Patients with severe active lupus nephritis (LN) require immunosuppressive therapy to induce remission. However, the development of profound hypogammaglobulinemia causing cytomegalovirus (CMV) disease is a rare occurrence during standard immunotherapy. A 27-year-old woman who presented with active LN along with moderate renal impairment was treated with of mycophenolate mofetil (MMF) and methylprednisolone. MMF was soon switched with low-dose intravenous (IV) cyclophosphamide (CYC) owing to the development of posterior reversible encephalopathy syndrome and deterioration of renal function requiring hemodialysis. After two cycles of IV CYC, she developed CMV colitis and pneumonia. Although her serum immunoglobulin (Ig) concentrations before receiving immunosuppressive treatment were normal, they were profoundly reduced at CMV disease onset and continued to maintain low level for 30 months. Severe hypogammaglobulinemia can occur during standard therapy for LN, especially in patients with impaired renal function, pointing out the importance of close monitoring of Ig levels and CMV infection.
Adult ; Agammaglobulinemia ; Colitis ; Cyclophosphamide ; Cytomegalovirus Infections ; Cytomegalovirus ; Female ; Humans ; Immunoglobulins ; Immunotherapy ; Lupus Nephritis ; Methylprednisolone ; Pneumonia ; Posterior Leukoencephalopathy Syndrome ; Renal Dialysis

Background: The number of patients requiring dialysis is increasing worldwide, and the atrial fibrillation and atrial flutter (AF) prevalence among hemodialysis (HD) patients is higher than in the general population. There have been no studies of Korean AF patients undergoing HD that investigated how AF affects outcomes, such as all-cause mortality, hospitalization, and stroke events. We conducted a large-scale retrospective cohort study with data from the National Health Insurance System to determine how AF affects these outcomes. Methods: In 2013, the Health Insurance Review and Assessment service, a Korean national health insurance scheme, collected data from 21,839 HD patients to evaluate the adequacy of dialysis centers. All-cause mortality, hospitalization, and stroke events were compared between patients with and without AF. Sub-analyses compared these outcomes between AF patients receiving warfarin and those not receiving warfarin. Results: Cox regression analysis found that AF was a significant risk factor for death from any cause (hazard ratio [HR], 1.356; 95% confidence interval [CI], 1.222–1.506; p < 0.001), hospitalization (HR, 1.323; 95% CI, 1.225–1.430; p < 0.001), and hemorrhagic stroke (HR, 1.500; 95% CI, 1.050–2.141; p = 0.026). AF was not significantly associated with an increased risk of ischemic stroke. The use of warfarin was significantly associated with hemorrhagic stroke incidence (HR, 1.593; 95% CI, 1.075–2.360; p = 0.020), while there was no significant correlation between warfarin treatment and all-cause mortality, hospitalization, and ischemic stroke. Conclusion This cohort study of Korean dialysis patients showed that AF was a risk factor for multiple outcomes among HD patients.

Background: The number of patients requiring dialysis is increasing worldwide, and the atrial fibrillation and atrial flutter (AF) prevalence among hemodialysis (HD) patients is higher than in the general population. There have been no studies of Korean AF patients undergoing HD that investigated how AF affects outcomes, such as all-cause mortality, hospitalization, and stroke events. We conducted a large-scale retrospective cohort study with data from the National Health Insurance System to determine how AF affects these outcomes. Methods: In 2013, the Health Insurance Review and Assessment service, a Korean national health insurance scheme, collected data from 21,839 HD patients to evaluate the adequacy of dialysis centers. All-cause mortality, hospitalization, and stroke events were compared between patients with and without AF. Sub-analyses compared these outcomes between AF patients receiving warfarin and those not receiving warfarin. Results: Cox regression analysis found that AF was a significant risk factor for death from any cause (hazard ratio [HR], 1.356; 95% confidence interval [CI], 1.222–1.506; p < 0.001), hospitalization (HR, 1.323; 95% CI, 1.225–1.430; p < 0.001), and hemorrhagic stroke (HR, 1.500; 95% CI, 1.050–2.141; p = 0.026). AF was not significantly associated with an increased risk of ischemic stroke. The use of warfarin was significantly associated with hemorrhagic stroke incidence (HR, 1.593; 95% CI, 1.075–2.360; p = 0.020), while there was no significant correlation between warfarin treatment and all-cause mortality, hospitalization, and ischemic stroke. Conclusion This cohort study of Korean dialysis patients showed that AF was a risk factor for multiple outcomes among HD patients.