Carlos Alberto Prompt

Acute Renal Failure Due to Leptospirosis in a Renal Transplant Patient

Roberto C. Manfro, MD, Hospital de Clínicas de Porto Alegre, Unidade de Transplante Renal, Porto Alegre, RS. 90210 (Brazil) Dear Sir, Acute renal dysfunction in the late course ofrenal transplantation is an unusual finding. The present report describes a case of acute renal failure (ARF), secondary to an episode of leptospirosis, in a renal transplant patient 20 years after transplantation. A 20-year-old man received a haplotype-matched kidney allograft in 1971. In September 1990, his serum creatinine was 97.3 μmol/ 1 (1.1 mg/dl) and he was receiving 150 mg of azathioprine q.d. since he had discontinued prednisone on his own 2 years before. Four months later, he presented to the emergency room with a 5-day history of muscle pain, fever, vomiting and diarrhea. He reported he had had contact with rat tissues 10 days prior to admission. The physical examination displayed an acutely ill patient with a blood pressure of 120/70 mm Hg, heart rate of 140 and a temperature of 38 °C. He also presented jaundice, bilateral conjunctival suffusion, a tender liver, splenomegaly and petechiae in the medial aspect of the right thigh. The allograft was not tender. Numerous warts were present in the patient’s hands. At that moment, his serum creatinine and BUN were 530.4 μmol/l (6.0 mg%) and 26 mmol/dl (73 mg%), respectively, SGOT 38 and SGPT 42 U/l. Total and direct bilirubin increased up to 9.8 and 7.0, respectively, 2 days later. Leukocytes were 15,600/mm3, and platelet count was 15,000/mm3. Urinalysis displayed 3 + proteinuria, and the urinary sediment had 5 erythrocytes and 20 leukocytes per high-power field with granular and hyaline casts. He was treated with intravenous fluids, penicillin, vitamin K, cimetidine and loperamide. The azathioprine dosage was halved in the next 2 days and discontinued by the 3 day when peritoneal dialysis was started due to worsening of uremia and continued for 48 h. Within 24 h. of admission, the urinary volume was 450 ml. Afterwards, he presented improvement of diuresis and renal function. Prednisone 10 mg/day was started by the 10th day and azathioprine 50 mg/day 2 weeks later. Antileptospira IgM antibodies tested positive (macroagglutination). The patient was discharged 14 days after admission with normal renal function. This report describes a case of ARF secondary to leptospirosis in a renal transplant patient 20 years after transplantation. We think that leptospira transmission may have occurred through

Caliceal-Cutaneous Fistula in Renal Transplantation:Successful Conservative Management

Caliceal-cutaneous fistula is an uncommon complication of renal transplantation that frequently leads to graft resection. We report our experience with the successful conservative management of a case of caliceal-cutaneous fistula secondary to acute allograft rejection in a renal transplant recipient.

Fine Needle Aspirative Biopsy of the Liver in HBsAG-Positive Patients with End-Stage Renal Failure

HBsAg-positive patients with end-stage renal failure have a high prevalence of asymptomatic chronic hepatitis. In order to determine the usefulness of hepatic cytology in the diagnosis of liver disease, the findings of hepatic needle core biopsy (NCB) and fine needle aspirative biopsy (FNAB) were compared in 15 HBsAg-positive uremic patients. The patients, aged 42 +/- 12 years, 14 males, were on hemodialysis for periods ranging from 13 to 105 months. The NCB was processed by standard histologic and immunohistochemical techniques and FNAB by the conventional technique, using the total corrected increment score (TCI). Plasma samples were collected for evaluation of hepatic function and for viral serologic tests. In 15 patients a diagnosis was made by NCB: normal, 7 cases; chronic persistent hepatitis, 4 cases; and chronic active hepatitis, 4 cases. When the patients were allocated into two groups according to the severity of the liver histologic findings [group I--minor changes (normal+chronic persistent hepatitis), 11 patients; group II--major changes (chronic active hepatitis), 4 patients], statistically higher values were found in the major changes group for alanine aminotransferase (49 +/- 33 vs. 24 +/- 11, p = 0.04), gamma-glutamyl transpeptidase [148 +/- 53 vs. 38 +/- 28, p < (minor) 0.02] and TCI (3.7 +/- 1.2 vs. 2.5 +/- 0.8, p = 0.04). In conclusion, liver FNAB can be useful as a screening procedure for the identification of liver histologic changes (minor or major) in uremic HBsAG-positive patients.

Budd-Chiari syndrome secondary to catheter-associated inferior vena cava thrombosis

INTRODUCTION Patients with chronic kidney disease (CKD) are at increased risk for thrombotic complications. The use of central venous catheters as dialysis vascular access additionally increases this risk. We describe the first case of Budd-Chiari syndrome (BCS) secondary to central venous catheter misplacement in a patient with CKD. CASE REPORT A 30-year-old female patient with HIV/AIDS and CKD on hemodialysis was admitted to the emergency room for complaints of fever, prostration, and headache in the last six days. She had a tunneled dialysis catheter placed at the left jugular vein. The diagnosis of BCS was established by abdominal computed tomography that showed a partial thrombus within the inferior vena cava which extended from the right atrium to medium hepatic vein, and continuing along the left hepatic vein. Patient was treated with anticoagulants and discharged asymptomatic. DISCUSSION Budd-Chiari syndrome is a rare medical condition caused by hepatic veins thrombosis. It can involve one, two, or all three of the major hepatic veins. It is usually related to myeloproliferative disorders, malignancy and hypercoagulable states. This case calls attention for inadvertent catheter tip placement into hepatic vein leading to this rare complication. CONCLUSION Assessment of catheter dialysis tip location with radiological image seems to be a prudent measure after each procedure even if the tunneled dialysis catheter has been introduced with fluoroscopy image.

Diálise peritoneal (DP) como tratamento da insuficiência cardíaca congestiva (ICC) em pacientes com doença renal crônica estágio IV

Congestive heart failure (CHF) has a growing incidence, a great impact on public health, and high morbidity and mortality. Excessive blood volume is a prevalent complication present in 80% of the patients diagnosed with CHF. Pharmacological and non-pharmacological strategies in the treatment of CHF aim to better manage blood volume and reduce the use of diuretics. Extracorporeal ultrafiltration has evidenced better weight control, and a reduction in the length of hospitalization and re-hospitalization of patients with CHF. We report the cases of 2 patients diagnosed with CHF and treated with peritoneal dialysis at Hospital de Clinicas de Porto Alegre.