P Sandeep

Emphysematous pyelonephritis: disappearing kidneys.

A 51-year-old man with type 2 diabetes mellitus for 10 years and hypertension for 8 years, who was a smoker and an alcoholic, presented with a history of fever, chills, and rigor of 4 days; abdominal pain and distension of 3 days; jaundice and anuria of 1 day duration. He had been binge drinking for 2 days before admission and had not taken insulin for several days. Examination revealed jaundice, tachypnea, tachycardia, a blood pressure of 90/70 mm Hg, and diffuse abdominal tenderness, with no guarding or rigidity. Investigations showed the following results: random blood glucose, 385 mg/dl; serum creatinine, 8.5 mg/dl; blood urea, 185 mg/dl; serum sodium, 142 mEq/l; serum potassium, 5.5 mEq/l; serum bilirubin, 8.0 mg/dl; hemoglobin, 13.5 g/dl; total leukocyte count, 30,800/μL; platelet count, 85,000/μL; and urine and blood cultures, sterile. Ultrasound abdomen showed multiple gas shadows in both the kidneys. Computerized tomography scan of the abdomen (Figure 1 and Supplementary Figure S1 online) revealed that the major parts of kidneys were replaced by gas, with only shreds of renal tissue visible. On the same day, bilateral ultrasound-guided percutaneous drainages were placed (Supplementary Figure S2 online). The pus revealed the growth of Escherichia coli. He was treated with pipercillin–tazobactum and aztreonam for 3 weeks. There was improvement in fever and hypotension. However, he remained dialysis dependent.

Employment status of patients receiving maintenance dialysis – peritoneal and hemodialysis: A cross-sectional study

The long-term dialysis therapy for end-stage renal disease takes a heavy toll of quality of life of the patient. Several factors such as fatigue and decreased physical capability, impaired social and mental functioning, contribute to this forlorn state. To meld maintenance dialysis treatment with a regular employment can be a serious test. A cross-sectional study of employment of patients on hemodialysis and peritoneal dialysis in a state government tertiary institute in South India was performed between June 2015 and December 2015. Patients who completed 3 months of regular dialysis were only included in the study. The number of patients on hemodialysis was 157 and on peritoneal dialysis was 69. The employment status before the initiation of dialysis was 60% (93 out of 155) and 63.7% (44 out of 69) in hemodialysis and peritoneal dialysis, respectively. After initiation, the loss of employment was observed in 44% (41 out of 93) in hemodialysis and 51.2% (26 out of 44) in peritoneal dialysis (P = 0.2604). Even though there was fall of absolute number of job holders in both the blue and white collar jobs, the proportion of jobholders in the white collar job holders improved. On univariate analysis, the factors which influenced the loss of employment were males, age between 50 and 60 years, number of comorbidities >2, illiteracy and blue collar versus white collar job before the initiation of dialysis. The majority of patients had the scores above 80 on Karnofsky performance scale and the majority belonged upper and middle classes than lower classes on modified Kuppuswamys socioeconomic status scale; however, the loss of employment was also disproportionately high. There appeared a substantial difference in the attitude of the patients toward the employment. There was no difference between hemodialysis and peritoneal dialysis in the loss of employment of our patients.

Renal infarction due to lupus vasculopathy

In the ISN/RPS 2003 classification of lupus nephritis (LN) renal vascular lesions are not mentioned. We present a patient with postpartum lupus vasculopathy. The renal biopsy in our patient showed concentric intimal thickening with narrowed lumen. No inflammatory changes were found. It also revealed immunoglobulin and complement deposition on the wall of the arteriole. These changes indicate lupus vasculopathy. The glomeruli revealed diffuse proliferative glomerulonephritis, with wire loops and cellular crescent in one glomerulus. The patient showed improvement with immunosuppression.

Management of Guillain-Barré syndrome with plasmapheresis or immunoglobulin: our experience from a tertiary care institute in South India.

Abstract Guillain–Barré syndrome (GBS), an acute inflammatory demyelinating polyneuropathy is the most common generalized paralytic disorder. The objective was to study the outcome of disability grade in two groups of GBS treated with plasmapheresis alone and treated with IVIg alone. A retrospective analysis of all consecutive patients with GBS, admitted in our intensive care unit during the period of 3 years, 2009–2012 were included in the study. All patients of GBS who were to be treated with plasmapheresis or IVIg, the modality of management were always decided at their preference and consent after explaining the modalities to patient/family. The plasma exchange done was ∼200–250 mL of plasma per kilogram weight in five sessions (40–50 mL/kg per session) within 7–14 days. The replacement fluid contained 100 mL of 20% albumin diluted in 1000 mL of normal saline and 1000 mL of fresh frozen plasma. IVIg was administered as 0.4 g/kg body weight daily for 5 days. Our observations brought out the following, both the plasmapheresis and IVIg treatments were effective in reducing the disability grade amongst all time points, i.e., at presentation, immediate post-therapy and after 4 weeks. There was a marginal superiority in plasmapheresis over IVIg effect. However, whether the delay in presentation as noted in our study probably would have contributed to this effect was conjectural.

Membranoproliferative glomerulonephritis and Pott's disease

The reports of glomerular lesions of kidney due to tuberculosis are sparse. A 48-year-old gentleman, presented with swelling of feet of 3 months duration. As he had renal impairment, proteinuria and normal-sized kidneys, he was subjected to renal biopsy. The light microscopy and immunofluorescence revealed the diagnosis was membrano-proliferative glomerulonephritis. During hospital stay, the patient complained fever and stiffness at thoracic spine. The MRI of thoraco-lumbo-sacral spine revealed paravertebral abscess at D11–D12. The pus aspirated was positive for Mycobacterium tuberculosis. He was started on anti-tuberculous medication. After 8 weeks of therapy, the serum creatinine was 1.5 mg/dL and 24 h urine protein 250 mg.

Insertion technique for prevention of peritoneal dialysis catheter tip migration

The peritoneal catheter migration may occur between 12.7 and 35 % of patients [1]. A one-stitch fixation of the catheter to the peritoneum and posterior sheath to prevent catheter tip migration had been advocated [1]. The drawback of this procedure is when the removal of catheter is planned, an elaborate surgery may be required. Another modification proposed is low-site peritoneal catheter implantation. The catheter is inserted approximately 6–8 cm above the pubic symphysis instead of the conventional procedure of using umbilicus as the reference point. By the low-site implantation technique, the catheter is much nearer and straighter to the pelvic cavity, thus preventing migration [2]. We present a modification to the procedure of catheter implantation to prevent its migration from pelvis. At our institute, a swan neck catheter is regularly used for peritoneal dialysis. The catheter insertion is performed by a gastroenterology surgeon under the laparoscopy. The precaution is always taken to direct the exit site caudally. Prior to this modification, we have not followed any surgical method to prevent migration. After insertion of a 10-mm subumbilical and a 5-mm right iliac fossa laparoscopic ports, the laparoscope is then shifted from subumbilical port to the right iliac fossa port. A 2-0 prolene (polypropylene; a non-absorbable suture) is passed around the 10-mm port by inserting a suture passer needle 5 cm below the subumbilical incision. The peritoneal dialysis catheter is then introduced into the peritoneal cavity through 10-mm port. The 10 mm port is then slowly withdrawn over the peritoneal dialysis catheter. The peritoneal dialysis catheter is now hitched to the anterior abdominal wall by tightening the suture around it. The extra length of suture is divided close to skin, as the tied knot gets buried in the subcutaneous tissue (Fig. 1). The peritoneal dialysis catheter is then tunneled in the subcutaneous tissue and brought out through a small skin incision lateral and inferior to the left of umbilical port site. Rectus sheath at 10-mm port is closed with 1-0 vicryl suture (polyglactin 910; an absorbable suture). Skin closed with staples or 2-0 nylon suture. Closure of skin at site of suture passage is optional. Between January 2010 and December 2013, this modification in the procedure of the catheter insertion was adapted. Peritoneal dialysis was initiated in 21 patients during this period. There were fifteen males and six females. The mean age was 51.2 years (range 33–70 years). The mean follow-up of all patients was 19.4 ± 8.3 months (range 3–32 months). The monthly abdominal radiograph did not reveal the migration of catheter in these patients. In 32-month period, prior to January 2010, 17 patients were initiated on peritoneal dialysis. There were 11 males and nine females. The mean age was 57.8 years (range 32–71 years). The mean follow-up of these patients was 25.2 ± 10.2 months (range 8–44 months). In eight patients (47 %), the catheter had migrated. K. Radhakrishna U. Chakarpani V. Venkata Rami Reddy Surgical Gastroenterology, Sri Venkateswara Institute of Medical Sciences, Tirupati 517502, India

Amelogenesis imperfecta and nephrocalcinosis syndrome

An 18-year-old boy presented with pain in left flank of 2 days duration. He had no history of oliguria, dysuria, pyuria, hematuria, graveluria or swelling of feet or face. Examination revealed yellow colored teeth. The labial surfaces of lower teeth showed irregular horizontal enamel defects [Figure 1]. Rest of the general and systemic examination was unremarkable. Ultrasound abdomen revealed bilateral nephrocalcinosis. It was confirmed on a computed tomography [Figure 2]. The other investigations showed serum creatinine to be 0.9 mg/dl, blood urea 24 mg/dl, sodium 138 meEq/l, potassium 4.5 mEq/l, calcium 9.2 mg/dl, inorganic phosphate 3.2 mg/dl, alkaline phosphatase 180 IU/l, parathormone 69 pg/ml, vitamin D 25 ng/ml, bicarbonate 24 mmol/l and urine pH: 5.5. His parents’ marriage was a consanguineous one. His elder brother and father also had yellow colored teeth. He was diagnosed amelogenesis imperfecta (AI) of hypoplastic type with nephrocalcinosis syndrome.

Membranous nephropathy and carbamazepine

DOI: 10.4103/0971-4065.132029 intra-abdominally.[3] About 66% of undescended testes are located distally to the external inguinal ring, 16% in the inguinal canal, 10% are intraabdominal and 3% are surgically absent.[4] As seminoma of testes is common between 30 and 55 years of age with pure seminoma being rare, here we are presenting a case of pure seminoma testes admitted with urinary tract obstruction leading to urinary stasis and urosepsis leading to acute renal failure.