Lionel Gnanaraj

Emphysematous Pyelonephritis: Outcome of Conservative Management

OBJECTIVES To identify the prognostic factors, assess the outcome of conservative management, and modify the existing radiologic classification of emphysematous pyelonephritis. METHODS Forty-one consecutive patients diagnosed with emphysematous pyelonephritis between January 2001 and February 2007 were studied retrospectively. On the basis of computerized tomographic scan they were grouped into four classes (1 to 4). The management was conservative with antibiotics alone or with a combination of percutaneous drainage and antibiotics. RESULTS Thirty-eight (93%) of a total of 41 patients were diabetic. Escherichia coli (in 97%) was the predominant pathogen identified in pus culture. With antibiotics alone treatment was successful in 40%, and with a combination of percutaneous drainage and antibiotics the success rate was 80%. None underwent nephrectomy as a primary procedure. The risk factors for mortality were thrombocytopenia, shock, altered sensorium, and hemodialysis. In the absence of risk factors the success rate with conservative management was 100%. The mortality rate was 27%, 75%, and 100% in the presence of one, two, and three risk factors, respectively. The mortality rate in class 1, 2, 3, and 4 was 9%, 13%, 50%, and 33% respectively. The overall success rate was 78%. CONCLUSIONS A combination of percutaneous drainage with antibiotics offers an effective therapy for emphysematous pyelonephritis.

Stone-bearing live-donor kidneys for transplantation

To evaluate potential donor kidneys with asymptomatic calculi detected during screening, and the management of the calculus before, during and after transplantation, as with fewer live donors, marginal kidneys and donors are a significant subgroup in renal transplantation.

Radiographic anatomical factors do not predict clearance of lower caliceal calculus by shock-wave lithotripsy.

Objective Use of shock-wave lithotripsy (SWL) for lower caliceal calculus is associated with a relatively high rate of residual fragments. Various radiographic anatomical factors of the lower calix predicting the outcome of lithotripsy have been described and have generated considerable discussion. We aimed to reassess the role of these factors in predicting clearance of lower caliceal stones by SWL. Material and methods Between January 1998 and December 2001, 148 patients underwent SWL for solitary lower caliceal stones using a Dornier Compact S lithotripter. The infundibular length, infundibular width, caliceopelvic height and infundibulopelvic angle were measured. Success was defined as either complete clearance or clearance with insignificant residual fragments <4 mm in size at 3 months follow-up. The results were analysed using the χ2 test and logistic regression analysis. Results Complete clearance was seen in 69% of cases and clearance with residual fragments <4 mm in size at 3 months was seen in 5%. The overall clearance rate at 3 months was 74%. Infundibular length, infundibular width, caliceopelvic height and stone size were not found to be statistically significant in predicting clearance. None of the patients had an infundibulopelvic angle of >90°. Contrary to most previous studies, univariate and multivariate analysis revealed that an infundibulopelvic angle of <70° was statistically significant in predicting clearance in the stone-free group. Conclusions The use of radiographic anatomical factors to predict clearance of lower caliceal stones following SWL is an attractive concept. However, based on this study, we feel that these factors do not merit the attention they have attracted. In routine practice, regardless of the radiological anatomy, SWL continues to be the initial treatment option, given its non-invasive nature and ease of administration.

Paediatric Renal Transplantation — a 15-Year Experience

OBJECTIVE To review the outcome of paediatric renal transplantation over a period of 15 years in a developing country. METHODS This is a retrospective study of 63 children, less than 15 years of age, who underwent living-related renal transplantation in Christian Medical College and Hospital Vellore between 1984 and 1996. RESULTS The records of 12 patients were not adequate for detailed analysis. Parents were the donors for these children in 84.3% of cases. The most common known cause of end-stage renal disease in these children was reflux nephropathy. Combinations of cyclosporine, azathioprine and prednisolone were used as immunosuppressive drugs. Complications occurred in 16 patients. During the follow-up period, eight patients died and two returned to receiving haemodialysis. Patient survival was 92% at the end of 1 year and 90% at the end of 3 years. Graft survival was 88% and 86% at 1 and 3 years, respectively. CONCLUSION Our study validates the concept of renal transplantation as optimal therapy with adequate medical, social and functional rehabilitation for children with end-stage renal disease. Our study also indicates that vesicoureteric reflux appears to be underdiagnosed and should be actively pursued to prevent complications.

Is Euro-Collins better than ringer lactate in live related donor renal transplantation?

Objectives: Euro-Collins and University of Wisconsin are preferred solutions in cadaveric renal transplantation. There are no guidelines regarding the perfusion fluids in live donor renal transplantation. We studied whether Euro-Collins was better than Ringer lactate in terms of protecting allograft function. Materials and Methods: A double-blind permuted randomized trial comparing Euro-Collins and Ringer lactate was performed on 100 patients undergoing live related donor renal transplantation. Outcome variable was serum creatinine. Results: Age, sex, donor nephrectomy and ischemia times, kidney temperature, time of first appearance of urine was not significantly different in both the groups. Fall in serum creatinine was significantly more in Euro-Collins than Ringer lactate in the first postoperative week (P-<0.05). The time to reach nadir creatinine was 4.97 days in Euro-Collins and 7.75 days in the Ringer lactate group (P-0.088). Serum creatinine was significantly lower in the Euro-Collins group till six months, thereafter it equalized with Ringer lactate. When individual parameters were analyzed for time to nadir creatinine, only the cold ischemia time of > 80 min was found to be significant (P-0.024). Twelve kidneys in Euro-Collins and 17 in the Ringer lactate group had cold ischemia times of ≥80 min and time to nadir creatinine was 4.33 ±3.74 and 12.76± 12.68 days (P-0.035). Conclusions: Renal function normalized rapidly when Euro-Collins was used. Cold ischemia time of ≥ 80 min was the most important factor affecting the graft function and perfusing with Euro-Collins could protect the allograft.

Is shock wave lithotripsy safe in bleeding diathesis

OBJECTIVE: To assess the safety of shock wave lithotripsy (SWL) in treatment of urinary calculi, in patients with bleeding diathesis. MATERIALS AND METHODS: From 1996 to 2004, seven patients with bleeding diathesis were treated by SWL for urolithiasis. Change of oral anticoagulants to heparin (low molecular heparin) and substitution of deficient coagulation factors was done on the day of treatment. RESULTS: Two out of seven patients had mild hematuria, which settled within 48 hours. None of them required transfusion. Six out of seven were stone-free at one month. None of them required any secondary procedure. CONCLUSION: SWL is a safe method for the treatment of urolithiasis in patients with bleeding diathesis, provided deficient coagulation factors are corrected.

A prospective randomised double-blind placebo-controlled trial to assess the effect of diuretics on shockwave lithotripsy of calculi

Abstract Objective: To assess the effect of diuretics with shockwave lithotripsy (SWL) on the treatment of renal and upper ureteric calculi. Patients and methods: Adult patients with a solitary non-obstructive radio-opaque renal or upper ureteric calculus with normal renal function were included. They were prospectively randomised to receive either SWL with placebo or SWL with diuretics (40 mg parenteral furosemide) in a double-blind manner with a sample size of 48 patients in each arm. The primary outcomes were the SWL success and failure rates. The secondary outcomes were the number of shocks and sessions. Results: Complete fragmentation was achieved in 89.6% of the patients in the furosemide arm as compared to 81.3% in the placebo arm. Clearance was achieved in 77.1% of the patients in the furosemide arm as compared to 70.8% in the placebo arm. The number of shocks and the number of sessions were higher in the placebo arm. These differences were not statistically significant. Conclusion: The use of diuretics along with SWL treatment of renal and upper ureteric calculi does not show a statistically significant improvement in fragmentation or clearance.