Champa N. Ratnatunga

Retrospective analysis of renal histology in asymptomatic patients with probable chronic kidney disease of unknown aetiology in Sri Lanka

OBJECTIVES To study the early pathological changes in renal lesions of asymptomatic patients with kidney diseases, with no definite aetiology living in regions endemic for chronic kidney disease of unknown etiology (CKDUe). Design Retrospective study. SETTING Regions endemic for CKDUe in and around the North Central Province of Sri Lanka. STUDY POPULATION Two hundred and eleven asymptomatic patients living in endemic regions detected with renal disease by screening for proteinuria using the dipstick method. Those with long standing hypertension, diabetes mellitus, histological diagnosis of primary glomerular diseases, immunocomplex mediated diseases or renal lesions secondary to systemic diseases were excluded. MEASUREMENTS Renal lesions were divided into seven histological categories depending on the pathological changes: Category 0: no detectable changes. Category 1: Interstitial fibrosis ± mild interstitial inflammation ± tubular atrophy; no glomerulosclerosis. Category 2: Interstitial fibrosis ± mild interstitial inflammation ± tubular atrophy; glomerulosclerosis. Category 3: Moderate or severe interstitial fibrosis, interstitial inflammation and tubular atrophy ± glomerulosclerosis; Category 4: Interstitial inflammation ± tubular atrophy ± glomerulosclerosis; no interstitial fibrosis. Category 5: The prominent change is interstitial inflammation with tubulitis. Category 6: Severely scarred kidney. Histological categories were compared with calculated glomerular filtration rates and age of the patients. RESULTS Number of cases in histological categories 0 to 6 were: 7 (3.3%), 71 (33.6%), 53 (25.1%), 63 (29.9%), 0, 2 (0.9%) and 15 (7.1%) respectively. The mean glomerular filtration rate was >90 ml/min in patients in category 0 and 1 and declined progressively in categories 2 and 3. Apart from category 0, all had interstitial fibrosis and in category 1, 62 (87.3%) had interstitial fibrosis without inflammation. Severity of interstitial inflammation increased from category 1 to 3. CONCLUSIONS The early disease among asymptomatic patients is characterized by interstitial fibrosis without significant interstitial inflammation and glomerular sclerosis with preserved glomerular function. Although the role of interstitial inflammation in the initiation of the disease is not clear, it appears to have a role in the progression of the disease.

Predictors of the development of myocarditis or acute renal failure in patients with leptospirosis: An observational study

BackgroundLeptospirosis has a varied clinical presentation with complications like myocarditis and acute renal failure. There are many predictors of severity and mortality including clinical and laboratory parameters. Early detection and treatment can reduce complications. Therefore recognizing the early predictors of the complications of leptospirosis is important in patient management. This study was aimed at determining the clinical and laboratory predictors of myocarditis or acute renal failure.MethodsThis was a prospective descriptive study carried out in the Teaching Hospital, Kandy, from 1st July 2007 to 31st July 2008. Patients with clinical features compatible with leptospirosis case definition were confirmed using the Microscopic Agglutination Test (MAT). Clinical features and laboratory measures done on admission were recorded. Patients were observed for the development of acute renal failure or myocarditis. Chi-square statistics, Fishers exact test and Mann-Whitney U test were used to compare patients with and without complications. A logistic regression model was used to select final predictor variables.ResultsSixty two confirmed leptospirosis patients were included in the study. Seven patients (11.3%) developed acute renal failure and five (8.1%) developed myocarditis while three (4.8%) had both acute renal failure and myocarditis. Conjunctival suffusion - 40 (64.5%), muscle tenderness - 28 (45.1%), oliguria - 20 (32.2%), jaundice - 12 (19.3%), hepatomegaly - 10 (16.1%), arrhythmias (irregular radial pulse) - 8 (12.9%), chest pain - 6 (9.7%), bleeding - 5 (8.1%), and shortness of breath (SOB) 4 (6.4%) were the common clinical features present among the patients. Out of these, only oliguria {odds ratio (OR) = 4.14 and 95% confidence interval (CI) 1.003-17.261}, jaundice (OR = 5.13 and 95% CI 1.149-28.003), and arrhythmias (OR = 5.774 and 95% CI 1.001-34.692), were predictors of myocarditis or acute renal failure and none of the laboratory measures could predict the two complications.ConclusionsThis study shows that out of clinical and laboratory variables, only oliguria, jaundice and arrhythmia are strong predictors of development of acute renal failure or myocarditis in patients with leptospirosis presented to Teaching Hospital of Kandy, Sri Lanka.

Necrotizing fasciitis and death following an insect bite.

AbstractA healthy man who presented to hospital with painful swelling of the left arm following a history of insect (tick) bite developed shock and died within 48 hours. The postmortem examination revealed swelling and desquamation of skin and erythema on the left arm extending below the elbow. The subcutaneous tissue was necrotic with healthy underlying muscles. Group A &bgr;-hemolytic streptococcus was isolated from postmortem swabs of the infected tissue. Histopathologic changes were consistent with necrotizing fasciitis.Secondary bacterial infection is an important possible complication following insect bite, and a high degree of suspicion with aggressive early treatment is required in cases of necrotizing fasciitis to prevent fatalities. Both clinicians and pathologists need to be aware of this rare, rapidly fatal condition that may follow an insect bite.

Predictors of the development of myocarditis and acute renal failure in patients with leptospirosis

Background: Leptospirosis has a varied clinical presentation with complications such as myocarditis and acute renal failure. There are various predictors of severity and mortality, including clinical and laboratory parameters. Early detection and treatment can reduce complications. Therefore, recognizing the early predictors of the complications of leptospirosis is important in patient management. Aims: This study was aimed at determining the clinical and laboratory predictors of myocarditis and acute renal failure. Setting and Design: This is a prospective descriptive study carried out in medical wards of our hospital from July 1, 2007, to July 31, 2008. Materials and Methods: Patients with clinical features compatible with leptospirosis case definition were confirmed using the Microscopic Agglutination Test (MAT). Clinical features and laboratory investigations done on admission were recorded. The patients were observed for the development of acute renal failure and myocarditis. Statistical Analysis: Chi-square statistics, Fishers exact test, and Students t test were used to compare patients with and without complications. A logistic regression model and backward stepwise elimination of variables was carried out to select final variables. Results: Sixty-two confirmed leptospirosis patients were included in the study. Six patients (9.6%) developed acute renal failure and five (8%) developed myocarditis, while three (4.8%) had acute renal failure and myocarditis together. Conjunctival suffusion - 40 (65%), muscle tenderness - 28 (45%), oliguria - 20 (32%), jaundice - 12 (19%), hepatomegaly - 10 (16%), arrhythmias (irregular radial pulse) - 8 (13%), chest pain - 6 (10%), bleeding - 5 (8%), and shortness of breath (SOB) - 4 (6%) were the common clinical features present in the patients. Of these, only oliguria {Odds Ratio (OR) = 4.14, 95% Confidence Interval (CI) = 1.003 - 17.261}, jaundice (OR = 5.13, 95% CI = 1.149 - 28.003), and arrhythmias (OR = 5.774, 95% CI = 1.001 - 34.692), were predictors of myocarditis and acute renal failure and none of the laboratory investigations could predict the two complications. Conclusion: This study shows that out of clinical and laboratory variables, only oliguria, jaundice, and arrhythmia are strong predictors of development of acute renal failure and myocarditis.