J. C. M. Shastry

Nondiabetic renal disease in noninsulin-dependent diabetics in a South Indian hospital

Eighty patients with non-insulin-dependent diabetes mellitus being treated in a south Indian hospital were biopsied to confirm suspected nondiabetic renal disease (NDRD). The positive predictive value of the standard clinical indicators for NDRD in the presence or absence of diabetic retinopathy was 54 and 87%, respectively. These values are higher than those given by comparable studies in Western populations. This is probably due to a higher prevalence of NDRD in the population of south India, and especially of proliferative glomerulonephritis, which was found in 21.5% of the patients studied. Standard clinical predictors of NDRD in diabetics have a high predictive value in the tropics where there is a high prevalence of proliferative glomerulonephritis.

Terminal Infections in Renal Transplant Patients in a Tropical Environment

Infections were a major cause of death in 84% of 38 autopsied renal allograft recipients in a south Indian hospital. Pyogenic bacteria and fungi were the most common etiological agents encountered, being present in 50 and 47% of cases, respectively. Tuberculosis and hepatitis B virus infection were more prevalent and Pneumocystis carinii and cytomegalovirus disease rarer than in comparable series from non-tropical countries. 1 case each of amoebiasis, strongyloidiasis and filariasis were the parasitic infections encountered.

Acute eosinophilic glomerulonephritis with Bancroftian filariasis

A case is reported of Bancroftian filariasis and acute immune complex glomerulonephritis in a 44-year-old man. Renal biopsy showed microfilariae and large numbers of eosinophils in the glomeruli (eosinophilic glomerulonephritis). The absence of other aetiological factors suggests that the glomerulonephritis may have been of filarial origin.

Minimal-Change Nephrotic Syndrome in Adults Treated with Alternate-Day Steroids

Fifty-eight previously untreated adults with minimal-change nephrotic syndrome (MCNS), who had a mean follow-up period of 35.8 months, were studied with regard to their response to alternate-day steroid therapy. The nephrotic syndrome in 54 patients (93%) remitted by 12 weeks and patients continued to be in remission at 16 weeks. Of the 54 patients, 8 (14.8%) had frequent relapses and 9 (16.6%) had infrequent relapses. No serious complications as a result of steroid therapy were encountered.

Indication for routine allograft nephrectomy in cases of irreversible rejection.

Toutes les greffes rejetees ne doivent pas etre enlevees avant la retransplantation. Limmunodepression peut etre progressivement reduite et arretee en cas dindication chez certains malades sans effets nefastes sur la greffe rejetee ou sur les greffes ulterieures

Haemolytic-uraemic syndrome complicating snake bite.

Anand Date, MD, Professor of Pathology, Christian Medical College Hospital, Vellore 632004, Tamil Nadu (India) Dear Sir, The triad of acute renal failure (ARF), thrombocyto-penia and haemolytic anaemia with fragmented erythrocytes (schistocytes) comprise the haemolytic-uraemic syndrome (HUS) [1]. In addition to its primary idiopathic childhood form, this syndrome can occur secondarily with viral and bacterial infections, oral contraceptive use and in pregnancy and in the puerperium [2]. Its occurrence after snake bite is not well known. During the period 1975–1983, 12 female and 12 male patients, with a mean age of 36 years (SD 14 years), were treated for ARF following snake bite at the Christian Medical College Hospital at Vellore in southern India. They had been referred for treatment from peripheral clinics 2–21 days after the onset of oliguria. Initially the patients had severe pain and swelling at the site of the bite and bleeding manifestations, most commonly haematu-ria with prolonged bleeding and clotting times. Oliguria or anuria developed within 24 h of the bite, and lasted for 4–47 days. The snake was identified by description as Vipera russelli in 7 cases. In the remainder, identification could not be made, although the symptomatology suggested that the Russell’s viper was involved in all cases and this is the only snake in this region whose bite is reported to cause ARF [3]. Results of laboratory investigations were as follows: Blood urea, mean 46.5, SD 25 mmol/l; plasma creati-nine, mean 967, SD 417 μmol/l; platelet count, mean 104, SD 92 × 10V1; packed cell volume, mean 0.27, SD 0.11; reticulocyte count, mean 5, SD 3%; total leukocyte count, mean 13.3, SD 4× 10V1; differential neutrophil count, mean 80, SD 8%. Schistocytes were present in the peripheral blood smears of 22 patients. Sixteen patients had HUS with anaemia, schistocytosis and thrombocyto-penia. Six patients had normal platelet counts when first examined 7 days or more after the bite, and there was no record of schistocytes in the peripheral blood smear in 2 cases. Absence of the complete triad could, in most cases, be attributed to incomplete or delayed investigation. Percutaneous renal biopsies performed in 15 patients showed cortical necrosis in 3 cases and acute tubular necrosis in the rest. Fibrin and platelet clusters were demonstrable in glomeruli and small calibre blood vessels in 5 of the 7 biopsies examined electron microscopically [4, 5]. Two patients were treated conservatively, 2 with hae-modialysis and the rest by peritoneal dialysis. One patient died of massive haematemesis soon after admission to hospital. Patients with cortical necrosis developed chronic renal failure, the others made a complete recovery.

Outcome of the haemolytic-uraemic syndrome complicating bacillary dysentery.

Seventy-eight children were treated for the haemolytic-uraemic syndrome complicating bacillary dysentery over a ten-year period. Early dialysis favoured survival significantly. The renal status of 22 of the 28 survivors was re-evaluated 18-84 months after initial hospitalization. Complete recovery was found in all except two patients; one of them had neurological sequelae and the other a glomerulonephritic disease.

Gastric aspiration for diagnosis of pulmonary tuberculosis in adult renal allograft recipients

Of 213 renal allgraft recipients suspected to have had pulmonary tuberculosis, 132 had sputum examinations and 14 showed acid-fast bacilli. Of the remaining 118 patients, 25 had gastric aspirations, 18 had bronchoalveolar lavage, and 75 did not require further investigation because of spontaneous improvement or confirmation of an alternative diagnosis. While 9 of the 25 patients gastric aspirate examination was positive, all the 18 who had bronchoalveolar lavage were negative for acid-fast bacilli. Eighty-one patients without expectoration had gastric aspiration directly and 14 showed acid-fast bacilli. Of the remaining 67 patients only 17 had bronchoalveolar lavage, of which three were positive for AFB and the rest did not require further testing for tuberculosis. A total of 106 patients had gastric aspiration. Acid-fast bacillus positivity was significantly more (P<.01) in patients with abnormal chest radiographs as compared with patients with normal chest radiographs as compared with patients with normal chest radiograph results. We suggest gastric aspiration for AFB in all renal transplant recipients who have fever, scanty expectoration, and abnormal chest radiograph with clinical suspicion of pulmonary tuberculosis.

Central nervous system disease in renal transplant recipients.

Anand Date, MD, Professor of Pathology, CMC Hospital, Tamil Nadu (India) Dear Sir, Diseases of the central nervous system (CNS) are an important cause of morbidity and mortality in renal transplant recipients [1]. Since there are few reports reviewing these lesions, we describe here the CNS complications that occurred in 38 of the 550 patients who received live-donor renal allografts at our centre during a 15-year period. The findings and methods of diagnosis are summarised in table I. As expected from other reports [1–3], infections were the commonest CNS complications, being seen in cases 1–16. However, tuberculous meningitis was much more frequent reflecting the higher prevalence of tuberculosis in the tropics. Case 4 who died of gram-negative bacillary septicaemia had microglial nodules in the pons; such lesions have been reported previously and are believed to be due to cytomegalovirus or herpes simplex virus infection [3, 4]. Cryptococcus was the fungus most frequently involving the CNS, though it is uncommon among all systemicfungal infections in suchpatients here [5]. Cerebrovascular accidents occurred in cases 17–25 including 8 of the 283 renal transplant recipients treated using a high-dose steroid schedule employed earlier and in only 1 of the 267 cases who were given steroids according to the newer low-dose regimen. This difference was statistically significant by Fisher’s exact test (p < 0.02). All these patients had hypertension and 2 had diabetes mellitus as well. Eight patients presented with convulsive disorders, of whom 4 had hypertensive encephalopathy and 2 idio-pathic epilepsy. Patients 30 and 31 had generalised convulsions with serum calcium levels of 0.95 and 1.05 mmol/l, respectively. Detailed investigations failed to reveal any cause for hypocalcaemia, but both patients improved with calcium supplements. All 3 patients with hepatic encephalopathy had HBs antigenaemia. Case 37 developed drowsiness 5 months after transplantation, at which time renal functions were only mildly impaired and other investigations including cerebrospinal fluid examination were normal. A CAT scan and EEG showed evidence of bilateral frontal lobe atrophy of unknown cause. Extensive investigations including a diagnostic laparotomy failed to show the cause of fever in case 38, but necropsy revealed pulmonary nocardiosis and central pontine myelinolysis

Medical Renal Disease in the Elderly in a Southern Indian Hospital

A review of 85 patients aged 60 years or more, treated in a southern Indian hospital for conditions requiring renal biopsy, showed that diffuse poliferative glomerulonephritis was the most frequent diagnosis, being present in 24 cases of whom 11 had elevated serum streptococcal antibody titres. Infections were also important in 2 patients with amyloidosis secondary to tuberculosis, in 3 patients with acute tubular necrosis following infectious gastroenteritis and in a patient with acute pyaemic interstitial nephritis with septicaemia. Drugs including indigenous medicines were the other important cause of renal disease, being implicated in 11 cases.