Fazal Akhtar

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.

Living‐related pediatric renal transplants: A single‐center experience from a developing country

Abstract: We retrospectively analyzed the results of 75 living‐related pediatric renal transplants performed at our center between January 1986 and December 1999. The major causes of end‐stage renal disease (ESRD) were glomerulonephritis (26%) and nephrolithiasis (16%), while the etiology was unknown in 50%. The mean age of the recipients was 12 yr (range 6–17 yr) and that of the donors was 39 yr (range 20–65 yr). The majority (73%) of donors were parents. Eighty five per cent of donors were one‐haplotype matched and the rest identical. Immunosuppression was based on a triple drug regimen. Thirty per cent of recipients were rapid metabolizers of cyclosporin A (CsA) (area under the curve [AUC]: < 6,000 ng/mL/h), while 16% were slow metabolizers (AUC: > 8,000 ng/mL/h). Forty three (57%) children encountered 59 rejection episodes, the majority of which (59%) were recorded in the first month post‐transplant. Seventy‐four per cent of the rejection episodes were steroid sensitive and the rest, except two, were resolved by therapy with antithymocyte globulin (ATG) or orthoclone thymocyte 3 (OKT3). After a mean follow‐up of 37 months, 17 (22%) grafts had chronic rejection and 76% of these recipients had previously experienced acute rejection episodes. The overall infection rate was high, necessitating two hospital admissions/patient/year. The majority (53%) of the infections were bacterial. Urinary tract infections (UTIs) were seen in 17 (23%) recipients. Twelve of these had ESRD as a result of stone disease and eight grafts were lost because of UTIs. Eight per cent of recipients developed tuberculosis (TB), and extra‐pulmonary lesions were seen in 50%. Surgical complications were encountered in eight patients. Free medication to all recipients and parental support ensured a compliance rate of 93%. Baseline growth deficit was seen in children of the two groups studied (the 6–12 yr and 13–17 yr age‐groups), with Z‐scores of – 2.39 and – 2.12, respectively. No growth catch‐up was observed at 12 and 24 months in either group. Post‐donation complications were seen most commonly in donors > 50 yr of age and included: proteinuria (> 300 mg/24 h, four patients), hypertension (three patients), and diabetes (one patient). Twenty‐four grafts were lost, 54% as a result of immunological and the rest as a result of non‐immunological causes, and 17 recipients died during the follow‐up period. Infections were the main cause of patient and graft loss. Overall 1‐ and 5‐yr graft and patient survival rates were 88% and 65%, and 90% and 75%, respectively.

Commercial transplants in local Pakistanis from vended kidneys: a socio-economic and outcome study.

Donor shortage and absence of transplant law lead to unrelated commercial transplants in Pakistan. We report the socio‐economic and outcome parameters of 126 local recipients of unrelated kidney vendor transplants presenting to our institute between 1997 and 2007. Their outcome was compared with 180 recipients of living‐related donor transplants matched for age, gender and transplant duration as controls. Age of commercial recipients was 35.63 ± 11.57 years with an M:F ratio of 2.4:1. Majority (92%) were transplanted in northern Pakistan paying US

Long-term Safety of Living Kidney Donation in an Emerging Economy.

7271 ± 2198. All were educated with 50% being graduates or above and rich earning a monthly salary of US

Cyclosporine withdrawal in post-renal transplant thrombotic microangiopathy.

517 ± 518 with 44% earning >US

Predictors of Outcome in Malarial Renal Failure

500. Comparison of commercial recipients with controls showed high comorbidities 35 (28%) vs. 14 (8%) (P = 0.0001) with diabetes, hepatitis‐C and cardiovascular diseases. Donor age was 29.97 ± 6.16 vs. 32.63 ± 9.3 years (P = 0.035). Biologic agents induction in 101 (80%) vs. 14 (8%) (P = 0.0001), acute rejections in 42 (33%) vs. 31 (17%) (P = 0.005), 1‐year creatinine 1.84 ± 1.28 vs. 1.27 ± 0.4 mg/dl (P = 0.0001), surgical complications 28 (22%) vs. 14 (8%) (P = 0.001), tuberculosis 14 (11%) vs. 6 (6%) (P = 0.007), acute hepatitis 20 (16%) vs. 3 (2%) (P = 0.0001), cytomegalovirus 33 (26%) vs. 21 (11%) (P = 0.001) and recurrent urinary tract infection 35 (28%) vs. 30 (16%) (P = 0.034). Overall 1‐ and 5‐year graft survival was 86% and 45% vs. 94% and 80%, respectively (P = 0.00001). Total deaths were 34 (27%) vs. 12 (6.0%) (P = 0.001). In conclusion, recipients of the vended kidneys are poor candidates, educated, rich and often self‐selecting. Their outcome is poor, which will leave them poorer still and back to dialysis if not death.

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

Background Long-term follow-up and management of donors was undertaken in a specialist kidney transplant unit in Pakistan to identify risk and prevent adverse outcomes in living related kidney donors. Methods In an observation cohort study between 1985 and 2012, 3748 donors were offered free medical follow-up and treatment 6 to 12 months after donation and annually thereafter. Each visit included history, physical examination, blood tests for renal, lipid, glucose profiles, and 24-hour urine for proteinuria and creatinine clearance. Preventive intervention was undertaken for new onset clinical conditions. Donor outcomes were compared with 90 nondonor healthy siblings matched for age, sex, and body mass index. Results Of the 3748 donors, 2696 (72%) were in regular yearly follow-up for up to 27 years (median, 5.6; interquartile range, 7.9). Eleven (0.4%) died 4 to 22 years after donation with all-cause mortality of 4.0/10 000 person years. Six (0.2%) developed end-stage renal disease 5 to 17 years after donation, (2.7/10 000 person years). Proteinuria greater than 1000 mg/24 hours developed in 28 patients (1%), hypertension in 371 patients (13.7%), and diabetes in 95 patients (3.6%). Therapeutic intervention-controlled protein was less than 1000 mg/24 hours, blood pressure was below 140/90 mm Hg, and glycemic control in 85% up to 15 years after onset. Creatinine clearance fell from 109.8 ± 22.3 mL/min per 1.73 m2 predonation to 78 ± 17 at 1 year, 84 ± 19 at 5 years, and 70 ± 20 at 25 years. Comparison of 90 nondonor sibling and donor pairs showed significantly higher fasting glucose and hypertension in nondonors. Conclusions Long-term follow-up of donors has demonstrated end-stage renal disease in 0.6% at 25 years. Regular follow-up identified new onset of disease and allowed interventions that may have prevented adverse outcomes.

Acute Renal Failure Due to Traumatic Rhabdomyolysis

Abstract:  Introduction:  Thrombotic microangiopathy (TMA) is a well known complication of cyclosporine (CsA)‐treated renal transplantation but optimum treatment strategies are not clearly defined.

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

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.