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Background: Diabetic ketoacidosis entails a huge health burden among patients with diabetes. Atrial fibrillation (AF) is the most common type of heart arrhythmia. This study aimed to evaluate the impact of AF on clinical outcomes in patients with diabetic ketoacidosis., Methods: Using the 2012-2014 National Inpatient Sample database, we identified adult patients hospitalized with diabetic ketoacidosis as the principal discharge diagnosis. The identified admissions were stratified into 2 cohorts based on the AF presence. We used multivariable regression models and propensity score matching models to evaluate in-hospital mortality, length of stay, comorbidities, and in-hospital complications., Results: The study included 478,890 adult patients who were admitted for diabetic ketoacidosis in the year 2012-2014. A total of 467,780 (97.68%) had no AF and 11,125 (2.32%) had AF. In both multivariable regression models and propensity score matching models, compared with nonatrial fibrillation group, the AF group had higher in-hospital mortality rates (2.36 [1.69-3.32], P < 0.001) and longer length of stay (5.5 versus 3.3 days, P < 0.001). AF was also associated with a significantly higher incidence of complications including septic shock, pulmonary failure, mechanical ventilation, neurological failure, cerebral edema, acute kidney injury, acute hematologic failure, and cardiac arrest., Conclusions: Among patients who were hospitalized for diabetic ketoacidosis, comorbid AF led to increasing in-hospital mortality rates and longer length of stay. A potential explanation was that AF increased the risk of in-hospital complications including respiratory failure with a more frequent requirement for mechanical ventilation, cardiac arrest, and metabolic encephalopathy., (Copyright © 2019 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Background: Diabetic nephropathy remains one of the most common causes of chronic kidney disease in the United States and is associated with significant morbidity and mortality. Recently, there have been emerging data highlighting the role of vitamin D and its analogue in chronic kidney disease especially diabetic nephropathy independent of its effect on bone metabolism., Methods: This study aimed to evaluate effect of supplementing vitamin D and its analogues on halting or slowing progression of diabetic nephropathy. Electronic databases (PubMed, Scopus, Google scholar) were searched and randomized controlled trials (RCTs) that investigated the use of vitamin D and its analogs for diabetic nephropathy were studied. This meta-analysis of RCTs performed in accordance with Preferred Reporting Items for Systematic review and Meta-analysis statement., Results: This meta-analysis included 9 RCTs and suggested a favorable trend with respect to an effect of vitamin D and its analogues on albuminuria though this did not reach statistical significance (MD, -0.17; 95% CI, -0.34-0.01; P = 0.06]. Serum calcium was unaffected suggesting safe use of these agents., Conclusions: Use of vitamin D and its analogues may have potential as an adjuvant therapy for reducing albuminuria and slowing progression of diabetic nephropathy but further studies are needed., (Copyright © 2018. Published by Elsevier Inc.)

Background: There is controversy over the prevalence of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral or renal salt wasting (RSW), 2 syndromes with identical common clinical and laboratory parameters but different therapies. The traditional approach to the hyponatremic patient relies on volume assessment, but there are limitations to this method., Methods: We used an algorithm that relies on fractional excretion of urate (FEurate) to evaluate patients with hyponatremia and present 4 illustrative cases., Results: Overall, 2 patients had increased FEurate [normal: 4-11%], as is seen in SIADH and RSW. A diagnosis of SIADH was made in 1 patient by correcting the hyponatremia with 1.5% saline and observing a characteristic normalization of an elevated FEurate that is characteristic of SIADH as compared to FEurate being persistently increased in RSW. A patient with T-cell lymphoma had symmetrical leg edema due to lymphomatous obstruction of the inferior vena cava, postural hypotension, pleural effusion, ascites, decreased cardiac output and urine sodium level of 10mmol/L. Saline-induced excretion of dilute urines and undetectable plasma antidiuretic hormone were consistent with RSW. Furosemide, given for presumed heart failure, induced a profound diuresis that required large volumes of fluid resuscitation. A normal FEurate identified a reset osmostat in a transplant patient with a slowly developing pneumocystis carinii pneumonia. A volume-depleted hyponatremic patient with Addison׳s disease had a low FEurate of 1.4%., Conclusions: These illustrative cases suggest that an approach to hyponatremia using FEurate may be a useful alternative to traditional volume-based approaches., (Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Background: Renin-angiotensin system (RAS) blockers slow the progression of chronic kidney disease (CKD). Despite this, up to 40% of patients with CKD and an indication for RAS blockade do not receive these medications. The purpose of this study was to examine variables associated with the prescription of RAS blockers in patients with CKD and to identify opportunities to increase their use., Methods: The electronic medical records of patients with moderate to severe CKD and an indication for RAS blockade were reviewed. For patients with an indication for RAS blockade who were not prescribed these medications, previous notes were reviewed to ascertain reasons why RAS blockade was not prescribed., Results: Six hundred twenty-seven patients with moderate to severe CKD and an indication for RAS blockade were identified. Of these patients, 225 (36%) were not prescribed RAS blockade. This group was found to have significantly less diabetes, to be significantly older and to have significantly lower estimated glomerular filtration rate and blood pressure than the group on RAS blockade. For the majority (59%), no documented reason for not being prescribed RAS blockade was found. Among documented reasons, hyperkalemia and a history of acute kidney injury were the most common., Conclusions: The authors found that a large proportion of patients with CKD and an indication for RAS blockade were not prescribed these medications. For the majority, there was no provider-documented reason explaining why these medications were not prescribed, and the findings suggest that there may be opportunities to increase RAS blocker prescribing.

Introduction: Acute kidney injury may be the presenting manifestation of multiple myeloma, although optimal use of immunofixation testing in this setting is incompletely defined. The authors attempted to determine clinical and laboratory predictors of positive immunofixation testing in patients with acute kidney injury., Patients and Methods: The authors did a retrospective study of hospitalized patients with acute kidney injury who had immunofixation studies done. Various clinical and laboratory variables that may be predictive of the presence of multiple myeloma were evaluated and correlations with immunofixation test results determined., Results: One hundred twenty-eight patients were studied. Thirteen had a monoclonal paraprotein detected by immunofixation testing (positive result). Patients with positive testing had higher total, ionized and corrected calcium levels, although the median total calcium in immunofixation-positive patients was normal at 9.7 mg/dL. Patients with positive testing also had lower hemoglobin and platelet counts. An anion gap of <7 mmol/L and total protein-albumin gap >4 g/dL were also associated with positive results., Conclusions: In patients with acute kidney injury, relatively higher total, ionized and corrected calcium levels and lower hemoglobin and platelet counts may predict the presence of a monoclonal paraprotein. An anion gap of <7 mmol/L and total protein-albumin gap >4 g/dL may also be predictors. The metabolic consequences of acute kidney injury may attenuate some of these abnormalities as well. These findings may help guide optimal use of immunofixation testing and hence help potentially identify patients who may have multiple myeloma.

Drug-induced acute renal failure is a commonly encountered mode of renal injury in the hospitalized patient. Vancomycin is a frequently used antibiotic in patients with Gram-positive bacterial infections. In the present study, we evaluated an index case of a patient who developed severe acute granulomatous interstitial nephritis and provided a review of the reported cases of vancomycin-induced acute renal failure in the literature. A Medline search revealed a total of 11 cases of vancomycin-induced interstitial nephritis. In 2 reported cases, interstitial nephritis has been reported with associated granuloma formation. However, the role of T cells in the formation of interstitial nephritis and in the choice of therapeutic modalities in this scenario has not been evaluated in the past. In the index case, we have evaluated the effect of treatment on the basis of the type of cellular infiltrates and provided a follow-up by carrying out the repeat biopsy.

Most forms of renal disease associated with monoclonal gammopathy result from deposition of monoclonal immunoglobulins or their subunits in different compartments of the kidney. Renal monoclonal immunoglobulin deposition disease (MIDD) is defined by linear deposits of monoclonal light-chain components in renal basement membranes, often producing a nodular sclerosing glomerulopathy. Clinical features of renal MIDD include proteinuria, with or without renal failure, and an association with dysproteinemias. Three types of renal MIDD have been reported, namely, light-chain deposition disease (LCDD), light- and heavy-chain deposition disease (LHCDD), and heavy-chain deposition disease (HCDD). Reports on LHCDD are rare. At present, follow-up data are limited on the management of renal monoclonal protein deposition disease. We present a case of monoclonal protein deposition in the kidney containing both heavy and light chains with unique characteristics that did not conform to any of the above previous established classes. Its follow-up revealed an unusual relapsing and remitting course in response to treatment.

Acute arterial occlusion can be the result of acute thrombosis or systemic embolism. Paradoxical embolism of a venous thrombosis through a right-to-left shunt is an important cause of acute limb ischemia. We describe a young patient with acute limb ischemia who was found to have multiple deep venous thromboses causing arterial embolization through a patent foramen ovale. Essential thrombocytosis was found to be the risk factor for venous thromboses in this patient. The patient was managed with embolectomy and anticoagulation along with chemotherapeutic cytoreduction of platelet count. This case illustrates the importance of considering the systemic embolism as a cause of acute arterial occlusion. The presence of a hypercoagulable status such as chronic myeloproliferative disorder does not eliminate the possibility of systemic embolism in the event of acute arterial occlusion. Patients presenting with acute limb ischemia should be evaluated for embolic sources. The presence of deep venous thrombosis in such a patient should prompt the evaluation for a patent foramen ovale.

Antiphospholipid antibody syndrome is an acquired autoimmune disorder characterized by vascular thrombosis and/or recurrent pregnancy losses along with laboratory evidence of antiphospholipid antibodies. Anticoagulation rather than immunosuppression is the mainstay of treatment. Despite the effectiveness of oral anticoagulation for the prevention of recurrent thromboembolic episodes, thrombotic complications in the setting of apparently therapeutic oral anticoagulation have been observed; this may at times be due to difficulties in maintaining a consistently therapeutic level of anticoagulation. Low-molecular-weight heparin has been a useful alternative for long-term anticoagulation when there is difficulty in managing oral anticoagulant therapy and has the advantage of a consistent anticoagulant effect. In this report, we describe a woman with primary antiphospholipid antibody syndrome who developed extensive pulmonary embolism despite receiving a proven therapeutic dosage of low molecular weight heparin.

Hepatitis C is a common infection with worldwide prevalence. It has a variable course and can lead to chronic hepatitis, cirrhosis and hepatocellular carcinoma. Until recently alpha-interferon (IFN-alpha) was the only effective treatment available. Combination therapy with IFN-alpha and ribavirin has been found to be more efficacious than IFN-alpha alone. Various side effects have been ascribed to interferon, such as arthralgias, myalgias, fatigue, and gastrointestinal and neuropsychiatric symptoms. Interstitial pneumonitis is a rare but known complication of IFN-alpha when given at a high dosage of 6 to 10 million units per day. Ribavirin is associated with dose-dependent hemolytic anemia, cough, dyspnea, rash, depression, and dyspepsia, although a potential role in interferon-induced interstitial pneumonitis has not been described. We describe a patient with an excellent clinical response of chronic hepatitis C to combination therapy with IFN-alpha at a dosage of 3 million units per day and ribavirin. The patient developed interstitial pneumonitis that resolved after discontinuation of IFN-alpha and ribavirin. Given that interstitial pneumonitis has previously been reported with high-dose IFN-alpha, this case suggests that this complication may occur with lower dosages of IFN-alpha, although a potential role for ribavirin in this disorder at present remains speculative.

Background: Systolic blood pressure is well known to increase significantly with age and is strongly correlated with stroke and coronary artery disease. We and other investigators have reported a low prevalence of hypertension in subgroups of patients with HIV infection. In the present study, we examined an ambulatory population of patients with HIV infection to determine whether in the outpatient setting they may lack an age-related increase in systolic blood pressure., Methods: In an ambulatory outpatient practice, medical records of 178 consecutive patients with HIV infection and those of 200 control subjects were examined. Systolic and diastolic blood pressure and other clinical and laboratory variables were recorded. Scatter plots were generated to compare age with systolic blood pressure. Spearman rank correlation analysis was carried out to determine the relationship between systolic blood pressure and age and other variables., Results: Patients ranged in age from 13 to 69 years. There was only a very slight increase (which did not achieve statistical significance) in systolic blood pressure with aging in the patients with HIV infection, in contrast to the control population, in which an age-related increase in systolic blood pressure was seen that was comparable to published Framingham data. Mean systolic blood pressure for the group as a whole was 118.2 +/- 1.1 mm Hg. Mean serum albumin was 4.2 +/- 0.04 g/dL and was only slightly diminished in older patients. Mean serum cholesterol was 176.8 +/- 3.4 mg/dL and this bore no relationship to aging. More advanced stages of HIV infection also did not correlate with the lack of age-associated systolic hypertension., Conclusion: The present population of ambulatory patients infected with HIV seem to lack an age-related increase in systolic blood pressure; this may be caused by such variables as autonomic dysfunction or factors that may attenuate the development of atherosclerosis.

Severe hyperkalemia may cause weakness that typically is ascending and symmetric. In an isolated case report, hemiplegia occurred after the development of hyperkalemia in a patient with a known central nervous system lesion. We describe a patient requiring long-term hemodialysis who had near-fatal hyperkalemia, hemiplegia, and rhabdomyolysis after abuse of crack cocaine. The hemiplegia resolved after normalization of serum potassium using emergency dialysis. No brain lesion could be identified during computed tomography or by electroencephalography, and the patient had no residual neurologic deficits. We conclude that this patient had hemiplegia secondary to cocaine-induced cerebral vasoconstriction because no structural lesion could be found and that the neurologic deficit was worsened by severe hyperkalemia, which probably resulted from cocaine-induced rhabdomyolysis. Hence, despite the absence of a structural lesion of the brain, severe hyperkalemia, typically associated with symmetric, ascending muscle weakness, may contribute to causing focal weakness in the condition of cocaine-induced vasoconstriction.

Cerebrovascular disease is a major cause of death in patients with end-stage renal disease, particularly in those with diabetes mellitus. Cardiac disease frequently presents itself atypically in diabetic patients. This awareness has led to earlier detection and treatment of cardiac disease in diabetic patients. Whether cerebrovascular disease may also present itself in a highly atypical fashion in the diabetic patient with end-stage renal disease has never been addressed. We report the case of a diabetic hemodialysis patient who had an extremely unusual manifestation of stroke. A 67-year-old diabetic hemodialysis patient had marked distress secondary to the sudden onset of a foreign body sensation in the oropharynx. Results of a laryngoscopy were negative; x-rays of the neck and computerized tomography of the head and neck showed no abnormalities. Neurologic evaluation revealed an inability to detect oropharyngeal stimuli and an absent gag reflex but no other deficits. Magnetic resonance imaging of the brain revealed an infarction in the left corona radiata that extended to the thalamocapsular region and external capsule, and a lacunar infarct in the right pons. Cerebrovascular disease in the diabetic patient with end-stage renal disease may present itself atypically, and we suggest that cerebrovascular disease in these patients merits the same level of suspicion as cardiac disease.

Adverse effects of nonsteroidal antiinflammatory drugs are frequently seen because of the extremely widespread use of these agents. Nephrotoxicity is relatively uncommon with the drug ibuprofen and, when present, is usually rapidly reversible. Fatal acute renal failure from ibuprofen has never been reported. This is the case of a patient with multiple medical problems who had near-fatal acute renal failure after the ingestion of 36 g ibuprofen, and who required dialysis for several months, at which point renal function improved. He did not admit to ibuprofen ingestion at the time of admission, and some of the clinical manifestations, including anion gap metabolic acidosis, respiratory alkalosis, and mental status abnormalities, could be accounted for by renal failure. Hence, this diagnosis was not considered during admission. However, the patient admitted to ibuprofen ingestion after his mental status improved with hemodialysis. A number of other variables were present that probably contributed to the development of acute renal failure, such as the presence of long-term renal insufficiency, hypotension, and possibly other drug ingestion. Acute renal failure with massive ibuprofen ingestion may be fatal or may show delayed reversibility even after necessitating dialysis for several months.