Dipak J Shah

Glomerulonephritis after human parvovirus infection in homozygous sickle-cell disease

Glomerulonephritis with proteinuria of sufficient degree to manifest the nephrotic syndrome followed aplastic crises induced by human parvovirus (B19) in seven patients with homozygous sickle-cell disease, within 7 days in five patients and 6-7 weeks in two. Segmental proliferative glomerulonephritis was found in all four patients who underwent acute renal biopsies and focal segmental glomerulosclerosis was found in the fifth patient who had a biopsy 4 months later. One patient recovered completely, one died in chronic renal failure after 3 months, and the others had impaired creatinine clearance, four with continuing proteinuria.

Adult T-cell leukemia/lymphoma in a renal transplant recipient: an opportunistic occurrence.

A 42-year-old man with chronic renal failure and homograft transplantation developed adult T cell lymphoma in one native kidney. The role of transfusion in the acquisition of human T-lymphotropic virus type I and its role in the early development of adult T cell lymphoma, particularly on the background of chronic immunosuppression, are discussed. To our knowledge, this is the first such case.

The Clinical and Epidemiologic Features in 140 Patients with Lupus Nephritis in a Predominantly Black Population from One Center in Kingston, Jamaica

Background:Lupus nephritis has emerged as a major factor in the overall survival of patients and may help to explain the poor prognosis associated with systemic lupus erythematosus (SLE) in black patients. Methods:The authors reviewed the clinical and epidemiologic features of lupus nephritis in 130 women and 10 men who were mainly of African descent. Results:The mean (standard deviation) age at diagnosis of SLE was 27.9 (10.3) years. The majority of patients (75%) developed renal involvement within 1 year of presentation with SLE. The most frequent extrarenal manifestations were arthritis (67%), malar rash (44%), serositis (41%), and neurologic disorders (30%). Class IV nephritis was the most common glomerular lesion, accounting for 49% of the biopsies, with class II accounting for a further 23%. Proteinuria was a common feature at presentation in all classes. Nephrotic range proteinuria was most common in classes III and IV. Prevalence of nephrotic range proteinuria was similar in classes II (23%) and V (19%). Hematuria occurred in more than one half of the patients with classes II, IV, and V disease. Fifty-nine percent of the patients had renal impairment at the time of renal biopsy. The prevalence of hypertension, the nephritic syndrome, and renal impairment was significantly higher in class IV patients compared with all the other groups. Factors that were significantly associated with classes III and IV disease compared with the other classes on univariate analysis were renal impairment, proteinuria (but not in nephrotic range), low C3 levels, and anemia. Conclusions:The clinical features of the study patients were similar to those of patients belonging to other ethnic groups, but a high proportion of the study patients had renal impairment at the time of renal biopsy.

The Outcome of Lupus Nephritis in Jamaican Patients

We investigated the outcome of a cohort of black Jamaican patients with systemic lupus erythematosus (SLE) with nephritis. In 66 patients, 0 (0%), 15 (23%), 4 (6%), 32 (48%), 6 (9%), and 3 (5%) had classes 1, II, III, IV, V, and VI, respectively. Six (9%) had interstitial nephritis. The patients were placed in 2 groups for comparison. Group 1 (n = 36) consisted of classes III and IV and group 2 (n = 27), classes II and V, and interstitial nephritis. The patients in group 1 had significantly lower hemoglobin, higher mean serum creatinine, higher prevalence of hypertension, and chronicity scores. The duration of follow-up was similar between the 2 groups. The percent events free for ESRD or death at 1 year was 80.1% for group 1 and 77.4% for group 2; 2 years, 69.0% for group 1 and 77.4% group 2; 5 years, 69.0% for group 1 and 57.4% for group 2. The percent events free for death at 1 year was 93.4% in group 1 and 90.9% in group 2; at 2 years, 86.7% for group 1 and 90, 9% for group 2; and at 5 years was 86.7% for group 1 and 67.3% (29.5 to 88.0) for group 2. Sixteen patients (25.4%) developed ESRD or died. Prognosis was not different between the groups for ESRD or death (P = 0.22) or death alone (P = 0.63).

Severity of systemic lupus erythematosus with diffuse proliferative glomerulonephritis and the ineffectiveness of standard pulse intravenous cyclophosphamide therapy in Jamaican patients

The majority of patients seen at the renal clinic of the University Hospital of the West Indies (UHWI) are of African descent. The case notes of patients with systemic lupus erythematosus(SLE) with class 4 nephritis and who were given standard pulse intravenous cyclophosphamide therapy during the period 1990-2000 were retrospectively reviewed. Primary outcomes were doubling of serum creatinine and development of end stage renal disease (ESRD). Secondary outcomes were return of proteinuriato normal and renal remission. A total of 117 patients had a renal biopsy for SLE nephritis at the UHWI between 1990 and 2000. Of the patients, 34 (29%) had diffuse proliferative glomerulonephritis(WHO class 4), of which 29 were reviewed. Twenty-two patients of 24 in whom it was measured (92%) had significant proteinuria at presentation. The 24-hour proteinuria was measured at final review in 16 patients and in 10 patients it went into complete remission. At the beginning of therapy, 24 patients (83%) had renal impairment. Of the 18 who had final creatinine values, the renal function returned to normal in eight patients (44%) and an additional six patients showed a significant improvement in renal function at final review. Six patients developed end stage renal disease (ESRD). The risk (95% confidence interval)of developingESRD at one year was 16.2% (CI, 6.4-37.6) and at two years was 23.2% (CI, 10.0-48.5). There were three deaths, two from sepsis and one from heart failure. The one-year mortality (95% CI) was 8% (CI, 2.0-28.5), the two-year mortality was 15.6% (CI, 4.9-43.5) and the five-year mortality was also 15.6% (CI, 4.9-43.5). Intravenous pulse cyclophosphamide for Jamaican patients with SLE and diffuse proliferative glomerulonephritisis an ineffective form of treatment.

Human T-cell lymphotropic virus-1-associated renal disease in Jamaican children.

Abstract This report documents the clinicopathological features in two Jamaican children who presented with infective dermatitis, glomerulonephritis, renal failure and human T-cell lymphotropic virus (HTLV-1) seropositivity. Severe hypertension with hypertensive encephalopathy was the most impressive clinical feature. Histological findings from renal biopsy specimens in both cases revealed significant glomerulosclerosis with fibrosis, chronic inflammatory cell infiltrates in the interstitium, and arteriolar hypertensive changes. Membranoproliferative glomerulonephritis (MPGN) was demonstrable in case 1 and marked focal glomerulosclerosis in case 2. Case 1 developed end stage renal failure and died within 3 years of diagnosis. Case 2 remains hypertensive and in chronic renal failure. Although a causal relationship between HTLV-1 infection and renal disease cannot be proven by these two cases, it appears that renal involvement in children with HTLV-1 infection is severe, with the potential for chronic renal failure and malignant hypertension. HTLV-1 nephropathy should be suspected in children with infective dermatitis and renal disease.

Hepatitis B-associated nephrotic syndrome in Jamaican children

Abstract Between December 1984 and November 1996, 171 children under 12 years old presented to the University Hospital of the West Indies with nephrotic syndrome. Hepatitis B surface antigen (HBsAg) was found in ten (6%) of these children, eight of whom had membranous nephropathy (MN), and one each had mesangial proliferative glomerulonephritis (MesN) and minimal change nephrotic syndrome (MCNS). Only those children with MesN and MCNS were steroid-sensitive. The HBsAg-positive status was identified incidentally on screening. At a mean follow-up of 34 months, seven of ten children had experienced complete or partial remission and three had persistent nephrotic syndrome, although none was in renal failure. Six of the ten had biochemical hepatitis. All the children were still HBsAg-positive. Hepatitis B virus (HBV) is a factor contributory to nephrotic syndrome in Jamaican children. As diagnostic clinical markers for HBV-associated nephropathy are usually absent, all children presenting with nephrotic syndrome should be screened for HBsAg. A policy should be implemented in Jamaica for screening pregnant women and at-risk groups for HBsAg, as well as for immunising susceptible neonates, in order to reduce the incidence of HBV-associated pathology.

Membranous Glomerulonephropathy with Crescents in Systemic Lupus erythematosus

Over a 2-year period percutaneous renal biopsies were carried out on 23 patients with systemic lupus nephritis. When classified by immunofluorescence, and light and electron microscopy, 4 patients had mesangial disease, 1 had focal and segmental proliferation, 5 had diffuse proliferation and 5 had membranous changes. 3 biopsies were unclassifiable with end-stage changes and 5 showed an unusual combination of pure membranous changes in association with significant crescent formation. The outcome of the latter group of patients was uniformly poor. We think that this group represents a distinct histological entity with a poor prognosis.