Background Cholesterol embolization syndrome (CES) is a disease associating with the systemic cholesterol crystal embolism and end-organ dysfunction due to the atherosclerotic plaque rupture, which is dominantly triggered by the intravascular intervention. There is no consensus for which types of anticoagulants we should use during the hemodialysis in patients with CES and end-stage renal disease. Case presentation We had a 68-year-old man with CES due to intravascular intervention, who suffered the omental bleeding, instead of the embolism, immediately after the initiation of hemodialysis with heparinization. An emergent laparotomy found active bleeding from the omentum, which was surgically repaired. The histopathological analysis showed the embolization of cholesterol crystal clefts in the omentum artery and the injury of arterial wall structure accompanied by the infiltration of inflammatory cells. We preferred nafamostat mesylate during hemodialysis and he had no adverse events following the surgery. Conclusions It should be noticed that, in addition to the embolic events, bleeding events can develop in patients with CES, particularly following the initiation of hemodialysis with anticoagulation therapy.

Objective:Xanthine oxidase (XO) activity has a key role in the development of oxidative stress and progression of cardiovascular diseases. In resistant hypertension, plasma XO activity is related to increased urinary sodium excretion and left ventricular hypertrophy. In this study, plasma XO activity and its related factors were investigated in essential hypertensive patients.Design and method:In 53 essential hypertensive patients (30 men, 64 ± 13 years) without taking anti-hyperuricemic agents, plasma XO activity was measured by using a high-performance liquid chromatography method. 38 healthy volunteers without any specific comorbidities were included as a control cohort. Associations between plasma XO activity and other clinical variables were also investigated in essential hypertensive patients.Results:Plasma XO activity was increased in essential hypertensive patients compared with the healthy cohort (log10XO 1.33 ± 0.47 nmol/L/hr vs 0.98 ± 0.37, p < 0.001). In essential hypertensive patients, plasma XO activity did not associate with age, blood pressure, estimated glomerular filtration and urinary protein excretion. There were weak correlations between plasma XO activity and the levels of serum uric acid and blood glucose (r = 0.28, 0.32, p < 0.05, respectively). Plasma XO activity strongly correlated with body mass index (BMI) and alanine aminotransferase (ALT) (r = 0.46, 082, p < 0.001, respectively), and in multiple regression analysis, BMI and ALT were independent determinants for plasma XO activity (R2 0.57, p < 0.001).Conclusions:In essential hypertension, plasma XO activity was increased accompanying with obesity and liver disfunction, irrespective of blood pressure elevation and renal dysfunction.

Background:Primary aldosteronism is associated with low plasma renin levels, while malignant phase hypertension is generally associated with raised renin activity. Therefore, these two conditions are at opposite ends of the renin spectrum, so in theory their co-existence would be unusual.Case presentation:We present a case of a 41-year-old male with uncontrolled hypertension on multiple antihypertensive drugs. He discontinued these drugs for three days, thereafter he admitted to our hospital with congestive heart failure and acute ischemic stroke. He manifested malignant phase hypertension (blood pressure 216/130 mmHg; Keith-Wagener IV) accompanying renal dysfunction (serum creatinine 2.4 mg/dL), high plasma aldosterone concentration (PAC, 221 pg/mL) and mildly elevated plasma renin activity (PRA, 3.0 ng/mL/hr). A computed tomography did not reveal the presence of adrenal mass. After the treatment for congestive heart failure, the reassessment for endocrine causes of hypertension showed high level of PAC (468 pg/mL) and low level of PRA (0.2 ng/mL/hr), resulting in a high PAC/PRA ratio under the treatment with angiotensin-converting enzyme inhibitor. Adrenal venous sampling (AVS) confirmed the excessive aldosterone secretion from bilateral adrenal glands. Given these findings, we diagnosed him with idiopathic aldosteronism. After an addition of the mineralocorticoid receptor antagonist, he could keep his blood pressure under control.Conclusions:PRA in patients with primary aldosteronism could be increased under the conditions in which renin release from the kidney is overstimulated by glomerular ischemia, leading to an incorrect diagnosis of primary aldosteronism. Repeated endocrine assessment including the measurement of PRA and PAC should be considered to reveal the cause of malignant phase hypertension.

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Pembrolizumab, an immune checkpoint inhibitor, is used to treat a variety of refractory malignancies. However, these agents are sometimes associated with immune-related adverse events. A 71-year-old woman received pembrolizumab-integrated chemotherapy to treat her recurrent mandibular gingival cancer. Five months after stopping pembrolizumab, she developed acute tubulointerstitial nephritis associated with Fanconi syndrome and type 1 renal tubular acidosis, which resolved with steroid therapy. We experienced a case of pembrolizumab-induced Fanconi syndrome and type 1 renal acidosis. We recommend follow-up of the tubular function in addition to the renal function even after discontinuation of pembrolizumab.