V Chaitanya

Isoniazid cerebellitis in a peritoneal dialysis patient

Isonicotinic acid hydrazide (Isoniazid, INH) is one of the primary drugs used in the treatment of tuberculosis. Adverse reactions to isoniazid occur in approximately 5%, including rash, fever, jaundice, peripheral neuritis, agranulocytosis, vasculitis and isoniazid hypersensitivity. From 75 to 95% of a dose of isoniazid is excreted in the urine. Slow acetylators rarely may accumulate toxic concentrations of INH if their renal function is impaired. In dialysis patients INH may cause cerebellitis, a rare adverse effect. A 53year-old patient of hypertension and end stage renal disease had been on peritoneal dialysis. He was on three 2.5% dextrose (Dianeal) exchanges. The peritoneal equilibration test revealed him to be a high transporter. He presented 15 days after initiation of isoniazid (5 mg/kg per day) and pyridoxine (40 mg/day) as a part of antituberculous treatment for pulmonary tuberculosis with clinical features like lack of finger-nose coordination, dysdiadokinesia, intentional tremor, wide based gait and impaired tandem walking. Brain MRI showed bilateral T2 weighted hyperintensities in dentate nuclei of cerebellar hemispheres (Fig. 1), hypointensity in T1 image sequences and there was no restriction in diffusion weighted sequences. The trough plasma pyridoxal5-phosphate (PLP) levels in fasting without abstaining from pyridoxine were < 5 μg/L (reference range; 5–50 μg/L by high performance liquid chromatography). Considering the low levels of PLP, the INH was stopped and pyridoxine supplemented at a dose, 120 mg/day. The clinical features disappeared in a week. In the last 5 years two more peritoneal dialysis patients have also had clinical features of cerebellitis and MRI for both of them revealed hyperintensities in dentate nuclei of cerebellar hemispheres. Both of them responded after stopping INH and increasing the dose of pyridoxine. Both of them were also high transporters. There have been a few reports of INH causing cerebellitis, but all patients were on haemodialysis. The increased sensitivity of the dialysis population to isoniazid neurotoxicity is predominantly due to inhibition the activation of pyridoxine to pyridoxal 5-phosphate by INH metabolites. In addition, there is rapid clearance of PLP by haemodialysis, resulting in a severe deficiency of this active metabolite. In peritoneal dialysis patients with high transporter membrane characteristic, the clearance of PLP may be profound. In addition

Disseminated Trichosporon infection in a renal transplant recipient

Trichosporon species are basidiomycetous yeast‐like anamorphic organisms (Basidiomycota, Hymenomycetes, Tremelloidae, Trichosporonales) that are widely distributed in nature. Trichosporon species colonize the skin and gastrointestinal tract of humans. We present a report of disseminated Trichosporon in a renal allograft recipient. Our patient satisfied the definitions of both “proven invasive trichosporonosis” and “probable pulmonary infection.” Only 2 reports of disseminated Trichosporon infection in renal transplant recipients, to our knowledge, have been published.

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.

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.

Thoracic kidney on right side

A 36-year-old gentleman presented with history of fever. The respiratory system examination was unremarkable. Chest radiograph revealed elevation of the right hemi-diaphragm. A smooth round mass was seen extending into the chest near the midline on a posteroanterior radiograph (Supplementary figure). A computerized tomography revealed presence of right kidney above the diaphragm (Fig. 1). Renal ectopy is reported in 1 in 900 patients. The ectopic kidney may be pelvic, iliac, abdominal, thoracic, contra lateral, or crossed. Thoracic kidney accounts for \5 % of renal ectopia. Thoracic kidney is twice as common in men as in women. Because of the location of the liver, thoracic kidney on the right side is much less common than on the left side. The ipsilateral ureter is usually elongated and not ectopic. In most patients the suprarenal glands, spleen and renal vessels are normally situated. It is uncertain whether the delayed closure of the diaphragmatic anlage allows excessive renal ascent above the level of the future diaphragm or whether the kidney overshoots its usual position because of accelerated ascent prior to normal diaphragmatic closure. A correct diagnosis of this condition would save patients from undergoing image guided biopsies. Compliance with ethical standard

Membranous nephropathy associated with the use of levodopa-carbidopa combination

127 Indian Journal of Nephrology Mar 2015 / Vol 25 / Issue 2 We showed that NLR, which is an important indicator of inflammation, was significantly increased in patients with community-acquired acute renal failure. Elevated NLR is a predictor of long-term mortality and bad prognosis; it can also be used in acute inflammatory conditions. The immune system of patients treated in the intensive care unit rapidly responds to systemic inflammation or sepsis. Neutrophilia and lymphocytopenia are related to disease severity. As the clinical condition worsens, neutrophilia and lymphocytopenia become significant and NLR is increased. NLR can be used as a parameter of disease severity in patients treated at the intensive care unit.[2] In our study, NLR was high at the time of acute renal failure diagnosis and decreased when renal function recovered. The mean duration of acute renal failure recovery was 7.8 days. As neutrophils and lymphocytes give more rapid response to the severity of inflammation, NLR can be used for monitoring acute inflammatory conditions. Studies are needed to evaluate the prognostic/diagnostic utility of NLR in monitoring acute inflammatory conditions and acute renal failure.

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.