Wk Lo

Star fruit intoxication in uraemic patients: case series and review of the literature

Abstract

Isoniazid induced encephalopathy in dialysis patients

Three dialysis patients with extrapulmonary tuberculosis developed confusion 4-14 days after commencement of treatment with anti-tuberculosis drugs, despite the use of prophylactic pyridoxine. Full recovery of conscious state resulted within 1 week in all patients after stopping isoniazid. In 2 patients confusion recurred on rechallenge of the drug. The risk factors of isoniazid induced encephalopathy and the dosage of isoniazid in uraemic patients were discussed.

A randomized prospective comparison of oral versus intraperitoneal ofloxacin as the primary treatment of CAPD peritonitis

Summary: Oral ofloxacin has been successfully used in our centres for the primary treatment of peritonitis complicating continous ambulatory peritoneal dialysis (CAPD). In view of the progressive rise in the resistance rate to ofloxacin among peritoneal bacterial isolates, a study was conducted to determine if oral ofloxacin remains a viable first line treatment for CAPD peritonitis in our centres and if the result can be improved by changing from an oral to an intraperitoneal (i.p.) route. In patients on three 2 L daily CAPD exchanges, ofloxacin given at the i.p. dosage of 200 mg loading followed by 25 mg/L of peritoneal dialysate achieved overnight trough peritoneal levels which are at least four times the minimal 90% inhibitory concentration (MIC90) of most bacterial pathogens without significant accumulation in the systemic circulation. This i.p. dosage was therefore chosen for the clinical study and the result was compared to that using ofloxacin given in the oral dosage of 400 mg loading followed by 300 mg once daily as maintenance. of all the recruited episodes, 35 were eligible for analysis. the overall primary cure rate including primary failures and relapses was 55.6% (10/18) in the oral treatment group and 70.6% (12/17) in the i.p. treatment group. the corresponding figures for gram positive bacterial (g +) infections were 36.4% and 50%, for gram negative bacterial (g ‐) infections were 66.7 and 80% and for culture negative infections were 75 and 80%. In culture positive cases, all treatment failures were due to resistant infections which were observed in 42.3% of all bacterial isolates, 47.1% of g + isolates and 33.3% of g ‐ isolates. Due to the high background level of bacterial resistance among our CAPD population, ofloxacin monotherapy given either by the oral or the i.p. route can no longer be recommended for the primary treatment of CAPD peritonitis.

Reactivation of systemic lupus erythematosus in a dialysis patient after tuberculous peritonitis

The disease activity of patients suffering from lupus nephritis usually becomes quiescent after the onset of end stage renal failure. Reactivation of lupus activity, especially after a long period of dialysis, is uncommon. Factors that might trigger off lupus reactivation after dialysis have not been well defined. We report a case of a 43-year-old Chinese woman on long-term peritoneal dialysis, who developed lupus reactivation with cerebral involvement 2 weeks after she was diagnosed to have tuberculous peritonitis. The close temporal relationship between the tuberculous peritonitis and the lupus reactivation raise the possibility that the tuberculous infection might have triggered off the lupus reactivation.

Adrenal Insufficiency in a Peritoneal Dialysis Patient Taking Megestrol Acetate

Two months before presentation, she had experienced 1 episode of peritonitis caused by Prevotella species, which was adequately eradicated by intravenous cefmetazole, as evidenced by white cell counts of less than 100/mm3 in effluent after treatment. At her current admission, she presented with fatigue, abdominal pain, fever, and turbid effluent. The physical examination revealed a painful abdomen with rebounding tenderness. The exit of the peritoneal dialysis catheter looked clean, without apparent sign of tunnel infection. Peritoneal effluent contained white cells 185/ mm3, with 98% polymorphonuclear leukocytes. Gram stain of the effluent failed to show any micro-organisms. Computed tomography imaging of the abdomen revealed no significant intra-abdominal lesions. We diagnosed CAPD-related peritonitis and gave empiric antibiotic therapy (intravenous cefmetazole 2000 mg once daily) after peritoneal fluid and blood cultures had been taken. Cultures of the peritoneal fluid subsequently yielded M. morganii on 2 occasions. The antibiotic regimen was then replaced with intraperitoneal ceftazidime 500 mg, 4 times daily. The woman’s abdominal pain, nausea, and vomiting steadily subsided. Peritoneal effluent cell counts returned to 5/mm3 by day 10. She was discharged and did not relapse. M. morganii has recently become an important opportunistic pathogen (2–6), being frequently encountered in the intensive care unit, partly because of its preponderance in immunocompromised individuals and also because of various invasive procedures (7). As first reported by Atalay et al. (1), M. morganii caused peritonitis in a polymicrobial fashion (with Providencia rettgeri). However, in the present patient, it was isolated as a single pathogen in CAPD-related peritonitis. To our knowledge, this case is probably the first of CAPD-related peritonitis attributable to M. morganii in a monobacterial setting. Another unique feature is that M. morganii was able to cause severe infection in an immunocompetent patient such as ours. Fortunately, the microbe was sensitive to amikacin, ceftazidime, cefepime, quinolone, imipenem, and piperacillin–tazobactam, as has been reported in the literature (8). Our patient recovered completely after the use of ceftazidime. In conclusion, M. morganii is a rare cause of CAPDrelated peritonitis, and our patient may be the second case of M. morganii peritonitis and the first of monobacterial infection with that organism.

Ruptured Abdominal Aortic Aneurysm As a Cause of Spontaneous Hemoperitoneum in a Patient on Peritoneal Dialysis

patients, 1-year survival was 56% in those with severe LVH and 91% in those without LVH (4). Moreover, in a previous cohort of HD patients, it was demonstrated that a 10% decrease in left ventricular mass was associated with a 22% reduction in the relative risk for all-cause death and a 28% reduction for cardiovascular death (7). The 17% decrease in LVMI in our patients might have a significant impact on their survival. In patients with decreased RRF, PD+HD has several advantages. First, PD+HD may achieve PD prolongation with a minimal change in lifestyle (2,3). The combined modality is suitable for those who prefer PD, a home-based continuous therapy. Second, PD+HD may be indicated for patients with hemodynamic instability, because it reduces the frequency of HD sessions (3). Third, PD+HD may prevent excessive use of hypertonic glucose solutions, which accelerate peritoneal membrane deterioration and increase the risk of encapsulating peritoneal sclerosis (3). In addition, the combined modality may permit a “PD holiday” with peritoneal rest, which can improve quality of life and might be beneficial for maintaining peritoneal function (3). The limitations of the present study include a lack of controls, a small number of patients, and a short follow-up period. In addition, the prognosis and longterm safety of PD+HD have yet to be established. Further studies are needed to shed light on these issues. In our patients, PD+HD improved LVH, volume status, and solute removal. Combined therapy with PD+HD might be useful for patients with decreased RRF and might permit the safe prolongation of PD.

Clinicopathologic features of antineutrophil cytoplasm autoantibody (ANCA)-associated acute renal failure in Chinese patients

Summary: The clinical course and renal pathologic features of anti‐neutrophil cytoplasm auto‐antibody (ANCA)‐associated renal disease were studied among Chinese patients from a single centre. Eight ANCA positive patients with acute renal impairment were studied, four of whom required dialysis shortly after presentation. Their mean age at presentation was 61.6 ± 4.2 years. Renal histology, obtained in seven patients, showed paucummune crescentic glomerulonephritis in five patients, interstitial nephritis in two patients, and small vessel vasculitis in one patient. Pulmonary baemorrhage was the other common disease manifestation, present in four of the eight patients, necessitating ventilatory support in three patients. Neurologic, cutaneous, and gastrointestinal involvement were also observed. Seven of the eight patients tested positive for pANCA and anti‐myeloperoxidase, while cANCA was detected in one patient of the eight patients, six (75%) responded to therapy, consisting of prednisolone and cyclophosphamide in five patients, and antibacterial therapy alone in one patient, who had interstitial nephritis but no evidence of vasculitis. Two patients died from sepsis and severe debilitation one month after presentation. of the other six patients, five had significant improvement of renal function, while one became dialysis‐dependent. the levels of ANCA and C‐reactive protein remained normal, and disease reactivation was not observed during follow‐up for 32.4 ± 6.1 months. Patient and renal survival rates at one year were 75% and 62.5%, respectively. It was concluded that the clinical and pathologic features of ANCA‐associated renal disease in Chinese patients are, in general, similar to those described in Caucasians. Nevertheless, cANCA‐positivity is distinctly uncommon. the demonstration of interstitial nephritis in two of the eight patients underlines the importance of renal biopsy for correct histologic diagnosis. Early institution of aggressive immunosuppression and supportive therapies are essential for the achievement of favourable outcome in patients with vasculitis.

Delayed recurrent thromboembolism of the allograft kidney

Renal artery thromboembolism is a rare event in native kidneys and has never been reported to occur in allograft kidney. We report a case of allograft kidney infarction secondary to embolisation from thrombus in the hypogastric artery supplying the allograft on two separate occasions 1 and 2 years after transplant. Anticoagulation therapy alone was given and the patient responded well with partial recovery of renal function.

Peritoneal Dialysis-Related Peritonitis Caused by Erosion of Umbilical Abscess into the Peritoneal Cavity

access and all-cause mortality: a propensity score analysis. J Am Soc Nephrol 2004; 15:477–86. 3. Brown PA, McCormick BB, Knoll G, Su Y, Doucette S, Fergusson D, et al. Complications and catheter survival with prolonged embedding of peritoneal dialysis catheters. Nephrol Dial Transplant 2008; 23:2299–303. 4. McCormick BB, Brown PA, Knoll G, Yelle JD, Page D, Biyani M, et al. Use of the embedded peritoneal dialysis catheter: experience and results from a North American Center. Kidney Int Suppl 2006; (103):S38–43. 5. Rambausek M, Zeier M, Weinreich T, Ritz E, Rau J, Pomer S. Bowel perforation with unused Tenckhoff catheters. Perit Dial Int 1989; 9:82. 6. Brady HR, Abraham G, Oreopoulos DG, Cardella CJ. Bowel erosion due to dormant peritoneal catheter in immunosuppressed renal transplant recipients. Perit Dial Int 1988; 8:163–5. doi:10.3747/pdi.2011.00016