P. Arora

Prognosis of acute renal failure in children: a multivariate analysis

Abstract. Various factors were analyzed in 80 consecutive children under 16 years who had acute renal failure (ARF), for various prognostic factors. Overall mortality was 42.5%, with significantly higher levels seen in hemolytic uremic syndrome (68%, P <0.05) and associated with cardiac surgery (90.9%, P <0.01). Anuria (67.6% vs. 43.5%, P <0.05), need for dialysis (85.3% vs. 56.5%, P <0.05), neurological complications (50% vs. 6.3%, P <0.01), and respiratory complications (35.2% vs. 2.1%, P <0.01) were significantly higher in nonsurvivors than survivors. Multiple regression analysis showed the presence of neurological and respiratory complications to be poor prognostic factors.

Role of captopril renography in the diagnosis of renovascular hypertension.

Eighty-six hypertensive patients with clinical suspicion of renovascular hypertension (RVH) were evaluated by captopril renal scintigraphy (CRS) and intra-arterial digital subtraction angiography (IADSA) to determine the usefulness of CRS in the diagnosis of RVH and to predict the outcome of revascularization procedures. Technetium 99m-diethlenetriaminepentaacetic acid (DTPA) renal scintigraphy was performed on 2 consecutive days before and after captopril administration. Captopril renal scintigraphy was considered positive if there were changes in the time activity curve according to the criteria specified by the American Society of Hypertension working group. Captopril renal scintigraphy data were compared with presence or absence of anatomic renal artery stenosis (RAS). Of 86 hypertensive patients investigated, 45 had RAS. Aortoarteritis was the cause of RAS in 40 (89%) patients. Revascularization was done in 25 patients, and response to revascularization was compared with that of captopril renography. Compared with IADSA, CRS showed a sensitivity of 82.8% and a specificity of 98.2%. Fourteen patients had bilateral RAS on IADSA. In these patients, CRS was suggestive of bilateral disease in seven patients, unilateral in four, and negative in three. Comparison of CRS with the results of revascularization showed a sensitivity and specificity in detecting curable RAS (RVH) of 95% and 100%, respectively (positive predictive value, 100%; negative predictive value, 85%). In conclusion, we found CRS to be useful in the diagnosis of RVH due to aortoarteritis.

Evaluation of Clinical and Histological Prognostic Markers in Drug-Induced Acute Interstitial Nephritis

We analyzed the case records of 19 patients diagnosed to have drug-induced acute interstitial nephritis to assess the clinical profile and role of steroids in renal recovery, and to correlate histological features to outcome. Patients with underlying glomerular diseases, malignancy, obstructive nephropathy, or systemic infections were excluded. Nonsteroidal anti-inflammatory drugs alone accounted for 6 cases (group A), whereas antibiotics were the major offender in the remaining patients (group B). In 13/19 (69%) cases, renal failure was severe enough to require dialytic support. Overall 14/19 (74%) of the patients recovered normal renal function within 6 weeks of withdrawal of the offending drugs. Neither the extent of renal recovery nor the time required for it was altered by oral steroids. Tubular atrophy and interstitial fibrosis adversely affected renal recovery. Oliguria, tubular necrosis, interstitial edema, and the density/distribution of interstitial infiltrate did not have any effect on the rate/extent of renal recovery.

ETIOLOGY, PROGNOSIS, AND OUTCOME OF POST-OPERATIVE ACUTE RENAL FAILURE

A Multivariate analysis was done in all patients who developed post operative ARF, during the period 1990–1995 to determine the etiological spectrum and to identify various variables affecting the outcome. Of 140 patients (110 operated at SGPGI and 30 operated outside) 116 underwent elective surgery. The different types of surgery leading to ARF were urosurgery (3.5%), open heart surgery (32.9%), gastrosurgery (16.4%), pancreatic surgery (9.3%), obstetrical surgery (3.6%) and others (2.8%). The incidence of ARF in SGPGI patients was highest in pancreatic surgery group (8.2%) followed by open heart surgery (3%). The different etiological factors responsible for ARF were perioperative hypotension (67.1%), sepsis (63.6%) and exposure to nephrotoxic drugs (29.3%). Sixty-four patients (45.7%) required dialysis. The overall mortality was 45% The mortality was highest in patients who underwent open heart surgery (89.1%) followed by pancreatic surgery (84.6%). The factors associated with high mortality, other than the type of surgery, were preoperative hypotension (p <0.05), oliguria (p <0.01), need for dialysis (p <0.05) and multiorgan failure (p <0.001). AM following emergency surgery had poor outcome, though not statistically significant. Perioperative sepsis (p <0.05) and preoperative use of aminoglycoside (p <0.05) were significantly higher in patients operated outside SGPGI. This was associated with higher incidence of ARF. Thus we conclude that presence of multiorgan failure, oligoanuria, preoperative hypotension and need far dialysis are poor prognostic markers in ARF following surgery.

Spectrum of infections in Indian children with nephrotic syndrome.

We conducted a retrospective analysis of infections in 154 children (114 boys, 40 girls) with nephrotic syndrome who satisfied the International Study of Kidney Disease in Children criteria. Their mean age at onset of symptoms was 6.2 years (range 6 months to 16 years) and the mean duration of follow-up was 32 months (range 6–55 months). One or more infectious complications were observed in 59 of the 154 children (38%), with urinary tract infection being the commonest (13.7%), followed by pulmonary tuberculosis (10.4%), peritonitis (9.1%), skin infections (5.2%), upper respiratory infections (5.2%), lower respiratory tract infections (3.9%) and pyomeningitis (0.6%). There were 3 deaths, the mortality in 2 patients being attributable to infections. There was no significant difference between children who developed infection and those who didnt in terms of age of onset, sex, duration of disease, serum creatinine, blood urea nitrogen and 24-h proteinuria. However, the children who developed infectious complications had significantly higher serum cholesterol levels (P<0.01) and lower serum albumin levels (P<0.02). The frequency of infections was higher inchildren who were frequent relapsers, steroid dependent and subsequent non-responders (28/60) compared with infrequent relapsers and initial non-responders (29/94).

Focal Segmental Glomerulosclerosis in a Patient with Polycythemia Rubra Vera

R.K. Sharma, MD, Department of Nephrology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014 (India) Dear Sir, We report a case of focal segmental glomerulosclerosis (FSGS) with polycythemia rubra vera. The relationship between polycythemia and a renal lesion is discussed. To the best of our knowledge, polycythemia vera in association with FSGS has not been reported so far. A 40-year-old female presented with throbbing headache, giddiness, visual blurring, chest pain and off and on facial flushing of 2 years duration. While undergoing investigations for surgery for a thyroid nodule, the patient was found to have a high hematocrit (Hb 18 g%) count. At that time urine examination did not reveal any proteinuria. One year later she was found to be hypertensive and urine examination showed significant proteinuria (2.0 g in 24 h). On examination the patient was plethoric with no facial or pedal edema, blood pressure was 160/100 mm Hg and the spleen was enlarged. Fundus examination revealed a hyperemic disc and tortuous vessels. Hb was 20.0 g%, hematocrit (Hct) 65%, red blood cell (RBC) count 62×105/cm, total leukocyte count (TLC) 32×103/cm, platelets 4.1×105/cm and the erythrocytic sedimentation rate was 7 mm in the 1 h. Bone marrow was hypercellular and showed erythroid hyperplasia with increased megakaryocytes. 51Cr RBC volume was 38 ml/kg (normal 27-32 ml/kg). Urine examination showed 10-12 RBC/high power field, 6-8 white cells/high power field. Urinary protein excertion was 1.8 g in 24 h. Blood urea nitrogen was 18 mg%, serum creatinine 2.0 mg%, serum uric acid 5.6 mg%, serum albumin 3.2 g% and serum cholesterol 230 mg%. Renal ultrasonography showed normal sized kidneys. Arterial blood gas analysis showed P02 93.6 mm Hg and oxygen saturation of 96.5%. Kidney biopsy was done which showed 15 glomeruli with focally accentuated mesangial proliferation and a mild increase in mesangial matrix, 5 glomeruli showed segmental areas of sclerosis and hya-linosis with synechia formation. Focal areas of tubular atrophy and mild interstitial fibro-sis were seen. Blood vessels displayed intimal fibroelastosis. Biopsy was consistent with FSGS.

Tuberculosis in childhood nephrotic syndrome in India

We studied the prevalence, clinical features, and impact of tuberculosis (TB) on children with nephrotic syndrome (NS). Of the 300 children with NS, 28 (9.3%) were diagnosed as having TB. This occurred following the initiation of immunosuppressive therapy in 27 children, and in 1 child it preceded the onset of NS. Pulmonary involvement was the commonest (22/28), followed by tubercular lymphadenitis (2/28), meningitis (2/28), and occult TB (2/28). Of the various diagnostic criteria, history of previous cough, fever, or exposure to a case of TB (23/28) and chest skiagram (21/28) were the most useful. The occurrence of TB did not induce a relapse or affect the subsequent response to steroid therapy (as is often seen with other infections) or have a deleterious effect on renal function. Patients who received higher doses of steroids (frequent relapsers, steroid dependent, initial non-responders, and subsequent non-responders) had a significantly higher prevalence of TB (19/148) than those who received lower doses (infrequent relapsers 8/151) (P = 0.04). We thus found TB to be an important complication of children with NS in our country. The conventional diagnostic tests, such as Mantoux and acid-fast bacilli isolation, are often unhelpful in these children, and a high index of suspicion is required, especially in children who require frequent courses of steroid therapy.

Outcome of live related and live unrelated renal transplants

Summary: This study compares the outcomes of 229 renal transplants, of which 156 were live related renal transplants done at our centre and 73 unrelated transplants done at other centres but followed up at our centre. All the patients were on triple immunosuppression for periods varying between 9 months and 1 year. Patient characteristics, rejections, infections and 1 and 5 years patient and graft survival were analyzed in the two groups. the outcome of patients who continued on cyclosporine beyond 1 year was compared to those who discontinued cyclosporine at 1 year. Males predominated (191 vs 38) in both groups, while younger patients (<50 years) predominated in live related group (152 vs four). There was no difference in the incidence of infection, rejection, graft dysfunction, graft loss or death between the two groups. the 1 and 5 year patient survival in the related and unrelated group, (93.7% and 71.4%vs and 85% and 66%) and graft survival (90.4% and 69.4%vs 83.3% and 65.4%) were similar. However, in the unrelated group, patients who discontinued cyclosporine had a higher incidence of rejections (38%vs 14%) and graft loss (43%vs 11.8%), while in the related group no such difference was found. It is concluded that 1 and 5 year patient and graft survival is comparable between live related and live unrelated transplantation. However, in the unrelated group it is necessary to continue cyclosporine beyond 1 year in order to achieve comparable results.

Role of intravenous cyclophosphamide in lupus nephritis patients with renal impairment

Summary: Twenty‐three patients with lupus nephritis (21 diffuse proliferative glomerulonephritis and two with focal proliferative glomerulonephritis) with impaired renal functions were evaluated for their response to pulse cyclophosphamide. Diagnosis of lupus nephritis was based on American rheumatism association criteria or on the basis of renal manifestations with high anti dsDNA antibody titres. Cyclophosphamide was given in dosage of 900mg/m2 as infusion in 500 mL of 5% dextrose (reduced by 25% if serum creatinine was more than 6 mg/dL) once every month for 6 months then 3 monthly for a minimum of 3 years. Response was defined by 24h protein excretion less than 500mg and serum creatinine less than 1.4mg/dL. Nine patients (group I) had normal function (serum creatinine 1.16 ± 0.21mg/dL) and 14 patients (group II) had impaired renal function at presentation (serum creatinine 3.72 ± 4.06 mg/dL). Both groups were compared for response to therapy. All patients in group I were in complete remission at last follow up of 44.6 ± 8.3 months (serum creatinine 1.14 ± 0.2mg/dL, 24h proteinuria 0.3 ± 0.3g). While in group 2, 13 patients showed improvement. Two patients were in complete remission, seven in partial remission, one patient died and four patients had mild renal failure at last follow up of 40.2 ± 10.4 months (serum creatinine 1.81 ± 0.74, 24h proteinuria 2.19 ± 2.54g). the side effects of therapy included infection, transient leucopenia and vomiting. We conclude that intravenous (I.V) cyclophosphamide is an effective therapy in severe lupus nephntis with renal impairment.