Patricia C.K. Chan

Tuberculous Peritonitis Complicating Long-Term Peritoneal Dialysis

The characteristics of 5 patients who developed tuberculous peritonitis while receiving long-term peritoneal dialysis (PD) are presented. There were 2 males and 3 females. 3 patients were on intermittent and 2 were on continuous ambulatory peritoneal dialysis when tuberculous peritonitis was first diagnosed. None of the patients had recently received immunosuppression therapy or were diabetics. The clinical presentations were similar to other forms of peritonitis complicating PD except for a more insidious onset. As extraperitoneal involvement and peritoneal lymphocytosis were rarely present, the diagnosis was mainly dependent on the direct demonstration of Mycobacterium tuberculosis with smear (1 patient) and culture (4 patients). In 1 patient with a pleuroperitoneal communication, the diagnosis was made by pleural biopsy and a positive response to antituberculous therapy. All patients responded to treatment with a combination of three antituberculous drugs which included streptomycin, isoniazid, rifampicin and pyrazinamide. Two patients were transferred to hemodialysis. In 3 patients, peritoneal dialysis was continued. Peritoneal clearance and ultrafiltration capacity were unchanged for up to 16 months after treatment in 2 patients who continued peritoneal dialysis but was reduced by 30 and 50%, respectively, in the remaining patient. Only 1 patient died, but her death was not directly related to tuberculous peritonitis. It was concluded that with a high index of suspicion and early institution of treatment, tuberculous peritonitis complicating PD can be successfully treated with low mortality and without compromising the dialysis capacity of the peritoneal membrane.

Living-Related Renal Transplantation in a Patient with Nail-Patella Syndrome

Living-related renal transplantation was performed successfully in a patient with nail-patella syndrome. Graft biopsy 18 months post-transplantation showed normal glomerular basement membrane by electron microscopy. Dystrophic nails of both index fingers had also regrown, suggesting the donor kidney might replenish deficient factors.

Urinary tract infections in post-renal transplant patients

The overall incidence of urinary tract infections (UTIs) in our renal transplant population was 30.9%, i.e. 0.15 episode per patient-year. UTIs occurred more often within the first 3 months (60%) of transplantation. Fifty per cent of UTIs were asymptomatic. Recurrences were common. Acute tubular necrosis and cellular rejections were important associations. UTIs had little effect on graft function and survival up to 3 years post-transplant.

Focal Sclerosing Glomerulopathy Risk Factors of Progression and Optimal Mode of Treatment

Focal sclerosing glomerulopathy and especially focal segmental glomerulosclerosis (FSGS) have been recognized as a distinct clinical entity, however, there still exist controversies in terms of prognostic risk factors of progression and optimal mode of treatment. A total of 32 patients (2 with focal global sclerosis; FGS, the remainder with FSGS) were followed up for a mean period of 82 months (3–240 months). Fourteen presented with nephrotic syndrome and 18 had proteinuria with or without hypertension. Thirteen patients, all of whom except 1 were nephrotic, received steroid treatment with or without other immunosuppressive agents (cyclophosphamide/cyclosporin A/azathioprine). Three of the steroid-treated remained stable in complete remission; 5 nephrotic non-responders had renal death. The mean slope of 1/creatinine versus time for steroid-treated and non-treated groups was −0.23 and −0.043, respectively (p=0.04), suggesting that nephrotic range proteinuria might be prognostically important. However, for the population of FSGS/FGS as a whole, only the initial serum creatinine predicted renal survival (p=0.001 by Coxs regression model). Hypertension and hypercholesterolaemia were not important variables by themselves. Nevertheless, we found that the 9 patients treated with antihyperlipidaemics (gemfibrozil/probucol/cholestyramine/maxEPA) fared better, mean slope being −0.023 versus −0.103 for non-treated, though not reaching statistical significance (p=0.96). Controlled prospective study involving a larger number of patients might be worthwhile.

Continuous ambulatory peritoneal dialysis (CAPD): experience with the first 100 patients in a Hong Kong centre.

We treated 100 Chinese patients age 16 to 83 years by CAPD, using three 2-litre exchanges per day. The treatment was self-financed in 69 patients, by charitable organisations in 25 patients, and by government funds in 6 patients. Satisfactory biochemistry was maintained and there was no gross hyperlipidaemia, renal osteodystrophy, or loss of ultrafiltration capacity of the peritoneum. Rehabilitation was good and 62% of patients returned to full-time employment. The average duration of hospitalization was 11.3 days per patient year. Peritonitis usually due to Staphylococcus pyogenes occurred at a frequency of one episode per 12.3 patient-months. Sixteen patients were transplanted and had a 2-year graft survival of 78.5%. The cumulative patient survival was 97% at 1 year and 84% at 2 years. The corresponding technique survival rates were 87% and 76% respectively.

Effect of phosphatidylcholine on ultrafiltration in patients on continuous ambulatory peritoneal dialysis

Oral phosphatidylcholine at 900 mg/day was given to 4 patients with high lymph absorption for 8 weeks. Fluid and solute transfer before and after treatment were compared to 4 similar controls given placebo. None of the patients had overt ultrafiltration problems. After treatment, overnight peritoneal effluent phospholipid content did not change significantly. Ultrafiltration as well as solute and glucose transfer remained unchanged at the end of 8 weeks. A controlled trial on patients with overt ultrafiltration problems for a longer duration is required to further elucidate the role of phosphatidylcholine supplementation in patients on continuous ambulatory peritoneal dialysis.

Haematological Changes after Renal Transplantation: Differences between Cyclosporin-A and Azathioprine Therapy

Haematological changes after renal transplantation in 76 patients were reviewed and the differences observed between patients treated with cyclosporin-A and prednisolone and those treated with azathioprine and prednisolone were compared. Erythrocytosis defined as haemoglobin concentration equal to or exceeding 17 g/dl occurred in 25% of patients treated with cyclosporin-A and in 11.4% of patients treated with azathioprine. Only one patient, who received cyclosporin-A, had clinical evidence of thrombosis. Eight patients treated with cyclosporin-A and five treated with azathioprine had therapeutic venesections. There was no difference in the incidence of putative risk factors for post-transplant erythrocytosis between the two groups.

A Patient with Focal Segmental Glomerulosclerosis and Acute Renal Failure Due to Crescentic Membranoproliferative Glomerulonephritis

We report a patient with relapsing nephrotic syndrome since the age of 4. Initial renal biopsy showed minimal change disease then focal segmental glomerulosclerosis. At the age of 21, he developed pulmonary tuberculosis, was treated with intermittent combination chemotherapy including rifampin and had oliguric acute or chronic renal failure 5 months later. Biopsy revealed crescentic membranoproliferative glomerulonephritis. The cause of the sequential glomerulonephritis is discussed.

1,25-Dihydroxycholecalciferol and peritoneal macrophage chemotaxis in patients on continuous ambulatory peritoneal dialysis.

Single graded doses of 1,25-dihydroxycholecalciferol of 2 and 4 micrograms were added intraperitoneally into the overnight 1.5% glucose dialysate of 6 patients on continuous ambulatory peritoneal dialysis. The effect on peritoneal macrophage chemotaxis and random migration was studied and compared with the baseline when no 1,25-(OH)2D3 was added. No consistent effect on peritoneal macrophage chemotaxis was observed. Random migration was significantly depressed at 4 micrograms when compared with baseline (5.4 +/- 1.9 vs. 12.2 +/- 3.7 cells/high-power field, p less than 0.05). The potential clinical role of 1,25-(OH)2D3 as an immune modulator requires further study.

IgA glomerulonephritis with irregular intramembranous dense deposits

A 30-year-old white male presented with hematuria, proteinuria and normal renal function following a flu-like illness. IgA was mildly elevated but C3 and C4 levels were normal in serum. Renal biopsy showed a mesangial proliferative nephritis with immunohistochemical features of IgA nephritis but with an unusual pattern and distribution of deposits in glomerular, tubular and Bowman’s capsular basement membranes.