Rushika Lanerolle

Kidney disease in the elderly: A Sri Lankan perspective

Renal disease in the elderly in Sri Lanka is a largely neglected area in the literature with hardly any publications. We carried out a hospital-based survey of elderly patients (elderly is defined in this article as patients aged 65 years or above) with renal disease. This prospective study included all patients aged 65 years or above admitted to the University Medical Unit, National Hospital of Sri Lanka, over a period of 1 year with a primary renal-related illness as the reason for hospitalization. This hospital-based survey is the first of its kind to look into the nephrological disease profile of elderly patients in Sri Lanka. Based on our findings, we have made several pertinent recommendations regarding the care of the elderly with renal disease in Sri Lanka that may be relevant to other developing nations as well.

A kidney transplant patient on cyclosporine therapy presenting with dural venous sinus thrombosis: a case report

Dural vein thrombosis is an important but rare cause of headache. Therapy with cyclosporine has been reported to result in thrombotic events. We report an unusual case of superior sagittal and transverse sinus thrombosis associated with cyclosporine therapy in a kidney transplant patient.

Embolizing pulmonary aspergillosis, mycobacterial & aspergillous splenic abscess and cytomegalovirus co-infection following steroid induced immunosuppression: a case report

BackgroundAspergillosis is a serious infection particularly affecting the immunodeficient host. Its co-infection with tuberculosis and cytomegalovirus has not been reported before. Embolic events are well recognized with aspergillous endocarditis and aortitis. Splenic abscess is a rare serious complication of disseminated aspergillosis and is difficult to treat. We report the first case of multiple embolic events and splenic abscess in a patient with pulmonary aspergillosis and cytomegaloviral and tuberculous co-infection, without endocarditis or aortitis.Case presentationThirty-year-old male presented with fever and non-productive cough while on glucocorticoids for glomerulonephritis. He was found to have pulmonary aspergillosis and subsequently developed bilateral lower limb and cerebral fungal emboli and fungal abscess in the spleen. He had IgM and B cell deficiency and cytomegalovirus (CMV) and tuberculous co-infections. He recovered after prolonged course of antimicrobials, splenectomy and cessation of glucocorticoid therapy which also lead to the resolution of immune deficiencies.ConclusionThis report illustrates rare combination of B and T cell suppressive effects of glucocorticoids leading to co-infections with CMV, Mycobacterium tuberculosis and Aspergillus and systemic fungal embolization from pulmonary aspergillosis.

PRIMARY HYPEROXALURIA PRESENTING WITH EARLY RENAL ALLOGRAFT DYSFUNCTION

The primary hyperoxalurias are a set of rare autosomal recessive disorders of inborn errors of metabolism resulting in endogenous overproduction of oxalate. A 16 year old girl with chronic kidney disease stage IV was transferred for further care to the adult nephrology clinic. She had undergone a right sided pyelolithotomy at the age of 8 years. The chemical analysis of the stone had revealed pure calcium oxalate. Further investigation at the time had shown a serum creatinine of 113 mmol/L with normal 24 h urinary oxalate (0.35 mg/day) and calcium levels (1.2 mmol/L). She was transferred to us for further care with end stage renal failure at the age of 16 until which time she had been lost for follow up. She underwent a living related transplant with her mother donating a kidney. Her graft functioned well for the first 3 days postoperatively. However, on the 4 day there was an abrupt decline in urine output and the Doppler sonography did not show any vascular abnormalities. The graft was oedematous and highly echogenic and she was started on IV antibiotics on the suspicion of graft pyelonephritis. Urine cultures remained sterile. Graft biopsy revelled mild to moderate peritubular capillaritis and mild tubulitis and heavy deposition of crystalloid material in the tubular lumina, which was assumed to be the debris of tubular epithelial damage. C4 d staining was not available and it was decided to treat the patient as an antibody mediated rejection. Despite plasma exchange and intravenous immunoglobulin the patient did not improve and remained anuric and dialysis dependant. Another graft biopsy was performed, which also showed the peritubular capillaritis and tubulitis and the intraluminal crystalloid material remained. This material was then examined under polarized light, which showed birefringent Calcium Oxalate crystals (Fig. 1). With the suspicion that this girl may have PH type I mutational analysis of the AGXT gene, we identified a previously reported 8 base pair deletion (c.447_454delGCTGCTGT) in exon 4 in a homozygous state, which confirmed the suspected diagnosis. Genetically confirmed primary hyperoxaluria has not been reported in Sri Lanka whereas the incidence in Europe is 1 in 120 000 live births. Over 150 disease causing mutations have been reported in the AGXT gene so far. Mutations can be distributed along the 11 exons of the gene. They are mostly point mutation, however, there may be minor or major deletions.

Posterior reversible encephalopathy syndrome as the first manifestation of chronic kidney disease

Posterior reversible encephalopathy syndrome (PRES), a term coined in 1996, describes a clinico-radiologic entity characterised by headache, seizures, decreased vision, impaired consciousness and white matter oedema in bilateral occipito-parietal regions [1]. Hypertensive encephalopathy, eclampsia, immunosuppressive/cytotoxic drugs, organ transplantation, renal disease, autoimmune diseases and vasculitides are reported risk factors of PRES [1, 2]. Although potentially reversible, delay in treatment can result in permanent brain damage [3, 4].