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Letters to the Editor 2. Ozdemir R, Bayrakci B, Teksam O. Fatal poisoning in children: acute colchicines intoxication and new treatment approaches. Clin Toxicol 2011;49:739–43. 3. Thamdrup B, Ostergaard OV, Clausen E. Plasma exchange in the treatment of propoxyphene intoxications. Int J Clin Pharmacol Ther Toxicol 1986;24:379–80. 4. Demirkol D, Yıldızdas D, Bayrakcı B et al. Hyperferritinemia in the critically ill child with secondary hemophagocytic lymphohistiocytosis/sepsis/multiple organ dysfunction syndrome/ macrophage activation syndrome: what is the treatment? Crit Care 2012;16:52.
Change of Chylous Ascites During Low-Density Lipoprotein Apheresis in a Patient With Idiopathic Nephrotic Syndrome Dear Editor Chylous ascites is a well-known complication of severe nephrotic syndrome (1). However, the pathogenesis of chylous ascites in nephrotic syndrome remains to be elucidated. We investigated the factors associated with chylous ascites in a patient with severe nephrotic syndrome. A 32-year-old Japanese man presenting with rapid onset of generalized edema was diagnosed with minimal change nephrotic syndrome (MCNS) and was treated with intravenous methylprednisolone at a dose of 500 mg daily for 3 days followed by oral prednisolone (50 mg/day) in 2002. However, the clinical findings indicating steroid-resistance and high pro-
97
teinuria selectivity index (0.29), led us to suspect focal segmental glomerulonephrosis (FSGS).Therefore, we also applied cyclosporin A (CyA) and therapeutic apheresis (low-density lipoprotein [LDL] apheresis: LDL absorption [LDL-A] using a dextran sulfate cellulose column, double filtration plasmapheresis [DFPP], as described previously) (2). After the initiation of CyA (100 mg/day) and LDL apheresis, the renal function and severe edema improved with no obvious improvement of the urinary protein excretion (UPE) or hypoalbuminemia. When the prednisolone was gradually tapered to 5 mg/day, generalized edema and renal failure developed rapidly. Upon admission, physical examination revealed massive ascites and severe generalized edema. Biochemical analysis of the paracentesis fluid was comparable with the chylous fluid (i.e., the maximum triglyceride level and the triglyceride to cholesterol ratio in the fluid were 221 mg/dL and 20.4, respectively). Chylomicron was positive on electrophoresis. Examination of the chylous fluid revealed neither inflammation nor malignancy. After administration of high dose oral prednisolone, CyA and LDL apheresis, the renal function (Fig. 1), massive ascites and severe edema improved immediately, and the proteinuria improved gradually. Therapeutic paracentesis was performed regularly, because the patient wanted to achieve symptomatic relief of the abdominal distension. We measured the ascites triglyceride levels (aTG) in all of the paracentesis fluid samples, and plotted the serum albumin, cholesterol and triglyceride levels, and UPE
FIG. 1. Longitudinal changes in serum creatinine (Cr), corrected urinary protein excretion (cUPE), ascites triglyceride (aTG) and serum albumin levels (sAlb). aTG was reduced by low density lipoprotein absorption (LDL-A) and double filtration plasmapheresis (DFPP), and increased after suspension of LDL-A and DFPP. Because renal function worsened during the treatment with LDL-A, and we previously reported that DFPP was potentially effective for nephrotic syndrome with acute renal failure (2), we decided to switch from LDL-A to DFPP.
© 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
Ther Apher Dial, Vol. 19, No. 1, 2015
98
Letters to the Editor
against the aTG during hospitalization. All parameters correlated significantly with aTG (P < 0.005, Wilcoxon signed-rank test). However, multiple linear regressions showed that only serum albumin level was an independent factor influencing the aTG among all parameters. To our knowledge, this is the first report to show serial changes of chylous ascites with treatment.While it has been reported that hypoalbuminemia may be related to chylous ascites (1,3), we demonstrated for the first time that there was an association between hypoalbuminemia and chylous ascites. Lindenbaum and Scheidt suggested that hypoalbuminemiainduced bowel edema might predispose to changes in the permeability of the mucosal or serosal lymphatics, which could result in the leakage of chylomicrons into the peritoneal cavity and chylous ascites (3). In addition, we showed that aTG was reduced by therapeutic apheresis and elevated after suspension of the therapeutic apheresis (Fig. 1). LDL apheresis has been reported to be effective by removing the permeability factors in MCNS and FSGS patients (4). Thus, alternative permeability factors that aggravate the permeability of the lymphatics may contribute to the pathogenesis of chylous ascites, and the waste fluid of therapeutic apheresis should be used to identify novel permeability factors on a large scale.
Ther Apher Dial, Vol. 19, No. 1, 2015
Acknowledgment: We do not report any financial support, conflict of interests or experimental investigations on human subject without informed consent.
Yoshitaka Iwazu, Satoko Komori, and Daisuke Nagata Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan Email: [email protected]
REFERENCES 1. Chen YC, Kuo MC, Chen HC, Liu MQ, Hwang SJ. Chylous ascites and chylothorax due to the existence of transdiaphragmatic shunting in an adult with nephrotic syndrome. Nephrol Dial Transplant 2005;20:1501–2. 2. Iwazu Y, Akimoto T, Izawa S et al. Accelerated recovery from nephrotic syndrome with acute renal failure by double filtration plasmapheresis in a patient with lupus podocytopathy. Clin Exp Nephrol 2012;16:485–9. 3. Lindenbaum J, Scheidt SS. Chylous ascites and the nephrotic syndrome. Report of a case, associated with renal vein thrombosis. Am J Med 1969;44:830–6. 4. Yokoyama H, Wada T, Zhang W, Yamaya H, Asaka M. Advances in apheresis therapy for glomerular disease. Clin Exp Nephrol 2007;11:122–7.
© 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
Letters to the Editor 2. Ozdemir R, Bayrakci B, Teksam O. Fatal poisoning in children: acute colchicines intoxication and new treatment approaches. Clin Toxicol 2011;49:739–43. 3. Thamdrup B, Ostergaard OV, Clausen E. Plasma exchange in the treatment of propoxyphene intoxications. Int J Clin Pharmacol Ther Toxicol 1986;24:379–80. 4. Demirkol D, Yıldızdas D, Bayrakcı B et al. Hyperferritinemia in the critically ill child with secondary hemophagocytic lymphohistiocytosis/sepsis/multiple organ dysfunction syndrome/ macrophage activation syndrome: what is the treatment? Crit Care 2012;16:52.
Change of Chylous Ascites During Low-Density Lipoprotein Apheresis in a Patient With Idiopathic Nephrotic Syndrome Dear Editor Chylous ascites is a well-known complication of severe nephrotic syndrome (1). However, the pathogenesis of chylous ascites in nephrotic syndrome remains to be elucidated. We investigated the factors associated with chylous ascites in a patient with severe nephrotic syndrome. A 32-year-old Japanese man presenting with rapid onset of generalized edema was diagnosed with minimal change nephrotic syndrome (MCNS) and was treated with intravenous methylprednisolone at a dose of 500 mg daily for 3 days followed by oral prednisolone (50 mg/day) in 2002. However, the clinical findings indicating steroid-resistance and high pro-
97
teinuria selectivity index (0.29), led us to suspect focal segmental glomerulonephrosis (FSGS).Therefore, we also applied cyclosporin A (CyA) and therapeutic apheresis (low-density lipoprotein [LDL] apheresis: LDL absorption [LDL-A] using a dextran sulfate cellulose column, double filtration plasmapheresis [DFPP], as described previously) (2). After the initiation of CyA (100 mg/day) and LDL apheresis, the renal function and severe edema improved with no obvious improvement of the urinary protein excretion (UPE) or hypoalbuminemia. When the prednisolone was gradually tapered to 5 mg/day, generalized edema and renal failure developed rapidly. Upon admission, physical examination revealed massive ascites and severe generalized edema. Biochemical analysis of the paracentesis fluid was comparable with the chylous fluid (i.e., the maximum triglyceride level and the triglyceride to cholesterol ratio in the fluid were 221 mg/dL and 20.4, respectively). Chylomicron was positive on electrophoresis. Examination of the chylous fluid revealed neither inflammation nor malignancy. After administration of high dose oral prednisolone, CyA and LDL apheresis, the renal function (Fig. 1), massive ascites and severe edema improved immediately, and the proteinuria improved gradually. Therapeutic paracentesis was performed regularly, because the patient wanted to achieve symptomatic relief of the abdominal distension. We measured the ascites triglyceride levels (aTG) in all of the paracentesis fluid samples, and plotted the serum albumin, cholesterol and triglyceride levels, and UPE
FIG. 1. Longitudinal changes in serum creatinine (Cr), corrected urinary protein excretion (cUPE), ascites triglyceride (aTG) and serum albumin levels (sAlb). aTG was reduced by low density lipoprotein absorption (LDL-A) and double filtration plasmapheresis (DFPP), and increased after suspension of LDL-A and DFPP. Because renal function worsened during the treatment with LDL-A, and we previously reported that DFPP was potentially effective for nephrotic syndrome with acute renal failure (2), we decided to switch from LDL-A to DFPP.
© 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
Ther Apher Dial, Vol. 19, No. 1, 2015
98
Letters to the Editor
against the aTG during hospitalization. All parameters correlated significantly with aTG (P < 0.005, Wilcoxon signed-rank test). However, multiple linear regressions showed that only serum albumin level was an independent factor influencing the aTG among all parameters. To our knowledge, this is the first report to show serial changes of chylous ascites with treatment.While it has been reported that hypoalbuminemia may be related to chylous ascites (1,3), we demonstrated for the first time that there was an association between hypoalbuminemia and chylous ascites. Lindenbaum and Scheidt suggested that hypoalbuminemiainduced bowel edema might predispose to changes in the permeability of the mucosal or serosal lymphatics, which could result in the leakage of chylomicrons into the peritoneal cavity and chylous ascites (3). In addition, we showed that aTG was reduced by therapeutic apheresis and elevated after suspension of the therapeutic apheresis (Fig. 1). LDL apheresis has been reported to be effective by removing the permeability factors in MCNS and FSGS patients (4). Thus, alternative permeability factors that aggravate the permeability of the lymphatics may contribute to the pathogenesis of chylous ascites, and the waste fluid of therapeutic apheresis should be used to identify novel permeability factors on a large scale.
Ther Apher Dial, Vol. 19, No. 1, 2015
Acknowledgment: We do not report any financial support, conflict of interests or experimental investigations on human subject without informed consent.
Yoshitaka Iwazu, Satoko Komori, and Daisuke Nagata Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan Email: [email protected]
REFERENCES 1. Chen YC, Kuo MC, Chen HC, Liu MQ, Hwang SJ. Chylous ascites and chylothorax due to the existence of transdiaphragmatic shunting in an adult with nephrotic syndrome. Nephrol Dial Transplant 2005;20:1501–2. 2. Iwazu Y, Akimoto T, Izawa S et al. Accelerated recovery from nephrotic syndrome with acute renal failure by double filtration plasmapheresis in a patient with lupus podocytopathy. Clin Exp Nephrol 2012;16:485–9. 3. Lindenbaum J, Scheidt SS. Chylous ascites and the nephrotic syndrome. Report of a case, associated with renal vein thrombosis. Am J Med 1969;44:830–6. 4. Yokoyama H, Wada T, Zhang W, Yamaya H, Asaka M. Advances in apheresis therapy for glomerular disease. Clin Exp Nephrol 2007;11:122–7.
© 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
