Peri-renal and Renal Involvement in Acute Pancreatitis

Introduction: Acute pancreatitis is a common disease characterized by release and activation of proteolytic enzymes which lead to nonspecific inflammation of the pancreas and surrounding tissue. Inflammation can spread to nearby retroperitoneal organs like the kidneys and spleen. Renal involvement can range from acute kidney injury, perirenal fat stranding with perirenal fluid collection to renal vein thrombosis and parenchymal abnormalities. Case Description: 68 years old male with past medical history significant for type 2 diabetes mellitus and bladder cancer s/p cystectomy with ileal conduit presented with acute onset peri-umbilical abdominal pain and vomiting. He was found to be in diabetic ketoacidosis (DKA) and had an elevated lipase. Abdominal CT without contrast showed a complex cystic mass associated with the pancreatic tail that drapes over the upper pole and anterior margin of the mid left kidney with stranding and haziness in the adjacent fat. CA 19-9 was elevated. Working diagnosis was acute pancreatitis and patient was treatment with aggressive fluid resuscitation. MRCP showed parenchymal changes within the left kidney with multiple perinephric loculations and complex collections, partially encasing the left kidney and extending superiorly to the tail of the pancreas. Findings were concerning for pyelonephritis and peri-nephric abscess therefore urology were consulted. Findings were attributed to acute pancreatitis with spread of inflammation to the left kidney. Patient’s symptoms improved and he was discharged home with repeat imaging in 2 weeks. Repeat imaging showed resolving inflammation and no underlying masses. Discussion: This case necessitated involvement of different specialties to determine whether the findings were due to renal process as opposed to a pancreatic process. Patient had complex urological anatomy after his cystectomy with ileal conduit which predisposed him to pyelonephritis. However, patient symptoms improved after conservative management. He was afebrile and did not develop any leukocytosis. Attempts to drain the fluid collection around the kidneys might predispose the patient to fistula formation. It is very important to know that renal and perirenal involvement is a common finding in acute pancreatitis. A study showed that perirenal fat stranding was found in 62% of patients with acute pancreatitis and 40% had perirenal fluid collection. Conclusion: Understanding that renal and peri-renal involvement is a common finding in acute pancreatitis can prevent unnecessary investigations and interventions.https://scholarlycommons.henryford.com/merf2019caserpt/1038/thumbnail.jp

A Medical Red Herring: Cardiomyopathy presenting as Acute Liver Injury

Introduction: Heart failure secondary to cardiomyopathy is a known cause of acute liver injury and in severe cases even progression to liver failure. In the setting of severe transaminase elevation, patients may often be misdiagnosed with primary liver injury secondary to acute viral hepatitis, or drug-induced liver injury. Case Presentation: 32-year-old female 5 months post-partum with no past medical history presented with a 2-week history of nausea, vomiting, abdominal pain, and general malaise. Initial laboratory studies revealed acute liver injury with ALT of 2086, AST of 1880, alkaline phosphatase of 400, an INR of 1.62. She denied any alcohol use, acetaminophen use, or intravenous drug use. On physical exam she had trace lower extremity edema, clear breath sounds bilaterally, strong peripheral pulses, and warm extremities. Her viral hepatitis screen was negative. Abdominal ultrasound showed increased echogenicity, mild ascites, and prominent hepatic veins. Echocardiography was completed which showed an ejection fraction of 21%, hypokinesis of the left ventricle, and severely reduced right ventricular function. Shortly thereafter she developed cardiogenic shock requiring inotropic agents, placement of Impella device, and was eventually listed for a heart transplant. Conclusion: This case highlights the importance of assessing cardiac function in patients with otherwise unexplained liver injury. In the absence of left ventricular symptoms and significantly elevated serum transaminases, patients may undergo in-depth liver evaluation prior to assessment of cardiac function. Prompt recognition of cardiocirculatory failure in such patients may expedite further cardiac workup and timely use of inotropes, hemodynamic support devices, and cardiac transplant evaluation.https://scholarlycommons.henryford.com/merf2020caserpt/1095/thumbnail.jp

Serum glutamine and hospital-acquired infections after aneurysmal subarachnoid hemorrhage

OBJECTIVE: To understand nutritional and inflammatory factors contributing to serum glutamine levels and their relationship to hospital-acquired infections (HAIs) after aneurysmal subarachnoid hemorrhage (SAH). METHODS: A prospective observational study of patients with SAH who had measurements of daily caloric intake and C-reactive protein, transthyretin, tumor necrosis factor α receptor 1a (TNFαR1a), glutamine, and nitrogen balance performed within 4 preset time periods during the 14 days after SAH. Factors associated with glutamine levels and HAIs were analyzed with multivariable regression. HAIs were tracked daily for time-to-event analyses. Outcome 3 months after SAH was assessed by the Telephone Interview for Cognitive Status and modified Rankin Scale. RESULTS: There were 77 patients with an average age of 55 ± 15 years. HAIs developed in 18 (23%) on mean SAH day 8 ± 3. In a multivariable linear regression model, negative nitrogen balance ( CONCLUSIONS: Declining glutamine levels in the first 14 days after SAH are influenced by inflammation and associated with an increased risk of HAI

Alginate reduces the increased uptake of cholesterol and glucose in overweight male subjects: a pilot study

Dietary fibers are of particular interest in the prevention and management of obesity and consequent pathologies. Among the proposed mechanisms of action of fiber is the modulation of nutrient uptake from the small intestine. We have used a crossover study design in human subjects to monitor the uptake of glucose, cholesterol, and triacylglycerols in human subjects with normal and high body mass index. Our data demonstrate that uptakes of glucose, triacylglycerols, and cholesterol are all increased with increasing body fat. We demonstrate that treatment with a 1.5-g dose of a strong-gelling alginate may restore uptake of cholesterol and glucose to the levels of healthy subjects. These data indicate a potential therapeutic application of gelling fibers. (C) 2008 Published by Elsevier Inc

Complex effects of inhibiting hepatic apolipoprotein B100 synthesis in humans

Mipomersen (Kynamro®) is an antisense oligonucleotide (ASO) that inhibits apolipoprotein B (apoB) synthesis; its LDL lowering effects should, therefore, result from reduced secretion of VLDL. We enrolled 17 healthy volunteers who received placebo injections weekly for 3-wks followed by mipomersen weekly for 7-9 wks. Stable isotopes were used after each treatment to determine fractional catabolic rates (FCRs) and production rates (PRs) of apoB in VLDL, IDL, and LDL, and of TG in VLDL. Mipomersen significantly reduced apoB in VLDL, IDL, and LDL associated with increases in FCRs of VLDL and LDL apoB and reductions in PRs of IDL and LDL apoB. Unexpectedly, the PRs of VLDL apoB and VLDL TG were unaffected. siRNA knockdown of apoB expression in HepG2 cells demonstrated preservation of apoB secretion across a range of apoB synthesis. Titrated ASO knockdown of apoB mRNA in chow-fed mice showed preservation of both apoB and TG secretion. In contrast, titrated ASO knockdown of apoB mRNA in high fat fed mice resulted in stepwise reductions of both apoB and TG secretion. Mipomersen lowered all apoB-lipoproteins without reducing the PR of either VLDL apoB or TG. Our first-in-human data are consistent with longstanding models of post-transcriptional and post-translational regulation of apoB secretion, and are supported by experiments with siRNA in HepG2 cells and ASO in mice. These results indicate that targeting apoB synthesis can lower levels of apoB-lipoproteins without necessarily reducing VLDL secretion, thereby reducing the risk of steatosis associated with this therapeutic strategy

Macronutrients, Food Groups, and Eating Patterns in the Management of Diabetes: A systematic review of the literature, 2010

The effectiveness of medical nutrition therapy (MNT) in the management of diabetes has been well established (1). Previous reviews have provided comprehensive recommendations for MNT in the management of diabetes (2,3). The goals of MNT are to 1 ) attain and maintain optimal blood glucose levels, a lipid and lipoprotein profile that reduces the risk of macrovascular disease, and blood pressure levels that reduce the risk for vascular disease; 2 ) prevent and treat the chronic complications of diabetes by modifying nutrient intake and lifestyle; 3 ) address individual nutrition needs, taking into account personal and cultural preferences and willingness to change; and 4 ) maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence (4). The literature on nutrition as it relates to diabetes management is vast. We undertook the specific topic of the role of macronutrients, eating patterns, and individual foods in response to continued controversy over independent contributions of specific foods and macronutrients, independent of weight loss, in the management of diabetes. The position of the American Diabetes Association (ADA) on MNT is that each person with diabetes should receive an individualized eating plan (4). ADA has received numerous criticisms because it does not recommend one specific mix of macronutrients for everyone with diabetes. The previous literature review conducted by ADA in 2001 supported the idea that there was not one ideal macronutrient distribution for all people with diabetes. This review focuses on literature that has been published since that 2001 date (5). This systematic review will be one source of information considered when updating the current ADA Nutrition Position Statement (4). Other systematic reviews and key research studies that may not be included in this review will also be considered. When attempting to tease out the role of macronutrients from other dietary

Effects of APOC3 Heterozygous Deficiency on Plasma Lipid and Lipoprotein Metabolism.

Objective- Apo (apolipoprotein) CIII inhibits lipoprotein lipase (LpL)-mediated lipolysis of VLDL (very-low-density lipoprotein) triglyceride (TG) and decreases hepatic uptake of VLDL remnants. The discovery that 5% of Lancaster Old Order Amish are heterozygous for the APOC3 R19X null mutation provided the opportunity to determine the effects of a naturally occurring reduction in apo CIII levels on the metabolism of atherogenic containing lipoproteins. Approach and Results- We conducted stable isotope studies of VLDL-TG and apoB100 in 5 individuals heterozygous for the null mutation APOC3 R19X (CT) and their unaffected (CC) siblings. Fractional clearance rates and production rates of VLDL-TG and apoB100 in VLDL, IDL (intermediate-density lipoprotein), LDL, apo CIII, and apo CII were determined. Affected (CT) individuals had 49% reduction in plasma apo CIII levels compared with CCs ( P<0.01) and reduced plasma levels of TG (35%, P<0.02), VLDL-TG (45%, P<0.02), and VLDL-apoB100 (36%, P<0.05). These changes were because of higher fractional clearance rates of VLDL-TG and VLDL-apoB100 with no differences in production rates. CTs had higher rates of the conversion of VLDL remnants to LDL compared with CCs. In contrast, rates of direct removal of VLDL remnants did not differ between the groups. As a result, the flux of apoB100 from VLDL to LDL was not reduced, and the plasma levels of LDL-cholesterol and LDL-apoB100 were not lower in the CT group. Apo CIII production rate was lower in CTs compared with CCs, whereas apo CII production rate was not different between the 2 groups. The fractional clearance rates of both apo CIII and apo CII were higher in CTs than CCs. Conclusions- These studies demonstrate that 50% reductions in plasma apo CIII, in otherwise healthy subjects, results in a significantly higher rate of conversion of VLDL to LDL, with little effect on direct hepatic uptake of VLDL. When put in the context of studies demonstrating significant protection from cardiovascular events in individuals with loss of function variants in the APOC3 gene, our results provide strong evidence that therapies which increase the efficiency of conversion of VLDL to LDL, thereby reducing remnant concentrations, should reduce the risk of cardiovascular disease