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Idiopathic adult focal segmental glomerulosclerosis: a clinicopathological study and response to steroid.

A total of 65 adult cases (53 males, 12 females) with biopsy-proven focal segmental glomerulosclerosis (FSGS) were studied. Hypertension, ascites and haematuria were seen in 13, 12 and 24 cases, respectively. Decreased creatinine clearance at presentation was found in 9 cases. Mean proteinuria per day, serum cholesterol and total protein were 7.5 +/- 4.3 g, 388.95 +/- 213.4 mg% (10.11 +/- 5.55 mmol/l) and 5.27 +/- 1.1 g% (0.527 +/- 0.11 milligram), respectively. Mesangial proliferation was seen in 13 cases and hilar sclerosis in 5. Fifty percent showed positive immunofluorescence; IgM in 10, C3 in 8, and IgG in 2. Forty-two cases could be followed (mean 32 months), out of which 38 had nephrotic syndrome and were treated with prednisolone; 58% showed response (31% complete remission and 27% partial remission). One patient in each group of responders and nonresponders had renal failure at the end of follow-up. Hypertension, degree of proteinuria, mesangial proliferation, degree of tubular atrophy and immunofluorescence findings did not significantly affect the response to steroids. We conclude that a group of patients with idiopathic adult FSGS has a favourable response to steroids, which cannot be predicted clinically.

Spectrum of poisoning requiring haemodialysis in a tertiary care hospital in India

We report our experience in 66 cases of acute poisoning requiring haemodialysis (HD) in the last 17 years. Barbiturate poisoning was the commonest poisoning (30 cases). Mean blood barbiturate level was 8.9 mg%. Twenty four were in grade IV coma at the time of presentation. Twenty five required one HD and 5 cases needed 2 HD. Four died due to respiratory infection or hypotension. Copper sulphate poisoning was encountered in 19 cases. Common features in this group were: acute renal failure (ARF) (19), haematuria (3), gastrointestinal bleeding (7), intravascular haemolysis (9), jaundice (11), hepatocellular toxicity (8), methaemoglobinuria (8) and circulatory collapse (5). The indication for HD in all these cases was ARF. Seven patients died. There were 9 cases of mercuric chloride poisoning requiring 2-5 HD. Common features in this group were; ARF (9), gastrointestinal bleeding (9), anaemia (8), jaundice (2). Two patients died. Other patients had Mandrax, Naphthalene, Tincture Iodine, Ethylene Bromide and Lithium poisoning. Overall mortality in our study was 24.2%. It is concluded that HD is not the primary mode of therapy for drug intoxication. Adequate supportive management is most important in determining final outcome of these patients.

CHRONIC INTERSTITIAL NEPHRITIS FOLLOWING PARENTERAL COPPER SULFATE POISONING

A 21-year-old male patient was admitted with acute renal failure and intravascular hemolysis following suicidal parenteral copper sulfate poisoning. He developed metabolic acidosis and septicemia; and was treated with intensive hemodialysis, blood transfusions and antibiotics. After remaining anuric for 4 weeks, his urine output gradually increased. However his renal functions improved only partially. Renal biopsy done 8 weeks after the episode showed chronic tubulo-interstitial nephritis (CIN). This is the first reported case showing CIN following acute copper sulfate intoxication.

Treatment of Acute Rejection in Live Related Renal Allograft Recipients: A Comparison of Three Different Protocols

We present our experience on the comparison of three different modes of steroid therapy, oral prednisolone (OP), intravenous dexamethasone (IVDX) and intravenous methylprednisolone (IVMP) in the treatment of acute rejection (AR) in renal allograft recipients. Between January 1980 and January 1992, 206 patients underwent live related renal transplantation. Before 1990, all received prednisolone (PRED) and azathioprine (AZA) only. After 1990, patients were given PRED, AZA and cyclosporine (CsA). After 1 year, CsA was stopped and patients were converted to a two-drug regimen only. Of the 206 patients, 180 (87.4%) were male and mean age was 30.3+/-8.7 years (range 14-63). During the mean follow-up of 43.5 months, 178 episodes of AR were seen in 121 patients. Each episode was considered as a separate entrant in the study. Conventional immunosuppression was given in 151 episodes and 27 episodes were on triple-drug therapy. Diagnosis of AR was made by clinical, sonography, nuclear scan with or without graft biopsy evidence. Of the 178 AR, 110 (61.8%) were within 3 months, 36 (20.2%) were between 3 months and 1 year and 32 (18%) were after 1 year. OP was given in 11 cases while IVDX and IVMP were given in 48 and 119 cases respectively. Overall, 154 (86%) showed either a complete or partial response to antirejection therapy. Response to therapy was 91, 90 and 85% in OP, IVDX and IVMP groups respectively. There was no statistical difference in response rate in different groups. There was also no difference in side effects in three different groups. Our data suggest that it is the high dose of steroid rather than mode of therapy which is responsible for therapeutic benefit in treatment of AR.

Fibrosing cholestatic hepatitis in renal transplant recipient with CMV infection: A case report

Fibrosing cholestatic hepatitis (FCH) is an uncommon complication of renal transplantation. It is usually associated with hepatitis B and C viral infection. It is further rare in renal transplantation in absence of HBV and HCV infection. To the best of our knowledge, only three cases of FCH in renal transplantation, which were both HBV and HCV negative, have been reported to date. Out of these, two cases were diagnosed to have CMV infection and the third was attributed to azathioprin. We are presenting another case of FCH in a renal transplant recipient with CMV infection.

Total dose iron infusion: safety and efficacy in predialysis patients.

Iron deficiency anemia isnot uncommon in predialysis patients. Oral iron often cannot maintain adequate iron stores. Hence we evaluated the safety and efficacy of total infusion (TDI) of iron in these patients. Anemic predialysis patients were screened and those with Hb < 7.0g/dL and serum ferritin < 200ng/mL were selected. Patients with active bleeding and acute livere disease were excluded. All patients were on oral iron 100mg/day. None of the patients were on erytropoeitin. 11 patients (6 males and 5 females). aged 45.9 + 15yrs. were suitable. Hb was 5.9 ± 1.0g/dL and serum ferritin was 89.5 + 50 ng/mL. The preparation used was iron dextran. A test dose of 25mg in 100mL normal saline was administeted over 1 hr to all patients. One patient had fever and chills during the test dose and was not given TDI. 10 patients received TDI. None of these patients had any problem during the infusion. The dose of iron administered was 900 + 316.2 mg. One patient who received 1600mg had arthralgia-myalgia and another patient had thrombophlebitis following TDI. One month after TDI, Hb was 8.0 + 1.0g/dL and serum ferritin was 362ng/mL. We feel that TDI is a safe and effective method of correcting iron deficiency in predialysis patients.

VISCERAL LEISHMANIASIS : A RARE CAUSE OF UNEXPLAINED PYREXIA IN A RENAL ALLOGRAFT RECIPIENT

Dr. Sanjiv Saxena, Assist. Prof., Department of Nephrology, AIIMS, New Delhi (India) Dear Sir, Visceral leishmaniasis or kala-azar has not been recognised as a common infection in renal allograft recipients. However, immunodeficiency states can facilitate the reactivation of a dormant illness in infected patients or predispose such patients to infection in endemic areas. Indeed, following its first description in renal transplant recipients in 1979 [1], in recent years more case reports have described such an association [2-5]. In contrast to the nonimmunodefi-cient patients, the disease is often more fulminant and poorly responsive to therapy in these high risk patients [3]. We report here a case of visceral leishmaniasis in a renal allograft recipient who presented with pyrexia of undetermined origin and showed an excellent response to pentavalent antimonials. A 23-year-old young male, resident of Bihar, India, underwent a one-haplotype-matched live related renal transplantation for Alport’s syndrome with end stage renal disease at our centre in December 1992. Immunosuppression given comprised three drugs – azathioprine, prednisolone and cy-closporine, with a gradual tapering off from cyclosporine from 3 months onwards so as to be completely weaned off by 9 months. The early posttransplant period was uneventful. In June 1993 the patient was admitted for evaluation of his pyrexia of unknown origin of 3 weeks duration. The fever was high grade and remittent in nature without any localising symptoms. He had received an empirical course of antimalarials twice (chloroquine followed by a sulphamethoxa-zole and pyrimethamine combination) and also broad-spectrum antibiotics (ampicillin and norfloxacin) for his pyrexia in Bihar without response. Physical examination revealed a pale, anicteric, febrile patient with no significant peripheral lymphadenopathy. He was normotensive and the cardiovascular and respiratroy systems were normal. Abdominal examination showed a 2-cm hepatomegaly and a firm 3-cm splenomegaly with the allograft being normal and non-tender. Investigations on admission revealed a haemoglobin of 6.4 g/dl, reticulocyte count 1%, total leucocyte count 3,200/mm3, platelet count of 90,000/mm3 and ESR of 33 mm in the 1st h. Blood urea was 30 mg/dl, serum creatinine 1 mg/dl, serum bilirubin 0.9 mg/ dl, SGOT 86

Urinary Sporotrichosis in a Renal Allograft Recipient

Dr. Sanjay K. Agarwal, Assistant Professor, Department of Nephrology, Aiims, New Delhi-110029 (India) Dear Sir, We are reporting a case of urinary sporotrichosis in a renal transplant recipient. The patient had a radiolucent calculus with recurrent urinary tract infection. A 23-year-old male, having chronic glo-merulonephritis with end-stage renal failure underwent renal transplantation in July 1985. His mother was the donor with one haplotype match with the recipient. Postoperatively his renal function did not improve steadily. Ultrasound examination of the abdomen showed moderate hydronephrosis of the graft with narrowing of the lower end of the ureter. After confirming the finding on radionucleid scan on the 7th postoperative day, he was reoperated and a ureteroneocystostomy was done. Postoperatively he developed supra-pubic urinary leak which was managed conservatively. Following surgery his renal function improved slowly and on the 17th postoperative day serum creatinine was 106 μmol/l (1.2 mg/dl). He continued to have recurrent urinary tract infections which were treated according to the urine culture and sensitivity. On the 75th day following transplantation, a follow-up ureterocystoscopy was done which was essentially normal. However, his symptoms of lower urinary tract infection continued to persist even though the urinary cultures were repeatedly normal. In April 1986, although a plain radiogram of the abdomen was normal, the patient passed a stone per urethra, which was mainly made of ammonium phosphate with traces of calcium and oxalate. Keeping the possibility of a radiolucent calculus he was admitted for investigations. While in the hospital, he had acute retention of urine associated with enlargement of the graft which spontaneously got relieved within 12 h. However, a repeat ultrasonogram still showed hydroureterone-phrosis of the allograft with an echoic shadow at the lower end of the ureter. An antegrade pyelography performed at this time showed a dilated ureter (1.2 cm) and a stone at the lower end of the ureter. As the stone could not be dislodged, a percutaneus nephrostomy was done. Once the acute stage was over, he was operated for ureterolithotomy. During surgery multiple small yellowish calculi were found at the lower end of the ureter with a large stone 2 cm proximal to the vesicour-eteric junction

Diagnosis of glomerular haematuria by imagecytometry of urinary red cells.

Accessible online at: www.karger.com/journals/nef Dear Sir, Haematuria is an important and common problem in clinical practice. It may be caused by urological problems or ailments related to nephrology such as glomerulonephritis. Early detection of haematuria and differentiation between glomerular and nonglomerular type is essential for determination of the correct line of investigation and treatment [1, 2]. Glomerular haematuria is associated with a marked variation in size and shape of red cells, frequently with loss of hemoglobin, leading to many ‘dysmorphic’ cell populations. Nonglomerular haematuria is accompanied by a uniform morphology with less hemoglobin loss leading to ‘isomorphic’ cell populations [1–3]. Phase contrast microscopy of red blood cells (RBCs) in urine is the standard practice for diagnosis of haematuria, but the method is subjective, less accurate and the criteria are variable [2]. Recently automated urine flowcytometer is being used for diagnosis of origin of haematuria where the size of the red cells is determined by estimating the forward scatter (FSC) intensity of the cells without taking into account the variation in their shape and hemoglobin content [4]. We have undertaken a study to evaluate the urine red cells with the help of an automated computerized image analysis system [5] for determination of (1) size (area, area equivalent diameter and perimeter), (2) variation in shape in the form of form factor and (3) hemoglobin content by integrated optical density (IOD). An unstained coverslip preparation [2] of mid-stream fresh second morning urine samples were subjected to image analysis [5, 6] from 86 patients in this study with 52 males and 34 females, age ranging from 5 to 68 years (mean 36 B 21). In all these cases the sites of origin of red cells were confirmed later with clinical, radiological and biochemical investigations [2]. Forty-six patients had glomerular haematuria with different types of glomerulonephritis and 40 patients had nonglomerular causes like cancers and stone diseases. The glomerular RBCs were significantly smaller in diameter, area and perimeter than nonglomerular RBCs with a greater variation in shape and lower IOD (p ! 0.0001 to ! 0.0002) (table 1). Taking the 95 percentile value (5.3 Ìm) as cut-off value of red cell diameter, 93% of cases of glomerular haematuria could be diagnosed correctly, similarly 93, 92, 90 and 95% of cases could be diagnosed by cut-off values of 33.6 Ì2 for area, 19.1 Ìm for perimeter, 0.5 for form factor and 0.035 for IOD, respectively. With multiparametric analysis with cut-off values of all Table 1. The range and mean (BSD) of different parameters in glomerular (I) and nonglomerular (II) haematuria

PREVALENCE OF ANTIBODIES AGAINST HEPATITIS E VIRUS IN HAEMODIALYSIS PATIENTS IN INDIA

Accessible online at: http://BioMedNet.com/karger Dear Sir, We report our observations of antibodies to hepatitis E virus (anti-HEV antibodies) in patients on maintenance haemodialysis (MHD). 64 consecutive patients with chronic renal failure over an 18-month period who underwent MHD followed by renal transplantation were screened for markers of anti-HEV antibodies. These patients were also screened for other viral markers such as hepatitis B surface antigen and antibodies against hepatitis C virus using a third-generation enzymelinked immunosorbent assay, according to our policy. The patients were screened for anti-HEV antibodies both at the time of entry into the MHD programme as well as at the end of the programme before undergoing renal transplantation. The presence of antibodies was determined by analyzing the sera for IgG antibodies to HEV. This test was performed using a recombinant anti-HEV antigen immunoassay (Genelab Diagnostic, India), where wells of the polystyrene microplate strips were coated with the recombinant antiHEV antigen corresponding to the structural region of HEV. Along with viral markers, serum alanine aminotransferase (ALT) and serum bilirubin levels were also analyzed in each patient. Patient’s age, sex, past history of hepatitis, and the history of jaundice in the family were also recorded. The mean age of the patients was 38 B 5.3 years, and 89% were male. A history of jaundice in the past or in family members was found in 19 and 9% of the patients, respectively. 6.25% of the patients had both histories. At the start of MHD, 30% patients had anti-HEV antibodies, while at the end of MHD, 41% were anti-HEV positive. One patient who was anti-HEV positive at the beginning became negative, while 5 patients who were negative at the beginning became positive for antiHEV antibodies. During MHD, the mean number of blood transfusions given to these patients was 4 B 2.8. HEV is primarily an enterically transmitted virus which has been responsible for outbreaks of hepatitis in many developing countries, including India. It tends to occur more commonly in young adults, causing acute hepatitis with a high fatality rate in pregnant women. Although transmission and spread of infection are primarily faecal-oral, vertical transmission [1], transmission through blood products [2], and sexual transmission [3] have also been reported. The high prevalence of HEV markers in haemodialysis patients has been reported earlier from another country [4]. In the present study, anti-HEV antibodies at the end of dialysis were found in a greater number of patients than at the beginning. This suggests that the prevalence of HEV increases during MHD. A high prevalence in intravenous drug users suggests that blood can be source of transmission of HEV infection. However, in haemodialysis patients, the significance of HEV infection remains unclear. None of the patients with isolated anti-HEV antibodies had abnormal liver function tests. At the start of MHD, only 2 patients had high ALT levels, and both had hepatitis C virus co-infection. At the end of MHD, 3 patients who had high ALT levels had co-infections with other viruses (2 hepatitis C and 1 hepatitis B). This suggests that isolated HEV infection itself may not be of clinical significance in these patients. The presence of IgG anti-HEV in patients with acute hepatitis has been correlated with acute HEV infection in studies performed in industrialized countries, but in endemic areas like India its significance is limited due to high exposure rate. But, even in India, the prevalence of IgG anti-HEV in healthy individuals varies from 5 to 100% in various studies [5]. There is no study from India on antiHEV antibodies in the dialysis population. Though IgG anti-HEV may be evidence of past exposure, 5 new patients having IgG anti-HEV at the end of MHD, who were initially negative, remain unexplained. Furthermore, in spite of the prevalence of IgG antiHEV being common in our dialysis population, its significance is, according to our results, minimal. None of the patients with isolated anti-HEV antibodies had biochemical or clinical evidence of liver dysfunction. We conclude from this preliminary report that anti-HEV antibodies are common in haemodialysis populations in India. A much larger study is required to clearly define the clinical significance in these patients.