hypoxia without concomitant use of percutaneous cardio-pulmonary support (POPS) and continuous hemofiltration (CHF). We diagnosed his condition as MPO-ANCA-associated rapidly progressive glomerulonephritis with diffuse alveolar hemorrhage. Treat ment with plasmapheresis, pulse methylprednisolone and pulse cyclophosphamide effectively improved his hemoptysis as well as chest X-ray findings and blood gas analysis. However on his later clinical course, he was complicated with superimposed complex infection and passed away. Autopsy findings showed crescentic glomerulonephritis in the kidneys and silica nodules in the lungs. Recently it has been postulated that some relationship exists between ANCA-associated (especially MPO-ANCA-associated) glomerulonephritis and silica exposure. The reported cases of glomerulonephritisin the patients with silica exposure showed a rapidly progressive clinical course and pauci-immune necrotizing crescentic glomerulonephritis in their histology. Gregorini et al, reported that 12 of 37 (32%) male patients with RPGN had either silicosis or significant silica exposure, and 7 of 8 patients examined were ANCA-positive (6 of 7 were MPO-ANCA-positive). Therefore silica seems to cause glomerulonephritis by disrupting the immune response. Including this case mentioned above, we have experienced 10 cases of MPO-ANCA-associated glomerulonephritis, at least 3 cases out of which had suffered from silicosis in the past (30%) . These results indicate that silicosis should be considered a relevant pathogen of MPO-ANCA-associated glomerulonephritis beyond the race.

View full abstract

A 56-year-old female with symptomatic epilepsy was admitted to our hospital because of acute renal failure (ARF) and liver dysfunction (LD) after receiving CBZ for two months. She had suffered a drug eruption caused by phenobarbital and valproate six months previously. Renal and liver biopsies presented acute interstitial nephritis and active chronic hepatitis, respectively. Drug-induced lymphocyte stimulating test showed CBZ positivity. Steroid therapy resulted in recovery from ARF and LD. CBZ sometimes causes ARF or LD, but rarely induces both simultaneously, especially in adults. Pathological evidence of two lesions other than from autopsy seems to be the first step in this case. Cross reaction with other antiepileptic agents was also of interest, suggesting that one member of the cytochrome P450 subfamily, CYP3A, participated in the mechanism.

View full abstract

Acute tubulointerstitial nephritis is associated with a variety of causes, such as drug interaction, and infectious or immunological mechanisms. We describe a patient who suffered from sepsis, septic shock, disseminated intravascular coagulation (DIC), hepatic failure and renal failure after receiving a bite from her house cat. The causes of her acute renal failure were initially thought to be due to circulatory failure with hypotensive shock, decrease in renal blood flow with fibrin formation by DIC, or microangiopathy such as hemolitic uremic syndrome. However, the renal biopsy on the 60th hospital day indicated tubulointerstitial nephritis, which was recognized by the presence of patchy and focal mononuclear small cell infiltration with invasion to the tubular epithelium. We concluded that prolonged renal failure was caused by tubulointerstitial nephritis. The cause of tubulointerstitial nephritis was not identified. Tubulointerstitial nephritis should be taken into consideration when the recovery from acute renal failure is slow.

View full abstract