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Urinary extracellular vesicles (uEVs) are emerging as non-invasive biomarkers for various kidney diseases, but it is unknown how differences in nephron mass impact uEV excretion. To address this, uEV excretion was measured before and after human kidney donor nephrectomy and rat nephrectomy. In male and female donors, uEVs were quantified in cell-free spot and 24-h urine samples using nanoparticle tracking analysis (NTA), EVQuant, and CD9-time-resolved fluorescence immunoassay. Female donors had significantly lower total kidney volume (TKV) and excreted 49% fewer uEVs than male donors. uEV excretion correlated positively with estimated glomerular filtration rate (eGFR), creatinine clearance, and TKV (R's between 0.6 and 0.7). uEV excretion rate could also be predicted from spot urines after multiplying spot uEV/creatinine by 24-h urine creatinine. Donor nephrectomy reduced eGFR by 36% ± 10%, but the excretion of uEVs by only 16% (CD9+ uEVs -37%, CD9- uEVs no decrease). Donor nephrectomy increased the podocyte marker WT-1 and the proximal tubule markers NHE3, NaPi-IIa, and cubilin in uEVs two- to four-fold when correcting for the nephrectomy. In rats, the changes in GFR and kidney weight correlated with the changes in uEV excretion rate (R = 0.46 and 0.60, P th nephrectomy). Taken together, our data show that uEV excretion depends on nephron mass, and that nephrectomy reduces uEV excretion less than expected based on nephron loss due to compensatory hypertrophy. The major implication of our findings is that a measure for nephron mass or uEV excretion rate should be included when comparing uEV biomarkers between individuals.

Infection is a possible cause of rhabdomyolysis. We describe the case of a 63-year-old male with malaise and erythematous papules on the right C5–C7 dermatomes, consistent with herpes zoster. Serum antibody and Tzanck tests of the skin lesion were positive. Increased serum creatine kinase (CK) and myoglobin levels and cola-colored urine indicated the development of rhabdomyolysis. Acute kidney injury was also observed. After excluding other possible predisposing factors, the patient was diagnosed with varicella-zoster virus (VZV)-induced rhabdomyolysis. Extracellular volume with alkalized fluids and topical acyclovir was administered. While CK levels declined to normal by day 13, the renal function was not restored. The skin lesion crusted by day 8 and scaled off gradually by day 13. Our case and literature review highlighted the necessity for systemic antiviral treatment and that poor VZV infection control could lead to irreversible kidney injury. In addition, systemic acyclovir should be administered carefully due to its complication of nephrotoxicity.

Introduction: Patients with carbon monoxide poisoning (COP) commonly have long-term morbidities. However, it is not known whether patients with COP exhibit an increased risk of developing chronic kidney disease (CKD) and whether hyperbaric oxygen therapy (HBOT) alters this risk. Methods: This study identified 8,618 patients who survived COP and 34,464 propensity score-matched non-COP patients from 2000 to 2013 in a nationwide administrative registry. The primary outcome was the development of CKD. The association between COP and the risk of developing CKD was estimated using a Cox proportional hazards regression model; the cumulated incidence of CKD among patients stratified by HBOT was evaluated using a Kaplan-Meier analysis. Results: After adjusting for covariates, the risk of CKD was 6.15-fold higher in COP patients than in non-COP controls. Based on the subgroup analyses, regardless of demographic characteristics, environmental factors, and comorbidities, the COP cohort exhibited an increased risk of developing CKD compared with the controls. The cumulative incidence of CKD in COP patients did not differ between the HBOT and non-HBOT groups (p = 0.188). Conclusions: COP might be an independent risk factor for developing CKD. Thus, clinicians should enhance the postdischarge follow-up of kidney function among COP patients.

A phytobezoar is defined as an accumulation of poorly digested fruit and vegetable fibers in the gastrointestinal tract. Phytobezoar-induced small bowel obstruction is an uncommon entity and is usually removed surgically. We herein describe an elderly man undergoing dialysis who developed a phytobezoar because of excessive consumption of high-fiber fruits and inappropriate chewing. His potential predisposing factors were dialysis-related lifestyle changes, reduced activity levels, fluid restriction, and gastrointestinal motility dysfunction; however, he had no history of gastric surgery. The patient’s clinical history and characteristic imaging features aided in the diagnosis. He underwent medical treatment, and his recovery was uneventful. This case highlights the importance of an awareness of phytobezoar-induced small bowel obstruction in patients at increased risk of developing bezoars and demonstrates that this condition can occur in the absence of previous gastric surgery. We believe that elderly patients undergoing dialysis are at increased risk of developing bezoars. Excessive consumption of a strictly fibrous diet and insufficient chewing exacerbate the risk. A detailed dietary history and imaging features can aid in early diagnosis, leading to appropriate medical or surgical care. Surgical treatment is not inevitable in all cases. Individualized dietary suggestions in these patients are important for effective preventive control.

Background Acute water intoxication after hysteroscopy is a rare, life-threatening condition, often accompanied with delayed diagnosis owing to masked symptoms because of general anesthesia. Case presentation Herein we presented a 39-year-old female who presented with cardiac arrest after hysteroscopic myomectomy because of acute water intoxication and survived after extracorporeal membrane oxygenation, continuous venous–venous hemofiltration, and aggressive high sodium fluid resuscitation. Conclusion Failure to recognize and treat this condition appropriately may lead to potentially lethal cardiopulmonary complications.

Methotrexate has immunosuppressive effects and is administered for refractory chronic urticaria. We present a case of Pneumocystis jirovecii pneumonia in a patient with refractory chronic urticaria managed by low-dose weekly methotrexate treatment (total cumulative dose 195mg). Our study highlights the importance of providing prompt diagnosis and treatment of Pneumocystis jirovecii pneumonia in patients with chronic urticaria under methotrexate therapy.

Object Traumatic intracranial hemorrhage (TICH) patients with acute kidney injury (AKI) were reported to have a high mortality rate. Renal replacement therapy (RRT) is indicated for patients with a severe kidney injury. This study aimed to compare the effects of different RRT modalities regarding chronic dialysis rate among adult TICH patients with AKI. Methods A retrospective search of computerized hospital records from 2000 to 2010 for patients with a discharge diagnosis of TICH was conducted to identify the index cases. We collected the data of TICH patients with increased intracranial pressure combined with severe AKI who received intermittent hemodialysis (IHD) or continuous veno-venous hemofiltration (CVVH) as RRT. The outcome was dialysis dependence between 2000 and 2010. Results From a total of 310 patients who were enrolled in the study, 134 (43%) received CVVH and 176 (57%) received IHD. The risk of dialysis dependency was significantly lower in the CVVH group than in the IHD group (adjusted hazard ratio: 0.368, 95% CI, 0.158–0.858, P = 0.034). Diabetes mellitus and coronary artery disease were risk factors for dialysis dependency. CVVH compared with IHD modality was associated with lower dialysis dependency rate in TICH patients combined with AKI and diabetes mellitus and those with an injury severity score (ISS) ≥16. Conclusion CVVH may yield better renal outcomes than IHD among TICH patients with AKI, especially those with diabetes mellitus and an ISS ≥16. The beneficial impact of CVVH on TICH patients needs to be clarified in a large cohort study in future.

Background We evaluated the risk of osteoporosis in patients with primary biliary cirrhosis (PBC) using a nationwide population-based dataset. Methods In a cohort study of 986,713 individuals, we selected 2,493 PBC patients who were aged 18 years or older and had been diagnosed with PBC, based on the International Classification of Disease (ICD-9-CM) codes 571.6, during 20002010. The control cohort comprised 9,972 randomly selected, propensity matched patients (by age, gender, and index date), without PBC. Using this adjusted data, a possible association between PBC and the risk of developing osteoporosis was estimated using a Cox proportional hazard regression model. Results During the follow-up period, osteoporosis was diagnosed in 150 (6.02%) patients in the PBC cohort and in 539 (5.41%) patients in the non-PBC cohort. After adjusting for covariates, osteoporosis risk was found to be 3.333 times greater in the PBC cohort than in the non-PBC cohort when measured over 6 years after PBC diagnosis. Stratification revealed that the use of ursodeoxycholic acid (UDCA) had no significance in decreasing the risk of osteoporosis when comparing the PBC cohorts with the non-PBC cohorts (P = 0.124). Additionally, osteoporosis risk was significantly higher in PBC patients with steroid use (aHR: 6.899 vs 3.333). Moreover, when comparing the PBC cohorts to the non-PBC cohorts, the non-cirrhotic patients were prone to osteoporosis at a younger age compared to those in the cirrhotic cohorts. We also found that the associated risk of fractures is only prominent for vertebral and wrist fractures in the PBC cohort compared to that in the non-PBC cohort. Conclusion A significant association exists between PBC and subsequent risk for osteoporosis. Therefore, PBC patients, particularly those treated with steroids, should be evaluated for subsequent risk of osteoporosis.

An 83-year-old man was admitted to our intensive care unit after endotracheal intubation for pneumonia associated with acute respiratory failure. He had a history of chronic obstructive pulmonary disease controlled with medication. Dyspnea and oxygen desaturation developed on day 7. A follow-up supine chest radiograph showed a linear radiolucent area in the right upper abdominal quadrant (Fig. 1a). Physical examination revealed mild upper abdominal tenderness and bilateral chest crackles. Computed tomography indicated a right pneumothorax and generalized emphysematous change of lung tissue (Fig. 1b). After placement of a chest tube, the clinical manifestations improved, and the radiolucent lesion disappeared on the subsequent chest radiograph (Fig. 1c). The deep sulcus sign, indicating a pneumothorax, appears as a continuous, radiolucent, and deep costophrenic angle on a supine chest radiograph. Intrapleural air distributes in a non-dependent way, and accumulates from the anteromedial region to the laterocaudal region as the pneumothorax increases [1]. In our case, the pneumothorax may have resulted from rupture of a bulla in the right upper lung. A pleural line due to expansion of the right posterior lobe of the lung was not visible on chest radiography. The deep sulcus sign was interrupted by adhesion of lung tissue

A 48-year-old man with a history of dilated cardiomyopathy was admitted because of acute decompensated heart failure. On day 4, the patient was transferred to the intensive care unit because of shock of unknown etiology. The patient complained of lower abdominal fullness, and the urine output was only 40 ml in the preceding 10 h. Suprapubic abdominal ultrasonography showed massive fluid accumulation (Fig. 1a, b). With the impression of acute urine retention, urethral catheterization was performed without difficulty, but no urine drainage occurred. A urethral false passage was suspected, and Urology was consulted for cystoscopy. Before cystoscopy, the patient had an abdominal computed tomography that showed massive ascites and an empty bladder (Fig. 1c). Heart failure-related massive ascites and prerenal acute kidney injury due to diuretic overdose over several days were diagnosed. Excluding post-renal acute kidney injury is the first of diagnosis in a patient with limited urine output and abdominal fullness. Although we performed ultrasonography on the patient, two factors led to misdiagnosis initially. First, an unskilled practitioner misinterpreted the ascites as a large bladder on ultrasonic imaging. Second, right-sided heart failure is a less common cause of massive ascites than cirrhosis in clinical practice. In the present case, pelvic ascites mimicked urine in the bladder, and a urethral false passage was suspected because the Foley catheter balloon was outside the fluid. A full bladder is usually rectangular, thin-walled in configuration, and anechoic with the urine on a transverse scan [1]. In comparison, the border confining the ascites in this case was pear-shaped and hyperechoic. The hyperechoic reverberation in the fluid on ultrasonography was the empty bladder (Fig. 1a). Ultrasonography of Morrison’s pouch or the splenorenal recess for ascites detection is another technique for a differential diagnosis. Skillfully interpreted abdominal ultrasonography prevented unnecessary invasive procedures in the present case.

Life-threatening refractory metabolic acidosis due to starvation ketoacidosis is rarely reported, even among nondiabetic pregnant women, and may be overlooked. Furthermore, stressful situations may increase the acidosis severity. In the present case, a nondiabetic multiparous woman was admitted for a near-fatal asthma attack and vomiting during the third trimester of pregnancy. She was intubated and rapidly developed high anion gap metabolic acidosis. We diagnosed the patient with starvation ketoacidosis based on vomiting with concomitant periods of stress during pregnancy and the absence of other causes of high anion gap metabolic acidosis. She responded poorly to standard treatment, although the ketoacidosis and asthma promptly resolved after an emergency caesarean section. The patient and her baby were safely discharged. Short-term starvation, if it occurs during periods of stress and medication, can result in life-threatening ketoacidosis, even among nondiabetic women during the third trimester of pregnancy. Awareness of this condition may facilitate prompt recognition and proactive treatment for dietary and stress control, and emergent interventions may also improve outcomes.