A hemodialysis patient who escaped aggravation of COVID-19 after SARS-COV-2 infection

　Dialysis patients are compromised hosts; thus, they might become even more seriously ill in the case of infection with severe acute respiratory syndrome coronavirus 2 (SARS-COV-2).　A man in his 50s under maintenance dialysis was accidentally a close contact of someone with SARS-COV-2 infection. Therefore, he received the PCR test for SARS-COV-2 three days a week at the time of his visit to our hospital for his hemodialysis session. He was admitted the day after the result of the PCR test was positive. This patient belongs to a high-risk group with severe illnesses, including the fact that he had not been vaccinated against SARS-COV-2. He received antibody cocktail therapy (casirivimab/imdevimab) on the day he was hospitalized. As a result, he escaped aggravation of COVID-19. This case suggests the important of early diagnosis and early treatment with this cocktail therapy for prevention of aggravation of COVID19 in high-risk hemodialysis patients

漢方薬と利尿薬による低カリウム血症によって横紋筋融解症が誘発された１例

　症例は92歳，女性．近医で高血圧や認知症で通院加療中であった．下肢の疼痛に対し，芍薬甘草湯が処方されていた．入院4か月前から下肢の浮腫が出現したためにループ利尿薬の内服が開始された．入院10日前の血液検査で血清カリウム値2.1 mmol/L と低カリウム血症であったために芍薬甘草湯とループ利尿薬の休薬を指示し，カリウム製剤の内服が開始となっていた．入院当日の朝、自宅内を歩行中に転倒し動けなくなったところを近隣の人に発見され当院へ救急搬送となった．受診時，著明な低カリウム血症（1.8 mmol/L），CK 3.612 U/L から低カリウム血症による横紋筋融解症と診断し，補液とカリウム補正を開始した．入院時の検査で低レニン・低アルドステロン血症，尿中カリウム排泄亢進を認めた．甘草を含有する芍薬甘草湯による偽性アルドステロン症と診断し，同剤の中止とカリウム補正によって入院10日目にほぼ正常化した．高齢者において，漢方薬は比較的副作用が少ないことから処方される機会が多い．しかし，高齢者では多数の内服薬が処方されることが多く，各薬剤の服用状況や副作用，それらの相互作用について注意する必要があると考えられる．　The patient was a 92-year–old woman, who was being treated at a nearby clinic for hypertension and dementia. She received Shakuyaku-kanzo-To, an herbal medicine for muscle pain and four months previously she had been started on a loop diuretic agent because of leg edema. However, her serum potassium gradually decreased to 2.1 mmol/L. Therefore, both Shakuyaku-Kanzo-To and the loop diuretic agent were discontinued and administration of potassium supplement was initiated. But, she noticed muscle weakness and was admitted to our hospital. Laboratory data revealed a serum potassium level of 1.8mmol/L. She was diagnosed with rhabdomyolysis indicated by markedly high levels of CPK and urinary myoglobin. On admission, she presented with low plasma rennin activity and hypoaldosteronism, as well as high urinary excretion of potassium. We diagnosed her with pseudoaldosteronism caused by the licorice extracts contained in Syakuyaku-Kanzo-To. Discontinuation of Shakuyaku-Kanzo-To and potassium supplementation successfully normalized her electrolyte imbalance. Because Shakuyaku-Kanzo-To has relatively few adverse effects, its use by elderly patients is continuing to increase. We think it is important to create awareness of the possible adverse effects of Shakuyaku-Kanzo-To

尿路感染症を合併した薬剤性横紋筋融解症の一例

　症例は74歳，女性．近医で糖尿病や脂質異常症，高血圧と診断され加療中であった．当院へ全身倦怠感や筋力低下を主訴に搬送された．搬送時の身体所見で全身倦怠感や筋力が低下しており，血中のCPK，ミオグロビンの著明な上昇を認めた．血中クレアチニンやBUN の上昇，乏尿を認め，急性腎不全を併発した．身体症状や血液検査，尿検査などから横紋筋融解症と診断し，入院１日目から持続血液透析を施行し，筋力や腎機能は徐々に改善した．横紋筋融解症の原因としては，外傷性要因と非外傷性要因に分類される．その中で薬剤性における脂質異常症治療薬の頻度が高い．他にも多くの原因があり，感染症を原因とした報告もある．また，多数の要因によって横紋筋融解症が生じると指摘されているが，詳細については明確にされていない．薬剤性横紋筋融解症の原因の一つに血糖降下薬が挙げられる．さらに感染症を併発することで横紋筋融解症を発症させた報告がある．しかし，発症機序として薬剤と感染症がどのように関与したかは明確でない．横紋筋融解症は，薬剤，外傷をはじめとして多くの原因によって発症する．そのため，それぞれ単一の要因では横紋筋融解が生じない場合でも，各々の要因が合併することでより発症しやすい状況になりえた可能性があり注意を要する．　The patient was a 74-year-old woman, who was being treated at a nearby clinic for diabetes mellitus, dyslipidemia and hypertension. She was admitted to our hospital with a chief complaint of general malaise and muscle weakness. The laboratory tests revealed increased serum levels of creatine phosphokinase (CPK) and myoglobin. Urinary volume was decreased and serum creatinine level was increased. A diagnosis of rhabdomyolysis was made based on physical findings and labolatory and urinary data. Continuous hemodialysis (CHD) was performed for acute renal failure. Muscular strength and renal function improved gradually. The causes of rhabdomyolysis could be traumatic and nontraumatic. Statin-induced rhabdomyolysis is the most commonly reported. There are multiple potential causes of rhabdomyolysis, but it isn\u27t done clearly about details. Prolonged use of oral hypoglycemic drugs also maylead to drug-induced rhabdomyolysis. There also has been the report of a case of infection-induced rhabdomyolysis. But, there is no evidence how infection related to a drug. Various factors have been reported to cause rhabdomyolysis. Rhabdomyolysis will rarely be induced by only one of those factors; however, it may easily develop in the presence of plural factors

The Effect of Medical Cooperation in the CKD Patients: 10-Year Multicenter Cohort Study

Introduction: While chronic kidney disease (CKD) is one of the most important contributors to mortality from non-communicable diseases, the number of nephrologists is limited worldwide. Medical cooperation is a system of cooperation between primary care physicians and nephrological institutions, consisting of nephrologists and multidisciplinary care teams. Although it has been reported that multidisciplinary care teams contribute to the prevention of worsening renal functions and cardiovascular events, there are few studies on the effect of a medical cooperation system. Methods: We aimed to evaluate the effect of medical cooperation on all-cause mortality and renal prognosis in patients with CKD. One hundred and sixty-eight patients who visited the one hundred and sixty-three clinics and seven general hospitals of Okayama city were recruited between December 2009 and September 2016, and one hundred twenty-three patients were classified into a medical cooperation group. The outcome was defined as the incidence of all-cause mortality, or renal composite outcome (end-stage renal disease or 50% eGFR decline). We evaluated the effects on renal composite outcome and pre-ESRD mortality while incorporating the competing risk for the alternate outcome into a Fine-Gray subdistribution hazard model. Results: The medical cooperation group had more patients with glomerulonephritis (35.0% vs. 2.2%) and less nephrosclerosis (35.0% vs. 64.5%) than the primary care group. Throughout the follow-up period of 5.59 +/- 2.78 years, 23 participants (13.7%) died, 41 participants (24.4%) reached 50% decline in eGFR, and 37 participants (22.0%) developed end-stage renal disease (ESRD). All-cause mortality was significantly reduced by medical cooperation (sHR 0.297, 95% CI 0.105-0.835, p = 0.021). However, there was a significant association between medical cooperation and CKD progression (sHR 3.069, 95% CI 1.225-7.687, p = 0.017). Conclusion: We evaluated mortality and ESRD using a CKD cohort with a long-term observation period and concluded that medical cooperation might be expected to influence the quality of medical care in the patients with CKD

透析患者に発症したアシクロビル脳症の1例

患者は75歳女性で,慢性腎不全に対して近医で透析を受けていた.右足底の帯状疱疹に対し近医皮膚科よりアシクロビル2,400mg/日が投与された.その後しゃべりにくさとふらつき,異常な言動が出現した.近医よりアシクロビル内服中止を指示され,内服を中止したが症状の改善がないため当院へ救急搬送され精査目的で入院した.入院時意識レベルはJCS20～30.構音障害を認め,顔面,口唇,舌,四肢にジスキネジア様の不随意運動を認めた.クレアチニンクリアランスは5.46ml/min/1.73m^2と著明に低下していた.髄液細胞数は正常であった.頭部MRIで左前頭葉の急性期脳梗塞と左頭頂葉の萎縮を認めたが症状と合致しないこと,髄液細胞数が正常であること,アシクロビル投与後に症状が出現していることから,アシクロビル脳症を疑った.透析を継続し,症状は改善を認めた.アシクロビルの血中濃度は,入院日が高値で,当院での第1回目の透析後に速やかに低下していた.アシクロビル脳症は,抗ヘルペスウイルス薬のアシクロビル,塩酸バラシクロビルの投与により誘発される精神神経症状であり,意識障害,振戦,ミオクローヌス,錯乱,混迷,傾眠,幻覚,昏睡など多彩な症状が出現する.本症例のアシクロビル投与量は,添付文書に記載されているクレアチニンクリアランスを考慮した投与量よりも過剰であったことが,脳症発症の一因と思われた.ヘルペスウイルス感染症に対してアシクロビルを投与後に精神神経症状が出現した場合,ウイルス性脳炎とアシクロビル脳症とを早急に鑑別することが重要で,早期に髄液検査や頭部CT,MRI等を施行すべきと考える.また,透析患者にアシクロビルを投与する場合は投与量に十分な注意を払い,脳症が出現する可能性も念頭に置き,慎重な経過観察が重要と考える.We report the case of a 75-year-old woman under hemodialysis who developed aciclovir encephalopathy. She was administered aciclovir at a dose of 2,400 mg/day by a dermatologist because of herpes zoster on her right sole. Later she complained of speech disturbance and dizziness. She said abnormal words. Although she discontinued using aciclovir, her symptoms did not improve. Thus, she was admitted to our hospital. Her consciousness level was JCS20～30. On neurological examination, she had dysarthria and dyskinesia-like involuntary movements in the face, lips, tongue and all extremities. On laboratory data, creatinine clearance was 5.46 ml/min/1.73m^2. Cell count of cerebrospinal fluid was normal. Brain MRI revealed acute cerebral infarction of the left frontal lobe and atrophy of the left parietal lobe. But these findings did not coincide with her symptoms. She was diagnosed with aciclovir encephalopathy. Her symptoms improved after hemodialysis. The serum concentration of aciclovir was 9.20μg/ml on admission, and decreased promptly after the first hemodialysis. Aciclovir encephalopathy is characterized by neuropsychiatric symptoms such as disturbance of consciousness, tremor, myoclonus, confusion, stupor, drowsiness, hallucination, and coma. It can be induced also by valaciclovir. The cause of aciclovir encephalopathy in our patient was assumed to be due to a dose too high for her low creatinine clearance rate. When neuropsychiatric symptoms occur during treatment with aciclovir for herpes viral infection, cerebrospinal fluid cytology and brain CT and/or MRI should be performed to distinguish viral encephalitis from acyclovir encephalopathy. When aciclovir is used in patients under hemodyalysis, attention must be paid to the aciclovir dose and the clinical course should be carefully monitored because of the risk of aciclovir encephalopathy

A hemodialysis patient who escaped aggravation of COVID-19 after SARS-COV-2 infection

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