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Case Records of the Massachusetts General Hospital
Case 4-2012 — A 37-Year-Old Man with Muscle Pain, Weakness, and Weight Loss
Presentation of Case. Dr. Ian J. Barbash (Medicine): A 37-year-old man was admitted to this hospital because of muscle pain and weakness. The patient had been well until the evening before admission, when mild diffuse myalgias developed. He awoke in the morning with diffuse muscle cramps and…
- CME
Case Records of the Massachusetts General Hospital
Case 26-2011 — A 7-Year-Old Boy with a Complex Cyst in the Kidney
Presentation of Case. A 7-year-old boy was seen in an outpatient clinic at this hospital because of a complex cyst in the kidney. The patient was born by vaginal delivery after an uncomplicated 38-week gestation. His birth weight was 3.04 kg. A diagnosis of tuberous sclerosis complex (TSC) was made…
- CME
Editorial
Preemptive Olmesartan for the Delay or Prevention of Microalbuminuria in Diabetes
Patients with either type 1 or type 2 diabetes mellitus are at high risk for chronic kidney disease, which is usually first evident with the onset of microalbuminuria. There is overall consensus that agents that block the renin–angiotensin system — particularly angiotensin-converting–enzyme…
Original Article
Olmesartan for the Delay or Prevention of Microalbuminuria in Type 2 Diabetes
Diabetic nephropathy is an increasingly common cause of end-stage renal disease, and the development and rate of renal deterioration are most closely related to the patient's blood pressure. Guideline committees worldwide concur that the blood pressure in patients with diabetes and chronic kidney…
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- CME
This study investigated whether an angiotensin-receptor blocker (olmesartan) would delay microalbuminuria in patients with type 2 diabetes and normoalbuminuria. Olmesartan was associated with a delayed onset of microalbuminuria, even though blood pressure control in both groups was excellent.
Editorial
Hypertension Control in African-American Patients with Chronic Kidney Disease
The risks of renal and cardiovascular disease — conditions that are often associated with long-standing hypertension — are far higher among people of African-American heritage than among those in other racial or ethnic groups. The African-American Study of Kidney Disease and Hypertension (AASK)…
Original Article
Intensive Blood-Pressure Control in Hypertensive Chronic Kidney Disease
Chronic kidney disease is a major public health problem. In national surveys, the prevalence of chronic kidney disease (stages 1 through 4) among adults in the United States increased from 10% during the period from 1988 through 1994 to 13% during the period from 1999 through 2004. In 2006, the…
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This trial tested whether intensive blood-pressure control retards the progression of chronic kidney disease in black patients with hypertension. Although there was an apparent benefit among patients with baseline proteinuria (urinary protein-to-creatinine ratio, >0.22), those with a normal protein-to-creatinine ratio had no benefit. Among all patients, intensive blood-pressure control had no effect on disease progression.
Clinical Therapeutics
Dietary Therapy in Hypertension
Foreword. This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies, the clinical use of this therapy, and potential adverse effects are…
- CME
A 57-year-old woman is seen in an outpatient clinic, where her blood pressure reading is 155/95 mm Hg. Dietary therapy is recommended. Dietary changes that have been shown to reduce blood pressure include reduced sodium intake, reduced caloric intake (for weight loss), and diets high in fruits, vegetables, low-fat dairy products, whole grains, poultry, fish, nuts, and unsaturated vegetable oils.
Correspondence
Thiazide Diuretics
To the Editor: Hyponatremia is an important side effect of thiazide diuretics, and I think that it deserved further discussion in the recent review article by Ernst and Moser (Nov. 26 issue). Although thiazide-induced hyponatremia is not as well characterized as thiazide-induced hypokalemia, it…
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Original Article
Childhood Obesity, Other Cardiovascular Risk Factors, and Premature Death
Despite recent increases in life expectancy, the rising global prevalence of obesity may reverse this trend. The rising rates and increasingly early onset of other chronic diseases such as type 2 diabetes may also affect mortality rates. Cardiovascular risk factors are common in children. Although…
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This study examined body-mass index, glucose tolerance, blood pressure, and cholesterol levels in American Indian children without diabetes who were then followed to adulthood. Obesity, glucose intolerance, and hypertension in childhood were strongly associated with premature death from endogenous causes, whereas hypercholesterolemia was not.
Editorial
Are Children the Future of Type 2 Diabetes Prevention?
The lifetime risk of type 2 diabetes is now more than one in three in the general U.S. population, and one in six adolescents is now obese, suggesting that prevention should start in childhood. Many consider diabetes and obesity to be "common-source" epidemics that are rooted in our culture, as…
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Images in Clinical Medicine
Extramedullary Hematopoiesis Associated with β-Thalassemia
Figure 1.
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Case Records of the Massachusetts General Hospital
Case 1-2010 — A 75-Year-Old Man with Hypertension, Hyperglycemia, and Edema
Presentation of Case. Dr. Jennifer L. Lyons (Medicine): A 75-year-old man was admitted to this hospital because of the recent onset of hypertension, hyperglycemia, and edema. The patient had been in his usual state of health, with borderline hypertension and glucose intolerance, until 11 days…
A 75-year-old man was admitted to this hospital because of the recent onset of hypertension, hyperglycemia, and edema. He had a history of prostate cancer, hemochromatosis, adrenal and thyroid nodules, and colonic polyps. The white-cell count was 17,400 per cubic millimeter with 87% neutrophils; the serum level of potassium was 2.6 mmol per liter and chloride 97 mmol per liter. Imaging studies showed pulmonary and hepatic nodules that had not been present on earlier studies. A diagnostic procedure was performed.
Correspondence
Renal Failure in Cirrhosis
To the Editor: Ginès and Schrier (Sept. 24 issue) offer a succinct and thoughtful review of various causes of renal failure in cirrhosis, including the hepatorenal syndrome, hypovolemia due to hemorrhage or fluid losses, parenchymal disease, and drug-induced renal failure. In addition,…
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Case Records of the Massachusetts General Hospital
Case 38-2009 — A 16-Year-Old Boy with Paroxysmal Headaches and Visual Changes
Presentation of Case. A 16-year-old boy was seen in the pediatric neurology clinic of this hospital because of paroxysmal headaches and visual changes. The patient had been well until approximately 4 months earlier, when severe headaches began to occur up to three times per month, lasting 3 hours…
A boy was first seen in the pediatric neurology clinic at 16 years of age because of paroxysmal headaches and visual changes. Physical and neurologic examinations were normal, and imaging studies showed no intracranial abnormalities. Headaches persisted despite a variety of therapies and during the next 4 years were associated with transient weakness, loss of consciousness, obtundation, and back pain. Intermittent optic-disk edema was noted. When the patient was 21 years old, lumbar puncture revealed an opening pressure of 25 cm of water; several hours later, symptoms of cauda equina syndrome developed. A diagnostic procedure was performed.
Review Article
Drug Therapy: Use of Diuretics in Patients with Hypertension
Thiazide diuretics became available in the late 1950s and were the first effective oral antihypertensive agents with an acceptable side-effect profile. A half-century later, thiazides remain important medications for the treatment of hypertension. These agents reduce blood pressure when…
The cause of autoimmune pancreatitis is unknown, and distinguishing autoimmune pancreatitis from pancreatic cancer can be difficult. The authors identified an antibody that they were able to detect in about 95% of patients with autoimmune pancreatitis but in only about 5% of patients with pancreatic cancer.
Clinical Practice
Renal-Artery Stenosis
Foreword. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors' clinical recommendations. Stage. A 73-year-old…
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A 73-year-old former smoker with a history of hypertension presents with shortness of breath. His blood pressure is 160/75 mm Hg, and his serum creatinine level is 1.4 mg per deciliter. Chest auscultation reveals diffuse rales. His condition improves with diuretics. Imaging shows a diseased aorta and a high-grade ostial lesion of the left renal artery. How should he be further evaluated and treated?
Clinical Problem-Solving
A Bloody Mystery
Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors' commentary follows. Stage. A 62-year-old woman presented to…
A 62-year-old woman presented to the urgent care clinic with gingival bleeding after periodontal scaling of her lower-right second molar 5 hours earlier. Bleeding had persisted despite the application of pressure and ice. The patient recalled a similar episode approximately 6 months earlier, also after a periodontal procedure.
Editorial
Blood-Pressure Control and Delay in Progression of Kidney Disease in Children
Many children with chronic kidney disease, even those in whom the disease is discovered very early, ultimately lose renal function; some ultimately progress to stage 5 chronic kidney disease (end-stage renal disease). Causes of chronic kidney disease in children differ substantially from those in…
