Ranjit Nanra

Use of the Fistula Assessment Monitor to Detect Stenoses in Access Fistulae

Twenty-three unselected hemodialysis patients with functioning access arteriovenous fistulae were studied prospectively to determine the best technique for detecting stenoses within the fistulae. Combined clinical assessment and fistula assessment monitoring were compared with transbrachial angiography. Fistula assessment monitoring was more accurate (96%) than combined clinical assessment (accuracy, 52%) in stenosis detection. Complications of angiography occurred in 17% of patients; there were no complications of fistula assessment monitoring. Fistula assessment monitoring was better than combined clinical assessment in predicting clinical outcome for arteriovenous fistulae over 6 months and was as good as angiography. Routine fistula assessment monitoring could reduce inappropriate angiography and detect clinically significant silent stenoses. It is an ideal method for monitoring arteriovenous access fistulae.

Eosinophils in acute renal allograft rejection.

Tissue eosinophils have been previously implicated in allograft rejection and graft loss. The aim of this study was to evaluate the role of eosinophils in acute renal allograft rejection. Data from 71 patients with 114 renal biopsies with acute allograft rejection were compared with those from 26 controls. The median tissue eosinophil density (0.4-1.1 eosinophils per micron2 x 10(6)) and the median peripheral blood eosinophilia (1.5-3.0%) in all grades of acute interstitial rejection and in acute vascular rejection were higher than in controls (0.0 eosinophils per micron2 x 10(6), p < 0.0023, and 0.9%, p < 0.035). In all grades of rejection, 36-54% of biopsies had tissue eosinophil density > or = 1 eosinophil per micron2 x 10(6), and 20-36% of patients had peripheral blood eosinophilia > or = 4%, compared with 0% and 4%, respectively, in controls (p < 0.000 and p = 0.0245). The sensitivity, specificity and overall accuracy of predicting acute rejection with tissue eosinophil density > or = 1 eosinophil per micron2 x 10(6) is 41%, 100% and 52%, and for peripheral blood eosinophila > or = 4% is 23%, 96% and 40%, respectively. The median tissue eosinophil density in acute rejection with graft loss was 1.9 eosinophils per micron2 x 10(6) compared to 0.2 eosinophils per micron2 x 10(6) in acute rejection without graft loss (p = 0.014), and 67% of acute rejection with graft loss had tissue eosinophil density > or = 1 eosinophil per micron2 x 10(6) compared with 28% of acute rejection without graft loss (p = 0.028).(ABSTRACT TRUNCATED AT 250 WORDS)

Xanthogranulomatous Pyelonephritis in a Renal Allograft: A Case Report

We report a case of xanthogranulomatous pyelonephritis in a renal allograft. The kidney was not removed and there was an initial response to antibiotic therapy, with amelioration of toxicity and improvement in renal function. However, the kidney failed 10 months later in association with histological changes of chronic rejection.

Acute Renal Failure due to Acute Pyelonephritis

We report a case of biopsy-proved acute pyelonephritis which caused acute renal failure. Despite appropriate antibiotic therapy, recovery of renal function was slow and incomplete. Renal papillary necrosis was an apparent complication, which the patient may have been predisposed to by alcoholism. Although rare, acute pyelonephritis is an important consideration in the differential diagnosis of acute renal failure because of the need for specific therapy.

Haemodialysis‐unresponsive blood pressure: Cardiovascular mortality predictor?

Aim:  The importance of ‘conventional’ cardiovascular risk factors in haemodialysis (HD) patients has been questioned following evidence that pre‐HD blood pressure (BP) might be inversely related to mortality in contrast to post‐HD BP. To evaluate this reverse BP epidemiology in HD patients, HD‐induced BP changes were compared with aortic pulse wave velocity (PWV), an independent predictor of cardiovascular mortality.

A female with X-linked Alport syndrome and compound heterozygous COL4A5 mutations

BackgroundFemale subjects with X-linked Alport syndrome have a single COL4A5 mutation, germ cell mosaicism in affected tissues and typically develop renal failure later or less often than male subjects. Women with two mutations are exceedingly rare, and usually have consanguineous parents or uniparental disomy. We describe here a 20-year-old woman who inherited two different COL4A5 variants, one from her father (c.2677G>C) and one from her mother (c.384 +1 G>A).Case-diagnosis/treatmentThe index case had normal renal function, proteinuria and no clinically detectable hearing loss, or ocular abnormalities. Her father and paternal uncle developed end-stage renal disease at 37 and 28 years respectively, together with hearing loss, but not lenticonus or central retinopathy. Her mother had mildly impaired renal function, proteinuria, hearing loss, but no ocular abnormalities. Her maternal grandfather and 22-year-old brother, both with this mutation, developed renal failure by 28 years with hearing loss, or had proteinuria and hearing loss respectively.ConclusionThe index case has clinical features consistent with germ cell mosaicism of two COL45A mutations associated with adult-onset renal failure, but no ocular abnormalities. Her risk of renal failure is high, but the rate of progression to end-stage disease depends on the underlying mutations, and disease modification with renin–angiotensin blockade.

Measurement of glomerular filtration rate in renal transplant recipients: A comparison of methods

SUMMARY: While single injection radionuclide and radio‐contrast glomerular filtration rate (GFR) clearance methods are widely used, the relative accuracy of single versus multiple sample techniques continues to be debated. In addition, GFR calculated from the serum creatinine concentration is considered by some to produce results comparable to clearance methods. In this study, 109 patients with stable renal transplant fraction were prospectively evaluated by yearly 51Cr EDTA clearance as well as by three published formulae used to predict GFR from serum creatinine. Analysis of 362 measurements demonstrated a highly significant correlation between multiple and single point clearance results, as well as the serum creatinine nomograms using least squares regression analysis (P<0.001). the mean GFR was, however, significantly higher using the Cockcroft and Gault formula; 64 ± 18 compared with 47 ± 14 and 50 ± 14 with other serum creatinine formulae, and 46 ± 21–50 ± 17mL/min per 1.73m2 with the three 51Cr EDTA methods (P<0.01). However, further statistical analysis using more appropriate methods, including an analysis of difference and least product regression analysis did not support any of the methods tested as reliable alternatives to multiple sample 51Cr EDTA clearance, because both fixed and proportional bias was noted. In a subgroup of 29 patients evaluated yearly over the 7‐year study period, serum creatinine derivations all demonstrated a greater year to year mean fluctuation compared with clearance methods. It is oncluded that while each GFR method has similarities, they are not interchangeable. Until clearance methods and serum creatinine formulae are directly compared with inulin clearance with the use of appropriate statistical evaluation, it is recommended that the Chantler 3 sample 51Cr EDTA method be the method of choice in clinical laboratories.