Kottarathil A. Abraham

Pathogenesis of acute renal failure associated with the HELLP syndrome: a case report and review of the literature

Acute renal failure is a rare but serious complication of pregnancy. We describe a 31-year-old woman with haemolytic anemia, elevated liver enzymes, low platelets (HELLP syndrome) who developed acute peripartum renal failure. Renal biopsy performed 2 weeks later because of persistent oliguria revealed thrombotic microangiopathy and acute tubular necrosis. This case highlights the probable pathogenesis of acute renal failure in HELLP patients and explains why it resolves in the majority of cases. A review of the literature that describes renal histology in HELLP patients is presented.

THE HELLP SYNDROME, A PROSPECTIVE STUDY*

Objective.We undertook this study to evaluate the incidence and outcome of HELLP in Irish patients. In addition, duration and trends of the abnormal laboratory results were studied. Study Design.This prospective observational study screened 12068 pregnant women between January 1995 and March 1997. Any pregnant woman with hypertension, proteinuria, thrombocytopenia or anemia was monitored for hemolysis and elevated liver transaminases, from the time of recruitment till six weeks postpartum or resolution. Results.Thirteen of 12068 pregnant women (0.11%) developed HELLP. All had hypertension and 84.6% had proteinuria. Delivery was the only factor found to terminate the syndrome. Acute renal dysfunction was noted in 53.8% but none required dialysis. Laboratory parameters stabilized by the sixth postpartum day. Fetal mortality was 1 out of 14. There were no maternal deaths. Conclusions.HELLP syndrome is a rare but potentially serious complication of pregnancy. Correlation with laboratory data and early intervention are vital in achieving a favorable outcome for both mother and fetus.

Long-Term Experience of Plasmapheresis in Antibody-Mediated Rejection in Renal Transplantation

BACKGROUND Antibody-mediated rejection (AMR) continues to pose a serious challenge in renal transplantation with potentially devastating consequences. Treatment options for this condition include plasmapheresis, high-dose intravenous immunoglobulin (IVIG), plasmapheresis with low-dose IVIG, and the use of rituximab (anti-CD20 chimeric antibody). We previously reported on the short-term outcome of plasmapheresis as a rescue therapy for AMR in our centre. We now report on the long-term follow up. METHODS Over a 2.5-year study period, 440 cadaveric transplants were performed. AMR developed in 20 (4.5%) patients. Treatment included plasmapheresis and intensification of their immunosuppressive therapy. RESULTS Excluding two patients who had infarcted their grafts at diagnosis, 18 patients received plasmapheresis treatment for AMR. Of the 18 patients treated, 14 recovered function, two developed graft infarction within a fortnight of starting plasmapheresis, and two patients were withdrawn from treatment. In the 14 who recovered renal function, graft survival was 86% at 12 months. In this study we report on the 5-year follow-up of these AMR-treatment responders. Eleven patients have a functioning graft at 5 years; graft function was stable with a mean serum creatinine of 130 micromol/L at 5 years compared to 123 mumol/L at 1 year. At 5-years follow-up; graft survival was 78% and patient survival 93%. CONCLUSIONS Little information is available in the literature regarding the long-term outcome of this therapy. This is the first report on the long-term (5-year) follow-up of plasmapheresis as a rescue therapy for AMR.

Pregnancy in Irish renal transplant recipients in the cyclosporine era.

BackgroundThe effect of renal transplantation on pregnancy in Irish women not receiving CyA has been reported previously.AimTo examine all pregnancies occurring in Irish female renal transplant recipients since the introduction of CyA.MethodsUsing a community based approach, we identified 29 pregnancies in 19 women, aged between 16 and 45, mean age 30.3 years.ResultsThese pregnancies ended in four miscarriages (13%), two intra-uterine deaths (6.9%) and 23 live births (79.3%). Of these live births, 73.9% were premature (≤36 weeks) and 65.2% were of low birth weight (<2500g). Admission to the neonatal intensive care was necessary in 61%, and two babies (8.7%) died in the neonatal period. Mean gestational age was 34 weeks, and mean birth weight was 2190g. There was no change in graft function during pregnancy, with a small rise in serum creatinine post-partum (+9.64μmol/L). The renal graft failed in three women (15.8%) by the end of the follow-up period. Compared with the precyclosporine era, the live birth rate was higher (79.3% versus 58%) with a trend towards lower birth weight and shorter gestation.ConclusionRenal transplantation with CyA use is not a contraindication to pregnancy, but it is associated with increased risk, especially when the serum creatinine is >175μmol/L.

Vancomycin-resistant peritonitis associated with peritoneal dialysis: a cause for concern

BackgroundPeritonitis resulting from peritoneal dialysis (PD) remains a serious cause of morbidity and even mortality among dialysis patients.AimTo highlight the danger of antibiotic resistance in patients on dialysis who have received multiple courses of antibiotics.MethodsTwo cases are reported in which the patients developed peritonitis resistant to vancomycin.ConclusionsMulti-drug resistance is a growing danger. It is imperative to use the most appropriate antibiotics in the proper dosage. If infections persist, early removal of the catheters is essential. The use of antibiotics in PD patients needs to be limited. Sensitivity patterns of the cultured organisms must be monitored regularly as the lack of vigilance may help accelerate the development of the so-called ‘super bug’ resistant to all antibiotics.

Effect of Cytomegalovirus Prophylaxis with Acyclovir on Renal Transplant Survival

It is recognized that cytomegalovirus (CMV) infection in transplant recipients may lead to graft loss. Prophylaxis with acyclovir has therefore gained widespread acceptance, but the debate on whether this intervention improves long term graft survival continues. All patients who received renal grafts at the National Renal Transplant Centre, Dublin, between January 1992 and December 1999 were retrospectively analyzed. During this time period, patients who were CMV positive and/or had received grafts from CMV-positive donors were administered prophylactic oral acyclovir 800 mg thrice daily, adjusted for calculated creatinine clearance, from the first day post-transplantation. This treatment was continued for three months unless the graft failed or the patient developed CMV disease or died. Graft and patient outcomes were compared in recipients who received acyclovir with those who did not. Over the study period, 935 patients received renal transplants in our center, of whom 487 were administered acyclovir. The incidence of CMV disease was 3.3 cases per 100 patients per annum in those who required prophylaxis. Despite prophylaxis, graft outcomes were found to be significantly worse (p value < 0.001) in the group that qualified for acyclovir. We conclude that acyclovir provides incomplete protection from the negative impact of CMV on graft survival.