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Pethő Á, Schnabel K, Dézsi L. Complement-mediated dialysis reaction during regular hemodialysis treatment: a case report. J Med Case Rep 2024; 18:46. [PMID: 38326856 PMCID: PMC10851616 DOI: 10.1186/s13256-024-04365-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/05/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Hemodialysis reactions (HDRs) are similar to complement activation-related pseudo allergy (CARPA), a hypersensitivity reaction that occurs when administering certain (nano)drugs intravenously. The pathomechanism of CARPA was described based on animal experiments. Typical CARPA-like dialysis reactions, which occur at the start of hemodialysis, have been reported using polysulfone dialyzers. However, to our knowledge, this is the first dialysis reaction that occurred towards the end of hemodialysis treatment. CASE PRESENTATION This report describes a 52-year-old Caucasian male patient who had been receiving chronic hemodialysis for 3 years and exhibited a CARPA reaction during his third hour of treatment. Upon activation of the microbubble alarm, the extracorporeal system recirculated for five minutes. Following reconnection, the patient exhibited a drop in systemic blood pressure, chest pain, and dyspnea after five minutes. Symptoms disappeared spontaneously after reducing the speed of the blood pump, placing the patient in a Trendelenburg position, and administering a bolus infusion from the dialysis machine. The remaining dialysis treatment was uneventful. CONCLUSION Numerous case reports about reactions occurring with modern high-efficiency polysulfone dialyzers have been published. However, due to changes in the material structure by the manufacturers, we have not encountered such cases lately. The recently reported increase in thromboxane-B2 and pulmonary arterial pressure and complement activation upon re-infusion of extracorporeal blood following dialysis may explain the reaction observed here.
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Affiliation(s)
- Ákos Pethő
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Korányi S. U. 2/a, 1083, Budapest, Hungary.
| | - Karolina Schnabel
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Korányi S. U. 2/a, 1083, Budapest, Hungary
| | - László Dézsi
- SeroScience Ltd., Budapest, Hungary
- Nanomedicine Research and Education Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
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Pethő Á, Fintha A, Kardos M. An unusual complication of kidney biopsy: a case report. J Med Case Rep 2024; 18:41. [PMID: 38308348 PMCID: PMC10837957 DOI: 10.1186/s13256-023-04338-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/26/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND The kidney biopsy is a routine procedure. Once an indication has been established, the benefit-risk balance may be considered. Sometimes, even with effective treatment, a severe complication may develop. CASE PRESENTATION We present the case of a Caucasian 20-year-old young woman admitted to investigating and treating acute kidney injury. Renal involvement was characterized by kidney damage requiring hemodialysis treatment, positive immunologic testing, 0.5 g/day proteinuria, and microscopic hematuria. Contraindications were excluded, so an ultrasound-guided kidney biopsy was performed. To reduce the bleeding complication, Octostim (desmopressin) was administered. There were no direct complications following the kidney biopsy, so we continued the immunosuppressive treatment. Histologically founded thrombotic microangiopathy. However, 1 week later, severe bleeding developed with the need for urgent surgical left kidney removal. CONCLUSION Kidney biopsy can be considered a routine procedure, and various bleeding episodes are most common in terms of complications, the detection of which is essential. Delayed bleeding complications are rare and can be caused by minor injuries. Our young patient had no injury during the hospitalization. We hypothesized that the developed serious and delayed bleeding complication resulted from effective immunosuppressive treatment. To the best of our knowledge, this is the first such case to date. However, renal biopsy in the case of thrombotic microangiopathy requires caution.
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Affiliation(s)
- Ákos Pethő
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary.
| | - Attila Fintha
- Faculty of Medicine, Department of Pathology and Cancer Research, Semmelweis University, Budapest, Hungary
| | - Magdolna Kardos
- Institute of Pathology, Forensic and Insurance Medicine, Semmelweis University, Budapest, Hungary
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Orosz P, Kollák Z, Pethő Á, Fogarasi A, Reusz G, Hadzsiev K, Szabó T. The Importance of Genetic Testing in the Differential Diagnosis of Atypical TSC2-PKD1 Contiguous Gene Syndrome—Case Series. Children 2023; 10:children10030420. [PMID: 36979978 PMCID: PMC10047143 DOI: 10.3390/children10030420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 02/24/2023]
Abstract
Background: In clinical practice, the possible diagnosis of tuberous sclerosis or polycystic kidney disease is primarily based on clinical criteria, which can later be verified by genetic testing. But in the case of TSC2/PKD1 contiguous gene syndrome (TSC2/PKD1-CGS), the renal appearance of the disease is more serious. Therefore, early genetic analysis is recommended. Methods: Herein we present the report of four children with TSC2/PKD1-CGS, one involving the NTHL1 gene. We aim to emphasize the importance of genetic testing in this rare syndrome. Results: During the follow-up of tuberous sclerosis and polycystic kidney disease patients, it is essential to reappraise the diagnosis if the clinical symptoms’ appearance or onset time is unusual. Targeted genetic testing is recommended. However, early tumor formation necessitates the extension of genetic analysis. Conclusions: An appropriate evaluation of the phenotype is the cornerstone of diagnosing the rare TSC2/PKD1-CGS with the help of genetic results. In addition, malignant tumors could draw attention to an infrequent large deletion.
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Affiliation(s)
- Petronella Orosz
- Bethesda Children’s Hospital, 1146 Budapest, Hungary
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Zita Kollák
- Bethesda Children’s Hospital, 1146 Budapest, Hungary
| | - Ákos Pethő
- Department of Internal Medicine and Oncology Clinic, Faculty of Medicine, Semmelweis University, 1083 Budapest, Hungary
- Correspondence: (Á.P.); (T.S.)
| | | | - György Reusz
- 1st Department of Pediatrics, Faculty of Medicine, Semmelweis University, 1083 Budapest, Hungary
| | - Kinga Hadzsiev
- Department of Medical Genetics, Medical School, Clinical Centre, University of Pécs, 7624 Pécs, Hungary
| | - Tamás Szabó
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- Correspondence: (Á.P.); (T.S.)
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Pethő Á, Szebeni J. Pulmonary hypertension in a hemodialysis porcine model: possible unforeseen causes? Ren Fail 2022; 44:693. [PMID: 35670118 PMCID: PMC9186346 DOI: 10.1080/0886022x.2022.2064305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ákos Pethő
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - János Szebeni
- SeroScience Ltd, Budapest, Hungary.,Department of Translational Medicine, Nanomedicine Research and Education Center, Semmelweis University, Budapest, Hungary
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Pethő Á, Piecha D, Mészáros T, Urbanics R, Moore C, Canaud B, Rosivall L, Mollnes TE, Steppan S, Szénási G, Szebeni J, Dézsi L. A porcine model of hemodialyzer reactions: roles of complement activation and rinsing back of extracorporeal blood. Ren Fail 2021; 43:1609-1620. [PMID: 34882053 PMCID: PMC8667923 DOI: 10.1080/0886022x.2021.2007127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Hemodialysis reactions (HDRs) resemble complement-activation-related pseudoallergy (CARPA) to certain i.v. drugs, for which pigs provide a sensitive model. On this basis, to better understand the mechanism of human HDRs, we subjected pigs to hemodialysis using polysulfone (FX CorDiax 40, Fresenius) or cellulose triacetate (SureFlux-15UX, Nipro) dialyzers, or Dialysis exchange-set without membranes, as control. Experimental endpoints included typical biomarkers of porcine CARPA; pulmonary arterial pressure (PAP), blood cell counts, plasma sC5b-9 and thromboxane-B2 levels. Hemodialysis (60 min) was followed by reinfusion of extracorporeal blood into the circulation, and finally, an intravenous bolus injection of the complement activator zymosan. The data indicated low-extent steady rise of sC5b-9 along with transient leukopenia, secondary leukocytosis and thrombocytopenia in the two dialyzer groups, consistent with moderate complement activation. Surprisingly, small changes in baseline PAP and plasma thromboxane-B2 levels during hemodialysis switched into 30%-70% sharp rises in all three groups resulting in synchronous spikes within minutes after blood reinfusion. These observations suggest limited complement activation by dialyzer membranes, on which a membrane-independent second immune stimulus was superimposed, and caused pathophysiological changes also characteristic of HDRs. Thus, the porcine CARPA model raises the hypothesis that a second "hit" on anaphylatoxin-sensitized immune cells may be a key contributor to HDRs.
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Affiliation(s)
- Ákos Pethő
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Dorothea Piecha
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | | | - Christoph Moore
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Bernard Canaud
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany.,School of Medicine, Montpellier University, Montpellier, France
| | - László Rosivall
- International Nephrology Research and Training Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Tom Eirik Mollnes
- Department of Immunology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Research Laboratory, Nordland Hospital Bodø and Faculty of Health Sciences and TREC, University of Tromsø, Tromsø, Norway.,Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sonja Steppan
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Gábor Szénási
- International Nephrology Research and Training Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - János Szebeni
- SeroScience Ltd, Budapest, Hungary.,Nanomedicine Research and Education Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - László Dézsi
- SeroScience Ltd, Budapest, Hungary.,Nanomedicine Research and Education Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
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Garam N, Tislér A, Pethő Á, Ledó N, Kárpáti Á, Fehér Á, Kardos M, Csomor J, Takács I. Hypercalcemia and renal insufficiency – where can we start? Orv Hetil 2021; 162:514-518. [PMID: 33774602 DOI: 10.1556/650.2021.32013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/31/2020] [Indexed: 11/19/2022]
Abstract
Összefoglaló. Közleményünkben egy 63 éves férfi esetét ismertetjük, aki fáradékonyság, fogyás miatt végzett laboratóriumi vizsgálatokon igazolódó veseelégtelenség és hypercalcaemia miatt került felvételre Klinikánkra. A területen végzett röntgenvizsgálaton a koponyán frontalisan és a sacrumon csonteltérések (temporofrontalisan 13 mm-es, körülírtabb, mérsékelten intenzív árnyék és az S1-es rés sclerosisa) ábrázolódtak, ultrahangvizsgálat során lépmegnagyobbodás volt látható. Tünetei hátterében endokrin vagy malignus betegség nem igazolódott. A háttérben elsősorban myeloma multiplex merült fel, ugyanakkor azt célzott vizsgálatokkal sem megerősíteni, sem kizárni nem lehetett, így csontvelő-biopszia történt. A vesefunkció-romlás okának tisztázása végett vesebiopsziát végeztünk, melynek előzetes eredménye interstitialis nephritist véleményezett óriássejtekkel. Az angiotenzinkonvertáló enzim szérumszintjének ez okból történő vizsgálata emelkedett szintet mutatott, így esetünket Boeck-sarcoidosis extrapulmonalis manifesztációjának tartottuk. Per os szteroidkezelésre a beteg tünetei egyértelmű regressziót mutattak. A csontvelő- és vesebiopszia eredménye megerősítette a Boeck-sarcoidosis diagnózisát. A sarcoidosis ezen extrapulmonalis formája hypercalcaemiával és veseérintettséggel - de tüdőérintettség nélkül - rendkívül ritka, különös tekintettel a vesét érintő formára. Hypercalcaemia nagyjából 7,9%-ban, veseelégtelenség 1,4%-ban fordul elő. Ezen eset alapján fontos hangsúlyozni, hogy a hypercalcaemia és a veseelégtelenség hátterében a gyakoribb endokrin, malignus, hematológiai okok mellett a Boeck-sarcoidosisnak is fel kell merülnie a differenciáldiagnosztika során. Orv Hetil. 2021; 162(13): 514-518. Summary. We present the case of a 63-year-old male patient who was admitted to our Clinic with fatigue, weight loss, hypercalcemia, renal insufficiency and anemia. X-ray showed lesions on the frontal skull and sacral region. On abdominal ultrasound, splenomegaly was detected. Based on these, myeloma multiplex was the most likely initial diagnosis; this, however, could not be confirmed with targeted serum tests, therefore bone marrow biopsy was performed. To clarify the underlying cause of decreased kidney function, renal biopsy was performed, the preliminary results of which revealed interstitial nephritis accompanied by giant cells. Serum angiotensin converting enzyme level was elevated, which led to the diagnosis of Boeck sarcoidosis with extrapulmonary manifestations. Oral corticosteroid therapy was commenced that was followed by regression of the patient's symptoms and laboratory abnormalities. Both the bone marrow and the kidney biopsies supported the diagnosis of Boeck sarcoidosis. Presentation of sarcoidosis with hypercalcemia and renal insufficiency but without the involvement of the lungs is extremely rare. Hypercalcemia occurs in about 7.9% and renal insufficiency in 1.4% of the cases. Based on this case, it is important to highlight that in the background of hypercalcemia and renal failure - beside the more frequent causes such as endocrine and hematological diseases, malignancy - one is to consider the possibility of Boeck sarcoidosis as well. Orv Hetil. 2021; 162(13): 514-518.
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Affiliation(s)
- Nóra Garam
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Onkológiai Klinika, Budapest, Korányi Sándor u. 2/a, 1083
| | - András Tislér
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Onkológiai Klinika, Budapest, Korányi Sándor u. 2/a, 1083
| | - Ákos Pethő
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Onkológiai Klinika, Budapest, Korányi Sándor u. 2/a, 1083
| | - Nóra Ledó
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Onkológiai Klinika, Budapest, Korányi Sándor u. 2/a, 1083
| | - Ágnes Kárpáti
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Onkológiai Klinika, Budapest, Korányi Sándor u. 2/a, 1083
| | - Ágnes Fehér
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Onkológiai Klinika, Budapest, Korányi Sándor u. 2/a, 1083
| | - Magdolna Kardos
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, II. Patológiai Intézet, Budapest
| | - Judit Csomor
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar, I. Patológiai és Kísérleti Rákkutató Intézet, Budapest
| | - István Takács
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Onkológiai Klinika, Budapest, Korányi Sándor u. 2/a, 1083
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Abstract
Objectives: The successful implantation of peritoneal dialysis (PD) catheters is a critical skill procedure with the potential to impact both the short- and long-term success of renal replacement therapy and the patients’ survival. Methods: We retrospectively reviewed our single-center experience with nephrologist-placed minimally invasive, double-cuffed PD catheters (PDCs). Results: The recruitment period was March 2014 through December 2015. The follow-up period lasted until 2016. The mean age of the subjects was 60 ± 18 years and indications for the PD were diuretic resistant acutely decompensated chronic heart failure in seven patients (47%) and end-stage renal disease in eight (53%) patients. Comorbid conditions included diabetes (27%), ischemic heart disease (47%), advanced liver failure (27%), and a history of hypertension (73%). The cohort had a high mortality with five subjects only in severe heart failure group (33%) passing away during the index hospitalization; of the rest, two (13%) had heart transplantation, three (20%) changed modality to hemodialysis, and only five (33%) continued with maintenance PD beyond 1 month. Acute technical complications within the first month were infrequent: one catheter (6%) had drainage problems and one (6%) was lost due to extrusion. There were no serious complications (e.g., organ damage, peritonitis, etc.). Conclusions: In selected cases, particularly in severe diuretic refractory heart failure, PDC placement placed by a nephrologist is feasible with a low rate of complications even in a low-volume center setting. The catheters we placed were all functioning with only minor complications and PD could be started immediately.
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Affiliation(s)
- Ákos Pethő
- a 1st Department of Internal Medicine, Faculty of Medicine , Semmelweis University , Budapest , Hungary
| | - Réka P Szabó
- b Department of Surgery, Faculty of Medicine , University of Debrecen , Debrecen , Hungary
| | - Mihály Tapolyai
- c Medical Services , Ralph H. Johnson VA Medical Center , Charleston , SC , USA.,d Hemodialysis Unit , Fresenius Medical Care Hungary , Hatvan , Hungary
| | - László Rosivall
- e Department of Pathophysiology, International Nephrology Research and Training Center , Semmelweis University , Budapest , Hungary
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Tapolyai MB, Pethő Á, Fülöp T. Whole-Body Imaging Procedures in Resistant Hypertension: Evaluating for Secondary Causes or to Define End-Organ Damages? J Clin Hypertens (Greenwich) 2017; 19:23-25. [DOI: 10.1111/jch.12918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Ákos Pethő
- Division of Nephrology; Department of Medicine; Semmelweis University; Budapest Hungary
| | - Tibor Fülöp
- FMC Extracorporeal Life Support Center; Fresenius Medical Care; Medical and Health Science Center; University of Debrecen; Debrecen Hungary
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