Internal Medicine Commons^™

Fatal Case Of Ebv-Negative Posttransplant Lymphoproliferative Disorder With Hemophagocytic Lymphohistiocytosis In An Adult Kidney Transplant Recipient, Sergio Mazzola Poli De Figueiredo, John C Johnson, Kirill A Lyapichev, Heather L Stevenson, Alfred Lea, Syed Hussain, Rupak D Kulkarni, Jeffrey H Fair, Muhammad Mujtaba, Mike L Kueht

Faculty, Staff and Student Publications

Renal transplantation usually requires the administration of lifelong immunosuppressive therapy to minimize rejection.1 However, while these immunosuppressants are vital to graft protection, they increase the risk of infection and malignancy. Posttransplant lymphoproliferative disorder (PTLD), a troublesome combination of both, covers a wide range of lymphomas, most commonly B-cell type and has been described in pediatric and adult patients.2 Risk factors for PTLD include Epstein-Barr virus (EBV) infection and immunosuppression and the prevalence of adult kidney transplant PTLD is estimated to be 0.5% to 4%, with the highest incidences occurring within the first year of transplant.2-5 …

Hepatic Circadian And Differentiation Factors Control Liver Susceptibility For Fatty Liver Disease And Tumorigenesis, Baharan Fekry, Aleix Ribas-Latre, Rachel Van Drunen, Rafael Bravo Santos, Samay Shivshankar, Yulin Dai, Zhongming Zhao, Seung-Hee Yoo, Zheng Chen, Kai Sun, Frances M Sladek, Mamoun Younes, Kristin Eckel-Mahan

Faculty, Staff and Student Publications

Hepatocellular carcinoma (HCC) is a leading cause of cancer deaths, and the most common primary liver malignancy to present in the clinic. With the exception of liver transplant, treatment options for advanced HCC are limited, but improved tumor stratification could open the door to new treatment options. Previously, we demonstrated that the circadian regulator Aryl Hydrocarbon-Like Receptor Like 1 (ARNTL, or Bmal1) and the liver-enriched nuclear factor 4 alpha (HNF4α) are robustly co-expressed in healthy liver but incompatible in the context of HCC. Faulty circadian expression of HNF4α- either by isoform switching, or loss of expression- results in an increased …

Targeting Hyaluronic Acid Synthase-3 (Has3) For The Treatment Of Advanced Renal Cell Carcinoma, Xiaohan Xu, Kyle L Poulsen, Lijuan Wu, Shan Liu, Tatsunori Miyata, Qiaoling Song, Qingda Wei, Chenyang Zhao, Chunhua Lin, Jinbo Yang

Faculty, Staff and Student Publications

Non-alcohol-associated fatty liver/steatohepatitis (NAFL/NASH) has become the leading cause of liver disease worldwide. NASH, an advanced form of NAFL, can be progressive and more susceptible to developing cirrhosis and hepatocellular carcinoma. Currently, lifestyle interventions are the most essential and effective strategies for preventing and controlling NAFL without the development of fibrosis. While there are still limited appropriate drugs specifically to treat NAFL/NASH, growing progress is being seen in elucidating the pathogenesis and identifying therapeutic targets. In this review, we discussed recent developments in etiology and prospective therapeutic targets, as well as pharmacological candidates in pre/clinical trials and patents, with a …

Renal Cell Carcinoma Of Pelvic Kidney With Atypical Nodal Metastasis: A Diagnostic Challenge, Roshan-E-Shahid Rana, Muhammad Hammad Ather

Section of Urology

Ectopic pelvic kidney is a known congenital anomaly; however, the presence of renal cell carcinoma (RCC) in an ectopic kidney is rare with the evidence available in the form of a few case reports only. In this case report, we present a case of metastatic RCC in the pelvic kidney which became a diagnostic challenge because of atypical contrast-enhanced computed tomographic (CT) characteristics and unusual pattern of lymph node involvement including cervical lymph node in the absence of visceral metastasis. Because of its unusual location and uncertain vascular anatomy, ectopic kidney poses a surgical challenge. Owing to the rarity of …

Role Of The Chemokine System In Liver Fibrosis: A Narrative Review, Kyle L Poulsen, Christina K Cajigas-Du Ross, Jarod K Chaney, Laura E Nagy

Faculty, Staff and Student Publications

BACKGROUND AND OBJECTIVE: Liver fibrosis is a disease with characteristics of an aberrant wound healing response. Fibrosis is commonly the end-stage for chronic liver diseases like alcohol-associated liver disease (ALD), metabolic-associated liver disease, viral hepatitis, and hepatic autoimmune disease. Innate immunity contributes to the progression of many diseases through multiple mechanisms including production of pro-inflammatory mediators, leukocyte infiltration and tissue injury. Chemokines and their receptors orchestrate accumulation and activation of immune cells in tissues and are associated with multiple liver diseases; however, much less is known about their potential roles in liver fibrosis. This is a narrative review of current …

Hiv-Associated Nephropathy Presenting As The First Manifestation Of Hiv-2 Infection, Kamil Sardarli, Rania Daboul, Sumesh Khanal, Sami Zarouk

Conference Presentation Abstracts

HIV-2 is distinguished from HIV-1 with low virulence, longer asymptomatic period, slower decline in CD4 count, low viral load, and low mortality from AIDS. While the kidney pathology associated with HIV-1 is well established, due to its low prevalence, kidney pathology in HIV-2 is not well documented. We report a case of HIV associated nephropathy (HIVAN) as the first presentation in a patient with HIV-2. A 65 year old man from Ghana presented within a few days of arrival to the United States with nausea, loss of appetite, shortness of breath, and bilateral lower extremity edema. He has a past …

Kidney Disease After Heart And Lung Transplantation, Carlos M Zapata, Hassan N Ibrahim

Faculty, Staff and Student Publications

Chronic kidney disease (CKD) is not only common after lung and heart transplantation but also is associated with increased morbidity and mortality due to multiple pre-, peri- and post-transplant factors. While the exact incidence of CKD in this population is not well-defined, it seems to have gradually increased over the years as older recipients are more frequently considered. The increasing success of the procedure and expanding transplant candidate pool has allowed many with comorbid conditions to receive a transplant, which was considered prohibitive in the past. This review presents risk factors that have been linked to CKD as well as …

Dual Paraneoplastic Syndrome In Small Lung Cancer, Kamil Sardarli, Austin M. Morris, Jamal Abukhaled

Conference Presentation Abstracts

Introduction: Small cell lung cancer (SCLC) is an aggressive neuroendocrine lung cancer associated with paraneoplastic syndromes – syndrome of inappropriate ADH (SIADH) in 7-16% of cases and Ectopic ACTH Syndrome (EAS) in 3.5-4.3% of cases. Both syndromes are associated with a poor prognosis in patients with SCLC. We describe a patient who presented with SIADH, leading to a diagnosis of SCLC who subsequently developed EAS. Case Description: A 71-year-old female with a past medical history of hypertension, depression, and tobacco use presented with lethargy. She noted headache, but otherwise was unable to provide history due to altered mentation. Per her …

Renal Disease And The Heart, Hassan N Ibrahim

Faculty, Staff and Student Publications

No abstract provided.

Urinary T Cells Are Detected In Patients With Immune Checkpoint Inhibitor-Associated Immune Nephritis That Are Clonotypically Identical To Kidney T Cell Infiltrates, Shailbala Singh, Leticia C Clemente, Edwin R Parra, Amanda Tchakarov, Chao Yang, Yisheng Li, James P Long, Cassian Yee, Jamie S Lin

Faculty, Staff and Student Publications

Acute kidney injury (AKI) occurs in ~20% of patients receiving immune checkpoint inhibitor (ICI) therapy; however, only 2-5% will develop ICI-mediated immune nephritis. Conventional tests are nonspecific in diagnosing disease pathology and invasive procedures (i.e. kidney biopsy) may not be feasible. In other autoimmune renal diseases, urinary immune cells correlated with the pathology or were predictive of disease activity. Corresponding evidence and analysis are absent for ICI-mediated immune nephritis. We report the first investigation analyzing immune cell profiles of matched kidney biopsies and urine of patients with ICI-AKI. We demonstrated the presence of urinary T cells in patients with immune …

The Impact Of Outpatient Laboratory Alerting Mechanisms In Patients With Aki, Nicole V Tolan, Salman Ahmed, Tolumofe Terebo, Zain M Virk, Athena K Petrides, Jaime R Ransohoff, Christiana A Demetriou, Yvelynne P Kelly, Stacy E F Melanson, Mallika L Mendu

Faculty, Staff and Students Publications

BACKGROUND: AKI is an abrupt decrease in kidney function associated with significant morbidity and mortality. Electronic notifications of AKI have been utilized in patients who are hospitalized, but their efficacy in the outpatient setting is unclear.

METHODS: We evaluated the effect of two outpatient interventions: an automated comment on increasing creatinine results (intervention I; 6 months;

RESULTS: Providers were more likely to document AKI in interventions I (

CONCLUSIONS: An automated comment was associated with improved documented recognition of AKI and the additive intervention of an email alert was associated with increased discontinuation of nephrotoxins, but neither improved clinical outcomes. …

Peritoneal Dialysis Vs. Hemodialysis: The Choice Of Modality Of Dialysis May Drastically Affect The Quality Of Life Of Patients Initiating Dialysis, Deepa Daryani

Clinical Research in Practice: The Journal of Team Hippocrates

A clinical decision report using

Jung HY, Jeon Y, Park Y, et al. Better Quality of Life of Peritoneal Dialysis compared to Hemodialysis over a Two-year Period after Dialysis Initiation. Sci Rep. Jul 16 2019;9(1):10266. https://doi.org/10.1038/s41598-019-46744-1

for a young patient initiating dialysis.

Serum Renin And Major Adverse Kidney Events In Critically Ill Patients: A Multicenter Prospective Study, Alexander H. Flannery, Victor M. Ortiz-Soriano, Xilong Li, Fabiola G. Gianella, Robert D. Toto, Orson W. Moe, Prasad Devarajan, Stuart L. Goldstein, Javier A. Neyra

Pharmacy Practice and Science Faculty Publications

BACKGROUND: Preliminary studies have suggested that the renin-angiotensin system is activated in critical illness and associated with mortality and kidney outcomes. We sought to assess in a larger, multicenter study the relationship between serum renin and Major Adverse Kidney Events (MAKE) in intensive care unit (ICU) patients.

METHODS: Prospective, multicenter study at two institutions of patients with and without acute kidney injury (AKI). Blood samples were collected for renin measurement a median of 2 days into the index ICU admission and 5-7 days later. The primary outcome was MAKE at hospital discharge, a composite of mortality, kidney replacement therapy, or …

Kidney Recovery In Patients With Acute Kidney Injury Treated In Outpatient Hemodialysis Or Rehabilitation Facilities, Melissa Jordan, Victor M. Ortiz-Soriano, Aaron Pruitt, Lauren Chism, Lucas J. Liu, Nourhan Chaaban, Madona Elias, B. Peter Sawaya, Jin Chen, Javier A. Neyra

Internal Medicine Faculty Publications

Rationale & Objective: Since January 2017, patients with acute kidney injury requiring dialysis (AKI-D) can be discharged to outpatient dialysis centers for continued hemodialysis (HD) support. We aimed to examine the rate of kidney recovery, time to recovery, and hospitalization-related clinical parameters associated with kidney recovery in patients with AKI-D.

Study Design: Single-center prospective cohort study.

Setting & Participants: 111 adult patients who were admitted to the University of Kentucky Hospital, experienced AKI-D, and were discharged with need of outpatient HD.

Exposure: Hospitalization-related clinical parameters were evaluated.

Outcome: Kidney recovery as a composite of being alive and no longer requiring …

Anti-Neutrophil Cytoplasmic Antibodies: To Care Or Not To Care, Sara Shahid, Syed H Alam, Lillian Gaber, Salman Ahmed

Faculty, Staff and Students Publications

Anti-neutrophil cytoplasmic antibodies (ANCA) associated vasculitis is a disease process with a wide range of presentations, from asymptomatic or minimally symptomatic disease with positive laboratory testing, to florid acute end-organ damage. Consensus has not been established as to the frequency and/or protocol by which ANCA testing should be repeated. We present the case of a 53-year-old woman who initially came to medical attention with persistent dyspnea and pulmonary infiltrates presumed to be due to acute exacerbation of chronic diastolic congestive heart failure. Extensive infectious disease testing was negative, but ANCA testing was positive. However, because antinuclear antibody (ANA) interference in …

The Relation Of Abo Blood Group To The Severity Of Coronavirus Disease: A Cross-Sectional Study From A Tertiary Care Hospital In Karachi, Fazal Ur Rehman, Syed Furrukh Omair, Fatima Memon, Bakhtawar J. Rind, Danish Ahmed Memon, Syed Ahsan Ali, Bilal Ahmed, Naureen Ali

Section of Internal Medicine

Background: Blood groups are considered to have an impact on the occurrence and severity of coronavirus disease. While among Chinese and Caucasian, blood group O individuals were less and group A were more likely to have severe disease and mortality, data on South Asians aren’t available.
Objective: This study aimed to find out the association of disease severity with blood group among coronavirus disease 2019 (COVID-19) patients.
Materials and methodology: Data were collected on a predesigned questionnaire containing details of patient demographics, medical comorbidities, clinical presentation, and laboratory parameters. Multiple logistic regression was used to determine the association of the …

Frequency And Risk Factors Of Non-Alcoholic Fatty Liver Disease In Helicobacter Pylori-Infected Dyspeptic Patients: A Cross-Sectional Study, Basit Siddiqui, Muhammad Kamran, Shiyam Sunder Tikmani, Rabeea Azmat, Zain Mushtaq, Saad Bin Zafar Mahmood, Muhammad Tahir Khan, Javed Yakoob, Zaigham Abbas

Section of Gastroenterology

Background: In dyspeptic patients with Helicobacter pylori contributes to non-alcoholic fatty liver disease. However, little evidence available from Pakistan.
Objective: The study aims to determine the frequency and risk factors of non-alcoholic fatty liver disease in dyspeptic patients with Helicobacter pylori.
Methods: This cross-sectional study was conducted between 22 November 2016 and 30 June 2018. Adults of age between 18 and 90 years who attended the out-patient department due to abdominal discomfort, pain, fullness, and bloating who underwent upper gastrointestinal tract endoscopy were enrolled after taking informed consent. Patients with celiac disease, inflammatory bowel disease, taking alcohol, pregnant women …

Acute Renal Failure And An Acid-Base Dilemma, Kamil Sardarli, Russell Leong, Matthew Weatherhead, Bhavinkumar Dalal

Conference Presentation Abstracts

Introduction: Acute renal failure (ARF) is well-recognized to result in metabolic acidosis. The acidosis of ARF is associated with decreased ammoniagenesis and anion excretion. Alkalosis in the presence of ARF presents diagnostic uncertainty and therapeutic challenges. This vignette describes a case of ARF resulting in several electrolyte imbalances and metabolic alkalosis. Case Description: A 54-year-old female with past medical history of small bowel resection with colostomy presented for nausea and vomiting for two weeks. On presentation, she was noted to be tachycardic and lethargic. Her workup revealed a serum creatinine of 6.8 mg/dL, blood urea nitrogen of 147 mg/dL, bicarbonate …

Bone Quality In Chronic Kidney Disease Patients: Current Concepts And Future Directions – Part Ii, Kamyar Asadipooya, Mohamed Abdalbary, Yahya Ahmad, Elijah Kakani, Marie-Claude Monier-Faugere, Amr El-Husseini

Internal Medicine Faculty Publications

Background: Patients with chronic kidney disease (CKD) have an increased risk of osteoporotic fractures, which is due not only to low bone volume and mass but also poor microarchitecture and tissue quality. The pharmacological and nonpharmacological interventions detailed, herein, are potential approaches to improve bone health in CKD patients. Various medications build up bone mass but also affect bone tissue quality. Antiresorptive therapies strikingly reduce bone turnover; however, they can impair bone mineralization and negatively affect the ability to repair bone microdamage and cause an increase in bone brittleness. On the other hand, some osteoporosis therapies may cause a redistribution …

Bone Quality In Ckd Patients: Current Concepts And Future Directions – Part I, Kamyar Asadipooya, Mohamed Abdalbary, Yahya Ahmad, Elijah Kakani, Marie-Claude Monier-Faugere, Amr El-Husseini

Internal Medicine Faculty Publications

Background: There is ample evidence that patients with CKD have an increased risk of osteoporotic fractures. Bone fragility is not only influenced by low bone volume and mass but also by poor microarchitecture and tissue quality. More emphasis has been given to the quantitative rather than qualitative assessment of bone health, both in general population and CKD patients. Although bone mineral density (BMD) is a very useful clinical tool in assessing bone strength, it may underestimate the fracture risk in CKD patients. Serum and urinary bone biomarkers have been found to be reflective of bone activities and predictive of fractures …

Adherence To The Kidney Disease: Improving Global Outcomes Ckd Guideline In Nephrology Practice Across Countries, Bénédicte Stengel, Daniel Muenz, Charlotte Tu, Elodie Speyer, Natalia Alencar De Pinho, Christian Combe, Kunihiro Yamagata, Helmut Reichel, Danilo Fliser, Ziad A Massy, Antonio A Lopes, Michel Jadoul, Wolfgang C Winkelmayer, Ronald L Pisoni, Bruce M Robinson, Roberto Pecoits-Filho

Faculty, Staff and Students Publications

INTRODUCTION: The uptake of the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 chronic kidney disease (CKD) Guideline is not fully described in real-world nephrology practice across the world.

METHODS: We used baseline data from the CKD Outcomes and Practice Patterns Study (2013-2017), a 4-country cohort of patients with estimated glomerular filtration rate/min per 1.73 m

RESULTS: The mean age ranged from 65 years in Brazil to 72 years in Germany. Albuminuria (mostly proteinuria) was measured routinely in 36% to 43% of patients in Brazil, Germany, and the United States. Blood pressure control (≤140/90 mm Hg) ranged from 49% in France …

Survey Of Current Practices Of Outpatient Hemodialysis For Aki Patients, Victor M. Ortiz-Soriano, Catherine R. Butler, Marla Levy, Sarah C. Huen, Jorge L. Castaneda, Ankit Sakhuja, Rajit K. Basu, Kathleen D. Liu, Jorge Cerda, Javier A. Neyra

Internal Medicine Faculty Publications

No abstract provided.

Diagnosis Of Early Delayed Graft Function (Dgf) Using Timp-2*Igfpb-7 Product In Transplant Recipients: Preliminary Results, Russell Leong, Cassandra Rodd, Kellyann M. Gomes, Solomiia Savedchuk, Paul S. Kellerman

Conference Presentation Abstracts

Background: DGF is acute kidney injury (AKI) defined as need for dialysis within one week of renal transplant. AKI is defined by a change in serum creatinine (SCr), however early recognition is limited by delay in creatinine rise. Accurate early biomarkers may lead to prevention or treatment of established AKI. The product of two novel biomarkers of cell cycle arrest, tissue Inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein (IGFBP-7) have shown promise in predicting AKI. In prior studies, TIMP-2*IGFPB-7 ≤0.3 had high negative predictive value, and ≥2 high positive predictive value for AKI. Aims - 1) Investigate …

A Patient With Combined Metformin-Induced Lactic Acidosis And Euglycemic Diabetic Ketoacidosis, Kamil Sardarli, Russell Leong, Inayat Gill, Sami S. Zarouk

Conference Presentation Abstracts

Introduction: Metformin is a small, non-protein-bound molecule that can cause lactic acidosis in 6 out of 100,000 patients with a mortality rate of 30-50%. Concurrent euglycemic diabetic ketoacidosis (DKA) from sodium-glucose co-transporter-2 (SGLT2) inhibitor has been reported in one case. We report a unique case of a patient with acute kidney injury (AKI) in the setting of metformin-induced lactic acidosis and osmotic diuresis due to euglycemic DKA complicated by celecoxib use. Case Description: A 66-year-old female with a past medical history of type 2 diabetes mellitus for 21 years on metformin 1000 mg twice daily and empagliflozin 25 mg daily …

Efficacy Of A Mobile Application In A Chronic Kidney Disease Population, Jennifer R. Zamora

Evidence-Based Practice Project Reports

Chronic kidney disease (CKD) is associated with high healthcare costs, poor health outcomes and low quality of life (Donald et al., 2018). The US CKD prevalence is 15%, costing Medicare $79 billion in 2016 (United States Renal Data System, 2018). Self-management could reduce CKD burden (Jeddi, Nabovati, and Amirazodi, 2017). Mobile technology offers a low-cost, ease-of-access platform for chronic disease self-management (Whitehead & Seaton, 2016), potentially slowing disease progression and improving health outcomes (Jeddi, 2017). The purpose of this project was to utilize a CKD-specific mobile application, CARELogiQ, to facilitate symptom management; increasing patient satisfaction and decreasing hospitalizations and ER …

The Implementation Of Exercise For Chronic Kidney Disease And Dialysis Patients, Syed Ahmad Rizvi

Honors College Theses

While commonly known to be the organ that helps with urine production within the human body, the kidney plays one of the most crucial roles in maintaining homeostasis. When establishing all of the roles the kidney has on keeping humans healthy, there is the question of how does the body cope when a patient is diagnosed with kidney failure. One of the more common treatment options that allows the body to continue to function without a kidney is by beginning a patient on a form of dialysis. However, as with any treatment, there will always be a list of side …

Case Series Of Anca Vasculitis As Prognostic Marker For Severity Or Relapse Of Glomerulonephritis., Jake N. Cho, Venkat Chitumalla, Izuchukwu Nwakoby

Nephrology

No abstract provided.

A Case Series Of Hyponatremia And Management In Hospitalized Patients, Jake N. Cho, Rebecca Ong, Izuchukwu Nwakoby

Nephrology

No abstract provided.

Calcium Alkali Thiazide Syndrome, Mehboob A. Rehan Md, Asma Rashid Md, Reema Singh Md, Gabutti Cristina, Luma Mohsin Md, Tausha Allen Md, Paul Stanford Md, James Thomson Md

Internal Medicine

No abstract provided.

Spitting Blood And Casts With Mud: A Rare And Unusual Presentation Of C3 Glomerulonephritis, Gerardo Mederos, Harsh Patel, Menalee Hapuarachchi, Som Aftabizadeh, Prashanth Reddy, Ranjit Nair, Dana Ciobanu, Machaiah Madhrira

Internal Medicine

C3 glomerulonephritis (C3GN) is a rare disease that falls under the umbrella of C3 glomerulopathy. It is manifested by abnormal activation of the alternate pathway resulting in complement deposition in the glomeruli. Kidney biopsy with characteristic findings of electron-dense deposits in the mesangial and capillary wall confirms the diagnosis. Until recently, C3GN presenting with primarily lung involvement had not been reported. We present a unique case of initial pulmonary manifestation C3GN.