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Background Acute tubulointerstitial nephritis (ATIN) is a very rare paraneoplastic manifestation in patients with multiple myeloma (MM). It is an uncommon pattern of renal disease in such patients. Case presentation We report a case of an 82-year-old male who was admitted with acute kidney injury. Renal biopsy showed typical findings of light chain-associated ATIN with scattered inflammatory cells in the interstitium and associated active tubulitis. No other common manifestations of MM were present at the time of presentation, including hypercalcemia, hyperuricemia, proteinuria, bone pain or lytic bone lesions. Subsequent immunoassays revealed significant serum lambda light chain burden and Bence Jones protein in urine. Immunofluorescence demonstrated linear tubular basement membranes with positive staining for lambda light chain (3+). Electron microscopy (EM) further showed interstitial edema and inflammation. All the aforementioned findings are consistent with ATIN and supported the diagnosis of MM. Conclusions In conclusion, light chain-associated ATIN should be considered in the differential diagnosis of acute interstitial nephritis. Henceforth, serum free light chains as well as serum and urine protein electrophoresis should be included in the workup of such patients. more...

Background: Calcium-alkali syndrome, formerly known as milk-alkali syndrome was a classic cause of hypercalcemia until newer therapies for peptic ulcer disease emerged is mostly seen today in osteoporosis prevention and secondary hyperparathyroid treatment in chronic kidney disease. Here we present the contemporary presentation as a result of the classic syndrome. Case: 57-year-old male, history of hypertension, type-2 diabetes, Hodgkin’s lymphoma in remission was admitted with lower abdominal pain and difficulty voiding. His vitals and physical exam were within normal limits. Medications included Janumet, Lipitor and Ramipril. Labs showed a white count of 15.3cells 103 /uL with a left shift and a normal hemoglobin level. Serum chemistry with BUN of 37mg/dl, creatinine at 3.86mg/dl, calcium at 15.3mg/dl, albumin level of 3.4g/dl, corrected to 15.5mg/dl, phosphorous was low at 1.6mg/dl with normal magnesium level of 1.7mg/dl. The patient had prior normal renal function and calcium levels. Lymphoma was highest on the differential for the hypercalcemia. Workup revealed intact PTH of 9.9pg/ml (Low), PTHrp at 12pg/ml (14-27), 1,25- dihydroxy vitamin D level of more...

Objective To compare the accuracy of R 2 CHADS 2 , CHADS 2 , and CHA 2 DS 2 -VASc scores vs the Society of Thoracic Surgeons (STS) score as predictors of morbidity and mortality after cardiovascular surgery. Methods All patients who underwent cardiothoracic surgery at our institution from January 2008 to July 2013 were analyzed. Only those patients who fulfilled the criteria for STS score calculation were included. The R 2 CHADS 2 score was computed as follows: 2 points for GFR 2 (R 2 ), prior stroke or TIA (S 2 ); 1 point for history of congestive heart failure (C), hypertension (H), age ≥75 years (A), or diabetes (D). Area under the curve (AUC) analysis was used to estimate the accuracy of the different scores. The end point variables included operative mortality, permanent stroke, and renal failure as defined by the STS database system. Results Of the 3,492 patients screened, 2,263 met the inclusion criteria. These included 1,160 (51%) isolated valve surgery, 859 (38%) coronary artery bypass graft surgery, and 245 (11%) combined procedures. There were 147 postoperative events: 75 (3%) patients had postoperative renal failure, 48 (2%) had operative mortality, and 24 (1%) had permanent stroke. AUC analysis revealed that STS, R 2 CHADS 2 , CHADS 2 , and CHA 2 DS 2 -VASc reliably estimated all postoperative outcomes. STS and R 2 CHADS2 scores had the best accuracy overall, with no significant difference in AUC values between them. Conclusion The R 2 CHADS 2 score estimates postoperative events with acceptable accuracy and if further validated may be used as a simple preoperative risk tool calculator. more...

Background Immune checkpoint inhibitors have become the first line therapy in melanoma treatment and their use is extending to other malignancies. However, we are still learning about immune side effects produced by these drugs and their severity especially in patients with history of inflammatory diseases. Case presentation We present two cases of metastatic melanoma treated with nivolumab and pembrolizumab (anti PD-1). Both patients developed acute interstitial nephritis during immune checkpoint therapy. We emphasize the causal association between immune checkpoint inhibitors and the nephritis. The timing of drug administration and appearance of nephritis is suggestive of a causal relation between the checkpoint inhibitor therapy and this adverse event. Conclusions Although uncommon, some side effects from checkpoint inhibitors can be severe and may need to be addressed with immunosuppression. Given the increasing frequency of immunotherapy use, awareness should be raised in regards to immune side effects and their appropriate management. more...