A Naqvi

Acute Renal Failure of Obstetrical Origin During 1994 at One Center

Although preventable, acute renal failure (ARF) of obstetrical origin continues to be common in developing countries. During the year 1994, we treated a total of 238 cases of ARE. Of these cases, 43 (18%) were of obstetrical origin. All of the patients were known to be previously healthy. Acute renal failure occurred in association with antepartum hemorrhage in 15, postpartum hemorrhage in 10, intrauterine death of fetus in 11, preeclampsia or eclampsia in 9, and septic abortions or puerperal sepsis in 7. Thirty-six patients required dialysis therapy because of moderate to severe azotemia. Renal histology was studied in 12 cases. Acute cortical necrosis was present in 9, extensive tubular necrosis in 2, and 1 patient had membranoproliferative glomerulonephritis. Twenty-two (51%) patients recovered normal renal function, while 11 (26%) developed irreversible renal dysfunction and 10 (23%) expired. Mortality and morbidity in this region is still quite high in obstetrical situations. Poor health infrastructure and lack of antenatal health clinics leads to development of major complications at the time of childbirth, which is mostly conducted at home by untrained personnel in quite a few cities of the country.

Use of isoniazid chemoprophylaxis in renal transplant recipients

BACKGROUND The use of isoniazid (INH) as chemoprophylaxis for tuberculosis (TB) in renal transplant recipients has not been widely studied or reported from a country where TB is endemic. We are reporting here the results of the largest ever-reported randomized, prospective study of the use of INH in renal transplant recipients. METHODS Four hundred consecutive live related renal transplant recipients between April 2001 and September 2004, from this single center, were randomized to receive or not receive INH for 1 year after transplantation. RESULTS There were 12 dropouts. Of the remaining 388, 181 recipients received INH for 1 year post-transplant and 207 did not. The primary disease, comorbidities, HLA (human leucocyte antigen) match, immunosuppression, episodes of rejection, the use of anti-rejection agents, a past history of TB in the donor, the recipients and in family members living in same house and a history of TB in the family were factors compared in the two groups. The only significant difference between the two groups was that there was an increased family history of TB in recipients who received INH (P = 0.01). One recipient from the INH group and 16 recipients from the non-INH group developed TB (P = 0.0003). Discontinuation of INH for hepatotoxicity was not required in any patient. CONCLUSION These results provide evidence that the use of INH following renal transplantation should be considered mandatory in geographical areas where the prevalence of TB is high. Furthermore, these results have important implication in patients from such areas who are immunosuppressed following other kinds of transplantation and for those who are immunocompromised for any other reason.

Predictors of Outcome in Malarial Renal Failure

We studied 38 patients with acute renal failure (ARF) due to malaria over a 5-year period between 1990 and 1994 at the Institute of Urology and Transplantation. There were 30 males and 8 females who ranged in age from 13 to 75 years. Most were critically ill on presentation with blood urea levels between 116 and 587 mg% and serum creatinine concentrations between 3 and 30 mg%. Anemia accompanied by hyperbilirubinemia was a result of severe hemolysis. Antimalarial therapy consisted of quinine sulfate, chloroquine, or both. Of the 38 patients, 32 required hemodialysis and eventually recovered normal (n = 29) or near normal (n = 3) function. Six patients died.

Azotemia protects the brain from osmotic demyelination on rapid correction of hyponatremia

Osmotic demyelination syndrome (ODS) is a dreadful, irreversible and well-recognized clinical entity that classically occurs after rapid correction of hyponatremia. However, it has been observed that when hyponatremia is rapidly corrected in azotemic patients by hemodialysis (HD), patients do not necessarily develop ODS. We studied the effect of inadvertent rapid correction of hyponatremia with HD in patients with azotemia. Fifty-two azotemic patients, who underwent HD at the Sindh Institute of Urology and Transplantation, having pre-HD serum sodium level <125 mEq/L and post-HD serum sodium levels that increased by ≥12 mEq/L from their pre-dialysis level, were studied. Serum sodium was analyzed before and within 24 h after a HD session. HD was performed using bicarbonate solution, with the sodium concentration being 140 meq/L. The duration of the dialysis session was based on the discretion of the treating nephrologist. Patients were examined for any neurological symptoms or signs before and after HD and for up to two weeks. Magnetic resonance imaging was performed in required cases. None of the 52 patients with azotemia, despite inadvertent rapid correction of hyponatremia with HD, developed ODS. This study suggests that patients with azotemia do not develop ODS on rapid correction of hyponatremia by HD, which suggests a possible protective role of azotemia on the brain from osmotic demyelination. However, the mechanism by which azotemia protects the brain from demyelination in humans is largely hypothetical and further studies are needed to answer this question.

Surgical complications after renal transplantation in a living-related transplantation program at SIUT.

Between November 1985 and November 1998, 647 renal transplants were performed at Sindh Institute of Urology and Transplantation (SIUT), Karachi. Records of all cases were reviewed and retrospective data were analysed for complications after transplantation. Diagnosis was based on ultrasound, diethylene triamine penta-acetic acid (DTPA scan), and in later years colour doppler imaging (CDI), percutaneous nephrostomy, and antegrade urographic studies. For early vascular complications immediate exploration was done, ureteric fistula and leakage were treated by exploration and reimplantation of ureter, Boari flap, and pyelovesical anastomosis.

Outcome of living-related donor renal allografts in hepatitis C antibody-positive recipients.

EPATITIS C virus (HCV) is now the leading cause of posttransfusion hepatitis worldwide. 1 HCV infection has a prevalence of up to 48% in hemodialysis patients. 2 In our unit, positivity is 40% and this correlates with the number of blood transfusions received and the duration of dialysis. 3 We developed a criterion whereby all patients on hemodialysis with liver histology showing chronic or benign changes with stable liver enzymes for 3 months were selected for renal transplantation. Our initial results of short-term follow-up showed comparable results compared to HCV-negative recipients who underwent transplantation in the same period. 3 We now report a cumulative 3-year follow-up of 96 anti-HCV-positive recipients in comparison with 191 anti-HCV-negative individuals who underwent transplantation in the same period.

Acute Renal Failure Due to Traumatic Rhabdomyolysis

Trauma and non-traumatic insults can cause muscle damage to such an extent that serious sequelae to other organs may result. Myoglobinuria and subsequent acute renal failure (ARF) is a well known and widely studied fact of such sequelae. Twelve cases of ARF (between 1990-1993) who have developed renal dysfunction after prolonged muscular exercise e.g., squat jumping, sit-ups and blunt trauma from sticks or leather belts mainly given by law enforcing personnel for certain issues were studied. None of them had previous history of myopathy, neuropathy or renal disease. All were critically ill on presentation and required renal support in the form of dialysis. Although morbidity was high in all, eleven of them recovered and one expired due to sepsis.

Range for normal body temperature in hemodialysis patients and its comparison with that of healthy individuals.

Background/Aims: Patients with chronic kidney disease undergoing hemodialysis have an altered homeostasis leading to altered body temperatures. We aimed to determine the range for normal body temperature in hemodialysis patients and compared it to healthy individuals. Also, we determined how much axillary temperatures differed from oral temperatures in both groups and whether axillary temperature is affected by the presence of an arteriovenous fistula (AVF) in hemodialysis patients. Methods: Oral and axillary (left & right) temperatures were recorded using an ordinary mercury-in-glass thermometer in 400 subjects (200 hemodialysis patients, 200 healthy individuals) at the Sindh Institute of Urology and Transplantation from mid-May to mid-June 2006. Comparisons were made between the temperatures of both groups. Results: Mean oral temperature in hemodialysis patients was higher than in healthy individuals [98.7°F (37°C) vs. 98.4°F (36.8°C); p < 0.001], as was the mean average axillary temperature [97.7°F (36.5°C) vs. 97.5°F (36.3°C); p = 0.02] and mean left axillary temperature [97.9°F (36.6°C) vs. 97.6°F (36.4°C); p < 0.001]. The fistula arm had higher axillary temperature in 77 (44%) hemodialysis patients. The difference between oral and axillary temperatures varied widely, making it impossible to obtain an accurate correction factor in both groups. Conclusion: Hemodialysis patients have higher normal body temperatures than healthy individuals. Axillary temperatures require cautious interpretation. In hemodialysis patients, the non-fistula arm should be preferred for recording axillary temperatures, as the presence of AVF may cause discrepancies in temperature measurements.

Acute Graft Dysfunction Due to Pyelonephritis: Value and Safety of Graft Biopsy

Urinary tract infections are the most common infection following renal transplant. Renal transplant recipient have 28% to more than 90% incidence of urinary tract infection occurring after hospital discharge. Risk factors of development of UTI include indwelling catheter, urinary bladder dysfunction especially in diabetic patients, anatomical abnormality, renal insufficiency, nutritional deficiency, and possibly rejection and immunosuppression. It can lead to graft dysfunction and may induce graft loss in severe pyelonephritis. Morbidity associated with urinary tract infection happens to be related to the timing of episode during post transplant period. Infection occurring during early transplant period is generally more serious. It can cause a graft dysfunction and even graft loss. While infection developing 3–6 months after transplantation are more benign and rarely associated with bacteremia. The role of renal allograft biopsy in patients with suspected pyelonephritis and graft dysfunction is not well defined. This study tries to analyze its value and safety in a living related transplant program.

Donor selection in living donors: prospects and problems

THE ESTIMATED prevalence of end-stage renal disease (ESRD) in Pakistan is 100 per million population. The cost of dialysis is approximately US