Know Your Patients’ History; Spleno-Renal Infarction as a Presentation of Infective Endocarditis

Bacterial endocarditis is an infection of the endothelial surface of the heart, including heart valves and is potentially life threatening. Antibiotic prophylaxis is indicated prior to invasive procedures in patients with certain high-risk cardiac conditions and thorough history needs to be elicited prior to performing such procedures. Herein, we present a case of splenorenal infarction secondary to septic emboli in a 42-year-old patient with prosthetic aortic valve who underwent a dental procedure without endocarditis prophylaxis

Natriuretic Peptides as Biomarkers for Congestive States: The Cardiorenal Divergence

Congestion represents the primary reason for hospitalization of patients with heart failure and is associated with adverse outcomes. Fluid overload has been shown to be inadequately addressed in a significant subset of these patients in part due to lack of robust, reliable, and readily available biomarkers for objective assessment and monitoring of therapy. Natriuretic peptides have long been used in this setting, often in conjunction with other assessment tools such as imaging studies. Patients presenting with concomitant cardiac and renal dysfunction represent a unique population with regard to congestion in that the interactions between the heart and the kidney can affect the utility and performance of biomarkers of fluid overload. Herein, we provide an overview of the currently available evidence on the utility of natriuretic peptides in these patients and discuss the clinical conundrum associated with their use in the setting of renal dysfunction. We highlight the potential divergence in the role of natriuretic peptides for assessment of volume status in a subset of patients with renal dysfunction who receive renal replacement therapy and call for future research to elucidate the utility of the biomarkers in this setting

Nephrotic syndrome in very elderly: Should we treat aggressively?

Chronic kidney disease and acute kidney injury are being increasingly recognized in very elderly patients, aged 80 or more. In cases of suspected glomerulonephritis with or without nephrotic syndrome, the clinical decision-making of whether to obtain a renal biopsy and treat with immunosuppressive therapy should not be based on advanced age alone but take into consideration the patient’s functional status and overall prognosis. Herein, we report a case of an elderly patient with minimal change disease who benefitted from a timely renal biopsy and aggressive immunosuppressive therapy

Venous Excess Doppler Ultrasound for the Nephrologist: Pearls and Pitfalls

The role of venous congestion in abnormal kidney function is being increasingly recognized. It is well known that unresolved congestion is associated with adverse kidney and overall outcomes in patients with heart failure. Similarly, any condition that leads to elevated central venous pressure, such as pulmonary hypertension, can result in impaired kidney perfusion by increasing its afterload. Point-of-care ultrasonography (POCUS) enables the clinician to objectively assess hemodynamics at the bedside and, thereby, guide patient management. Lung POCUS has received widespread attention in the recent past because of the relative ease of the technique, but it reflects only left heart pressures and not venous congestion. Although inferior vena cava POCUS is used to estimate right atrial pressure, its isolated use cannot demonstrate organ congestion. Moreover, it is associated with several technical and conceptual limitations. Recently, venous excess Doppler ultrasound has emerged as a tool to assess venous congestion at the organ level in real time. Severe flow abnormalities in hepatic, portal, and kidney parenchymal veins have shown to predict the risk of congestive kidney injury. In addition, it helps to objectively monitor the efficacy of decongestive therapy. In this review, we provide a brief overview of various components of venous excess Doppler ultrasound and share our perspective on incorporating this novel tool in nephrology practice

Hypokalemia: A potentially life-threatening complication of tenofovir therapy

Tenofovir is a nucleotide analog reverse transcriptase inhibitor approved for the treatment of HIV and hepatitis B infections. It is widely prescribed and an integral part of the recommended regimens for the treatment of HIV infection in antiretroviral-naive patients. Tenofovir is implicated in renal proximal tubular dysfunction, which can be associated with Fanconi syndrome and hypokalemia. When the hypokalemia is severe, it can lead to life-threatening complications. We describe the case of a 59-year-old woman who suffered a cardiac arrest secondary to severe hypokalemia from tenofovir use

Bone-eating kidney disease

In the current era of early detection of chronic kidney disease and efficient therapeutic options for management of its complications, skeletal manifestations of renal hyperparathyroidism are increasingly rare. A 31-year-old female patient presented for evaluation of severe pain in the left forearm, right hand, right knee, right hip, and lower back following a fall sustained 3 days prior to presentation. She had a history of end-stage renal disease and received maintenance hemodialysis. Review of the medical records revealed that she had poor compliance with her diet, medications, and dialysis treatments. Laboratory values were significant for marked elevation in serum parathyroid hormone level (1735 pg/mL), as well as hyperphosphatemia and normal serum calcium levels. Interestingly, X-ray images showed generalized severe demineralization of the extremities with the pelvic computed tomography scan revealing presence of diffuse brown tumors. In addition, she had insufficiency fractures of the extremities that left her incapacitated and had to be managed conservatively due to her poor functional status and ongoing severe hyperparathyroidism. Unfortunately, the patient refused surgical removal of the parathyroid glands and was hence treated with a high-dose phosphate binder and a calcimimetic agent together with reinforcement of compliance. This case highlights the importance of metabolic assessment of patients presenting with unexpected bone complications and can be used to raise awareness of the physicians on the extreme cases of mineral bone complications secondary to renal disease that are observed rarely

Transcending boundaries: Unleashing the potential of multi-organ point-of-care ultrasound in acute kidney injury

Acute kidney injury (AKI) is a clinical syndrome characterized by a rapid increase in serum creatinine levels or a decrease in urine output or both. In spite of thorough history-taking, physical examination, and laboratory analysis, there are limitations in the diagnostic process and clinical monitoring of AKI. Point-of-care ultrasonography (POCUS), a limited ultrasound study performed by clinicians at the bedside, has emerged as a valuable tool in different clinical settings. In this discussion, we explore the potential of POCUS performed by nephrologists to address specific questions encountered in the diagnosis and management of AKI patients. POCUS not only aids in excluding hydronephrosis but also provides real-time insights into hemodynamics, enabling formulation of individualized treatment plans. Further studies are required to assess the impact of multi-organ POCUS on pragmatic patient outcomes related to AKI, as well as its potential in risk stratification and identification of different levels of AKI severity and pathophysiological signatures