Tak Mao Chan

Optimal treatment and long-term outcome of tuberculous peritonitis complicating continuous ambulatory peritoneal dialysis

A retrospective study of the treatment and short- and long-term outcomes of tuberculous peritonitis (TBP) complicating continuous ambulatory peritoneal dialysis (CAPD) among our dialysis patients over a 6-year period was performed. Ten cases of TBP complicating CAPD were identified among 601 dialysis patients between January 1988 and December 1994. There were four male and six female patients. The most common clinical features were abdominal pain, fever, and cloudy peritoneal fluid (PDF). Two patients had concurrent bacterial peritonitis. Extraperitoneal tuberculosis was not observed. The majority of the patients showed neutrophil predominance in the PDF. Only one patient had a positive acid-fast bacilli smear of the PDF. The acid-fast bacilli culture of the PDF was positive in all patients. The patients were treated with isoniazid, rifampicin, and pyrazinamide for 9 to 12 months (mean, 11 months). Continuous ambulatory peritoneal dialysis was continued in all patients. Two patients died, one from multiorgan failure at 2 months and the other from sudden cardiac death at 9 months. Two patients were converted to hemodialysis at 3 months. Six patients continued to receive CAPD after completion of the antituberculous treatment. Four of these six patients were still alive 5 years after the TBP. Three patients were still undergoing CAPD with satisfactory ultrafiltration and solute clearance. None of the patients developed relapse of TBP. We concluded that (1) TBP is a rare but important complication of CAPD, (2) removal of the Tenckhoff catheter is not mandatory in the management of TBP complicating CAPD, and (3) long-term continuation of CAPD is possible after TBP.

Free-hand, ultrasound-guided percutaneous renal biopsy: experience from a single operator

UNLABELLED Percutaneous renal biopsy is a useful diagnostic procedure for many renal diseases. The experience with ultrasound-guided percutaneous renal biopsy from a single operator was reviewed to identify the possible risk factors of complications after the procedure. METHODS AND RESULTS From 1995 to 1998, 203 biopsies (141 on native kidneys with 14G needles, 62 on transplant kidneys with 18G needles) were performed on 186 individuals as clinically indicated. The biopsy tissue specimen was adequate for histological diagnosis in 96.4% of the biopsies performed. IgA nephropathy followed by lupus nephritis were the most frequent diagnoses in our locality. Haematuria was the most common complication observed: mild bleeding occurred in 4.5%, while major complications (those that required blood transfusion or other intervention) were encountered in 1.5% of patients. Impaired renal function was identified as the single most important risk factor of bleeding complication after renal biopsy, while the presence of systemic hypertension or nephrotic syndrome did not increase the risk of bleeding. There was no correlation between bleeding and the type of renal pathology or the number of needle passes. Continuous haematuria may result from blood clot retention in the bladder. Over 97% of the cases were discharged from hospital within 48 h. CONCLUSIONS We conclude that ultrasound-guided renal biopsy remains a safe, fast, and accurate procedure for the definitive investigation of renal diseases.

Tuberculous infection in southern Chinese renal transplant recipients.

Abstract:  A retrospective study of the prevalence and pattern of tuberculosis among renal transplant patients in a single centre in southern China was performed. Twenty‐three cases of tuberculosis were diagnosed among 440 patients between January 1991 and December 2002. There were 18 men and five women. The mean age of the patients was 39.3 ± 13.4 yr. There were 13 living‐related and 10 cadaveric renal transplants. The interval between renal transplantation and the development of tuberculosis ranged from 3 to 127 months with a median of 46 months. There were 18 cases of pulmonary tuberculosis, two cases of pulmonary plus laryngeal tuberculosis, two cases of disseminated tuberculosis, and one case of tuberculosis involving the urinary tract. Diagnosis was established by positive culture for Mycobacterium tuberculosis in 21 patients and response to empirical anti‐tuberculosis treatment in two patients. The duration of symptoms before the diagnosis of tuberculosis was 27 ± 12 d. The patients were treated with standard anti‐tuberculosis drugs for 11 ± 3 months. The anti‐tuberculosis treatment was in general well‐tolerated. Five patients developed transient hepatitis, three patients developed thrombocytopenia and five patients developed gouty arthritis. One patient died 2 months after initiation of anti‐tuberculosis therapy. All other patients completed anti‐tuberculosis treatment. No recurrence of tuberculosis was observed after a median follow‐up of 90 months. We concluded that (i) tuberculosis is prevalent among southern Chinese renal transplant recipients; (ii) high index of suspicion for tuberculosis among renal transplant recipients is warranted to ensure early diagnosis and prompt initiation of treatment; and (iii) treatment with standard anti‐tuberculosis drugs for an extended period of time is well‐tolerated and is associated with favourable outcome.

Seroprevalence of Helicobacter pylori in Chinese patients on continuous ambulatory peritoneal dialysis.

Backgrounds and Aims:  There is relatively little data on the seroprevalence of Helicobacter pylori in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). This study aims at establishing the seroprevalence of and the factors associated with H. pylori infection in Chinese CAPD patients.

Fibrillary glomerulonephritis in siblings

Fibrillary/immunotactoid glomerulopathy is characterized by organized glomerular deposition of extracellular, nonbranching, immunoglobulin-derived microfibrils, which is not associated with systemic diseases such as amyloidosis, cryoglobulinemia, or monoclonal gammopathy. This is an uncommon condition with an obscure etiology and accounts for approximately 1% of primary glomerular diseases in white populations. We report the first case of familial fibrillary/immunotactoid glomerulopathy affecting a brother and a sister in a Chinese family. Both patients presented with heavy proteinuria, which improved transiently on treatment with prednisolone and cyclophosphamide. Human lymphocyte antigen typing for the siblings showed no haplotype association. Despite the generally poor renal prognosis reported in the literature, with 50% of patients reaching end-stage renal failure within 2 to 4 years, both patients had relative preservation of renal function (creatinine clearance from 79 to 76 mL/min/1.73 m2 after 2 years in one patient and from 111 to 99 mL/min/1.73 m2 after 3 years in the other). Our observations show that fibrillary/immunotactoid glomerulopathy can present as a familial condition. Compared with sporadic cases, patients with familial fibrillary/immunotactoid glomerulopathy may have a more favorable renal prognosis.

LONG-TERM RENAL ALLOGRAFT RECIPIENTS FROM SOUTH-EAST ASIA IN THE PRE-CYCLOSPORIN ERA

The clinical outcome of long-term renal allograft recipients in the Chinese population has not been reported previously. We analysed patients from the pre-cyclosporin era who had grafts that functioned for > 10 years. Forty-five patients (31 men, 14 women; mean age 30, follow-up duration 13.3 years), representing a 10-year graft survival of 53%, were included. Thirty-six patients (80%) received living-related allografts and 9 (20%) received cadaveric or living-unrelated renal transplantation. The mean serum creatinine at last follow-up was 1.36 mg/dl (range, 0.83–4.08). Major posttransplantation complications included: hypertension in 25 (56%), infection in 16 (36%), acute rejection in 15 (33%), lipid disorder in 13 (29%), liver disease in 7 (16%), osteonecrosis in 5 (11%), malignancy in 4 (9%), coronary artery disease in 3 (7%), and diabetes mellitus in 3 (7%). Five grafts were lost: 3 to chronic rejection, and 2 to patients with stable function who died of non-renal causes. Proteinuria correlated strongly with graft function and survival, and marginally with hypertension. In hepatitis B carriers, serum α-feto protein is useful in the early detection of hepatocellular carcinoma. We conclude that while patients in the pre-cyclosporin era can survive with excellent graft function beyond the first decade, the risk of complications leading to significant morbidity still remains even when patients are receiving minimal doses of immunosuppression in the second decade.

Dosing regimen and tolerability of methoxy polyethylene glycol–epoetin beta in Chinese dialysis patients

To investigate methoxy polyethylene glycol‐epoetin beta dosing regimen in treatment naïve subjects and dose conversion in darbepoetin alpha treated subjects, in Chinese dialysis patients.

Chronic inflammatory demyelinating polyneuropathy after initiation of peritoneal dialysis--a distinct clinical entity?

(CIDP) is an acquired immune-mediated peripheral demyelinating neuropathy, characterized by subacute or chronic onset of symmetrical sensorimotor peripheral neuropathy, elevated cerebrospinal fluid protein levels and nerve conduction block on electrophysiological studies (1, 2). CIDP is a relatively uncommon condition with a prevalence of around 1 to 2 per 100,000 population (3, 4). Recently, there are several reports on the occurrence of a rapidly progressive demyelinating neuropathy that is consistent with a diagnosis of CIDP, in chronic renal failure patients shortly after the initiation of peritoneal dialysis (5-7). The close temporal relationship between the development of CIDP and the initiation of peritoneal dialysis in these patients raises the possibility that the two events could be causally related and that CIDP occurring in the setting of peritoneal dialysis could represent a distinct clinical entity. The clinical presentation of the reported cases of CIDP in peritoneal dialysis patients was remarkably similar (5-7). All the patients were young or middle aged men who presented with progressive bilateral limb weakness of subacute onset between 4 to 12 weeks after the initiation of peritoneal dialysis. The lower limbs were usually more severely affected than the upper limbs. Physical examination showed marked wasting and generalized weakness of the limb muscles, diminished sensation and areflexia. Some of the patients would eventually become chair or bed bound as a result of severe weakness of both the upper and lower limbs. Cerebrospinal fluid analysis revealed elevated protein levels without pleocytosis. Screening tests for autoimmune diseases, vitamin deficiency, paraproteinemia and heavy metal poisoning were typically unrevealing. There was no history of recent exposure to neurotoxic drugs. Electrophysiological testing showed predominantly demyelination changes with moderate to severe motor conduction slowing or blocks. The overall clinical features of these patients’ neuropathy were consistent with the diagnosis of CIDP. The optimal treatment for CIDP developing in chronic renal failure patients after the initiation of peritoneal dialysis has not been established. Different therapeutic options have been attempted in these patients. Intensification of the dialysis regime was not helpful in limiting the progression of the neuropathy. Termination of peritoneal dialysis and conversion to hemodialysis only improved the neuropathy slightly. Treatment with immunosuppressive modalities including plasmapheresis, intravenous immunoglobulin infusion and high dose corticosteroids resulted in partial recovery of the neuropathy. Near complete recovery of the neuropathy was achieved in two patients after successful renal transplantation. The exact cause of the development of demyelinating neuropathy after initiation of peritoneal dialysis remains to be elucidated. Uremic neuropathy per se could not adequately explain the severity and rapid progression of the neuropathy. Typically, uremic neuropathy is a symmetrical sensorimotor disturbance that mainly affects the lower limbs and it tends to run a mild and slowly progressive course (8). Although uremic neuropathy that runs a rapidly progressive course has been reported in the literature (9), it is a variant that tends to improve with intensification of the dialysis regime. The demyelinating neuropathy developing soon after the init iation of peritoneal dialysis was unresponsive to vigorous dialysis treatment. Vitamin deficiency, heavy metal poisoning, monoclonal gammopathy or drug-induced neurotoxicity as the cause of the neuropathy had been ruled out. The clinical presentation, laboratory investigation results, electrophysiological study findings and response to immunosuppressive therapy suggest that the demyelinating neuropathy is due to CIDP. CIDP is an autoimmune disease, the triggering factors of which have not been clearly identified (1, 2). The close temporal relationship between the initiation of peritoneal dialysis and the development of CIDP in the cases reported recently suggests that the initiation of peritoneal Editorial The International Journal of Artificial Organs / Vol. 26 / no. 11, 2003/ pp. 969-971

Significance of monocytic cytokines at single cell level for the immune responsiveness in renal transplant recipients

Abstract Cytokine dysregulation is an important factor underlying the immune unresponsiveness to hepatitis B vaccination (HBV) in renal transplant recipients. This study investigated the relationship between monocyte‐derived interleukin‐6 (IL‐6) and interleukin‐10 (IL‐10) production and the immune responsiveness using flow cytometry (cytoflow) after whole blood culture. According to their previous response to hepatitis B vaccination, 40 renal transplant recipients were divided into two groups of 20 patients. The percentage of CD14 + monocytes stained positive for intracellular IL‐6 or IL‐10 was measured using flow cytometry after 4 and 20 h of whole blood culture with lipopolysaccharide stimulation. The percentage of CD14+/IL‐6+ cells after incubation in vitro for 4 h was lower in the responders compared to the non‐responders and controls (27.15±8.93 vs 35.47±9.95, P= NS; and 37.06±10.89, P<0.05 respectively). The staining intensity of IL‐6 at 4 h for responders was also significantly reduced. At 20 h, there were a significantly higher percentage of CD14+/IL‐10+ positive cells in the responders compared to the non‐responders (41.87±18.39 vs 27.55±17.25, P<0.05). These results indicate that alteration of intracellular cytokine profile in activated monocytes distinguishes the HBV vaccination responders from the non‐responders among renal transplant recipients. The capacity to upregulate monocyte IL‐10 production in this subset of patients may modulate the immune responsiveness and effectively assists in mounting a positive response to HBV vaccination.