Early onset primary pulmonary cryptococcosis in a renal transplant patient.

We report a case of primary pulmonary cryptococcosis in a post-renal transplant patient. A 65-year-old male renal transplant patient was admitted to the hospital with a low grade fever of 1 month, radiologically mimicking tuberculosis (TB). Broncho-alveolar fluid (BAL) shows capsulated yeast, and Cryptococcus neoformans was grown on culture supported by cytology and histopathological examination. Cryptococcal antigen was positive (32-fold) in serum and was negative in cerebrospinal fluid (CSF). The patient was given amphotericin B and 5-flucytosine and clinical improvement was seen on a weekly follow up. The serum cryptococcal antigen test might contribute to the early detection and treatment of pulmonary cryptococcosis. The results of antifungal susceptibility were aid in selecting the drug of choice for treatment.

Intravenous pulse cyclophosphamide--a new regime for steroid resistant focal segmental glomerulosclerosis.

OBJECTIVE: A prospective study was conducted to evaluate the role of intravenous pulse cyclophosphamide (IVCP) infusions in the management of children with steroid resistant (SR) idiopathic focal segmental glomerulosclerosis (FSGS). METHODS: The study group comprised of 20 consecutive children with idiopathic nephrotic syndrome secondary to FSGS who were SR. All of them were subjected to standard baseline investigations. They were started on monthly infusions of IVCP in a dose of 500-750 mg/m2. Adjunctive prednisolone was given in a dose of 60 mg/m2/day for 4 weeks followed by 40 mg/m2/alternate day for another 4 weeks and tapered off over next 4 weeks. RESULTS: The study group comprised of 15 boys and 5 girls with mean age of onset of disease of 5.5 +/- 3.5 years. Two of these children had chronic renal insufficiency prior to starting therapy. At the end of the study, after a mean duration of disease (since onset of NS) of 77 +/- 55 months, all 20 children had normal renal functions. After a mean follow up post IVCP therapy of 21.2 +/- 13.4 months, 13 of the 20 children (65%) had attained a complete remission. Of these, 10 children were infrequent relapsers, 2 frequent relapsers and 1 steroid dependent. The mean duration of remission following last dose of IVCP in these children was 12.5 +/- 11.9 months. Of the 7 children who continued to be proteinuric, 3 became edema free and have not required any albumin infusion or diuretics. One other died due to peritonitis 2 years after the last dose of IVCP. The mean total protein and serum albumin levels following the IVCP infusion were significantly higher than those prior to therapy (6.5+/-1.0 mg/dl Vs 5.0+/-0.8) (p=0.0004) and (3.5+/-0.7 g/dl Vs 2.3+/0.7) (p = 0.000007) respectively. The serum creatinine levels following IVCP therapy (0.8+/-0.2 mg/dl) were significantly lower than those prior to treatment (1.0+/-0.6 mg/dl) (p=0.02). The only side effects that were observed were transient nausea and vomiting during infusion (n=2) and alopecia (n=1). None of the children developed leukopenia or hemorrhagic cystitis. CONCLUSION: IVCP infusions appear to be safe, effective and economical therapeutic modality in steroid resistant children with idiopathic FSGS.

Calcitropic hormonal status in north Indian patients with end-stage renal disease.

BACKGROUND: Bone disease in chronic renal failure has a wide spectrum that includes both high and low turnover conditions. Specific preventive and therapeutic measures require knowledge of the nature of bone involvement. Bone biopsy with static and dynamic histomorphometry is the gold standard for characterization of renal bone disease. However, non-invasive biochemical tests, especially serum intact parathyroid hormone (PTH), have a good correlation with histomorphometry. We studied the clinical and biochemical profile of bone disease in a sample of north Indian patients with chronic renal failure. METHODS: Twenty-nine patients of chronic renal failure were evaluated clinically, radiologically (subperiosteal erosions on hand X-rays) and biochemically (serum calcium, phosphorus, total alkaline phosphatase, intact PTH, osteocalcin, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D). Bone histomorphometry could be done in 4 patients. RESULTS: Serum intact PTH within or below the non-uraemic normal range, an index of low bone turnover, was seen in 17 (58.6%) patients. Serum osteocalcin, a bone formation marker, was within or below the non-uraemic normal range in 65.5% patients. Serum intact PTH and osteocalcin had a significant positive correlation (r = 0.6). Patient groups with clinical or radiological evidence of bone disease had serum intact PTH and osteocalcin levels comparable to those lacking such features. Serum intact PTH and total alkaline phosphatase were lower in haemodialysed (n = 25) patients than in those who had not received haemodialysis (n = 4). Low (< 10 ng/ml) serum 25-hydroxyvitamin D levels were seen in 7 (24%) patients while 1,25-dihydroxyvitamin D was low (< 15.9 pg/ml) in 20 (69%) patients. The biochemical parameters accurately reflected the bone histology (n = 4). CONCLUSIONS: Our data show that the majority of north Indian patients with chronic renal failure have biochemical evidence of low bone turnover. Empirical use of calcium salts and active vitamin D analogues without documentation of parathyroid status carry the risk of further suppression of bone turnover.

Effect of antihypertensives on plasma potassium in end stage renal disease: a retrospective study.

The antihypertensive drug therapy and the peri-operative plasma potassium trend in end stage renal disease (ESRD) patients undergoing renal transplant were analysed. Out of consecutive 107 live related donor renal transplant, complete data available for 74 patients between June 1991 and March 1993, were entered in proforma and analysed. On the basis of antihypertensive or no antihypertensive drugs prescribed, patients were grouped in 6 categories. Group I patients taking no antihypertensives were taken as control. All patients were comparable for their age, sex, weight, immunosuppressive therapy, anaesthetic and fluid management during surgery. At the time of induction of anaesthesia, patients taking atenolol (plasma K+ levels being 5.34 +/- 0.75 mmol/l in group II and 5.44 +/- 0.63 mmol/l in group III) or captopril (serum K+ level being 5.05 +/- 0.94 mmol/l in group V) in combination with nifedipine and with or without clonidine had significant hyperkalaemia than the patient without antihypertensives (serum K+ level being 4.49 +/- 0.71 mmol/l). Patients, on these two antihypertensives, frequently needed active treatment of alarming hyperkalaemia (blood K+ more than 5 mmol/l and tall 'T' wave in lead II) and cardiac arrhythmias. In conclusion, ESRD patients taking atenolol or captopril are needed to be frequently monitored for blood potassium levels and it would be advisable to avoid these drugs to control hypertension in ESRD patients, especially, when scheduled for renal transplantation.

Defective lymphoproliferative responses & interleukin-2 production in chronic renal failure patients.

Cellular immune responses were evaluated in 12 early renal failure (ERF) patients who were not on maintenance haemodialysis, 43 end stage renal disease (ESRD) patients on haemodialysis (HD) and 25 healthy volunteers. Peripheral blood mononuclear cells (PBMC) of ERF and ESRD patients on HD had a significantly diminished lymphoproliferative responses to phytohaemagglutinin and a monoclonal antibody to the CD3 (anti-CD3) receptor on T-cells as compared to normals. The interleukin-2 (IL-2) production by the PBMC was also significantly reduced in renal failure patients as compared to normals. These data suggest that both IL-2 dependent and IL-2 independent T-cell functions are defective in renal failure patients.

Pattern of acute renal failure at a referral hospital.

Fifty two children (upto 12 years age) with acute renal failure (ARF) admitted to the Nephrology services between January, 1989 to August, 1992 were studied to determine the cause and outcome. Of these, 39 were boys and 13 girls; 27 (51.9%) patients were below 4 years of age. Hemolytic uremic syndrome (HUS) was the commonest cause of ARF (30.8%) followed by acute tubular necrosis (ATN) in 28.84% and acute glomerulonephritis in 19.23%. All patients had severe renal involvement with anuria in 53.6% and oliguria in 46.4% at presentation. HUS was the leading cause of anuria (53.6%), followed by obstructive uropathy (21.4%). Thirty five patients required dialytic support for a median duration of 18 days (2-90 days). The mortality was 34.6%. Seven patients of HUS, 4 patients of ARF following surgery, 3 patients each of ATN and glomerulonephritis and one patient of obstructive uropathy died. Anuria at onset, central nervous system or respiratory complications and delay in institution of dialytic support were bad prognostic factors. We conclude that early referral and prompt institution of dialytic support may be helpful in decreasing the mortality.

99m Tc DTPA scan as a diagnostic marker of acute rejection in renal transplantation.

Forty renal transplant recipients were subjected to 99m Technicium Diethylene triamine pentacetic acid (DTPA)scans at regular intervals & whenever there was suspection of rejection. Serial scans of a group of 15 recipients from immediate post transplant period till withdrawal of cyclosporine were analysed separately & the results compared to with single scan analysis. The sensitivity & specificity of DTPA scan in the absence of acute tubular necrosis (ATN) was 94.1% & 87.5%, while the positive & negative predictive values were 88.8 & 93.3% respectively. Sensitivity & specificity of serial scan analysis (88.8% and 75%) in early post transplant period was higher than that of interpretation of single scan (75% & 66%). Serial scan changes predated clinical rejection during cyclosporine withdrawal period. We conclude that DTPA scan is both a sensitive & specific non-invasive diagnostic marker of acute rejection in absence of ATN & serial scans during early post transplant period & at the time of cyclosporine withdrawal are helpful in detecting the rejection accurately & at the earliest.

Treatment of nephrotic syndrome.

There are well defined therapeutic protocols for childhood nephrotic syndrome. Appropriate therapy helps in minimizing side effects besides decreasing referrals to tertiary care centres. We have analysed the appropriateness of therapy of primary care physicians in 111 children with nephrotic syndrome referred to our Institute from January 1989 to December 1991. Prednisone was administered in adequate doses in 51 (52.6%), and for adequate duration in 41 children (42.2%). Adjunctive cyclophosphamide therapy was administered in the recommended doses and duration in 33% of the cases. On evaluation of the therapy it was observed that inappropriate treatment had been administered by 39.4% of the pediatricians, 59% of internists and 80% of general practitioners. This study highlights the lacunae in the current state of knowledge amongst the primary physicians and highlights the need for creating greater awareness regarding the therapy of children with nephrotic syndrome.

Wegener's vasculitis: diagnostic and therapeutic problems.

A case of Wegener's granulomatosis (WG) presenting with pulmonary manifestation which were initially suspected to be due to tuberculosis is being reported. Renal involvement appeared later. He developed complications of antitubercular treatment and of immunosuppression. The difficulties in distinguishing pulmonary manifestation of WG from tuberculosis and other diagnostic and therapeutic problems are discussed.

Prolonged peritoneal dialysis in acute renal failure using Tenckhoff catheter.

The changing spectrum of acute renal failure (ARF), in children has necessitated the support by peritoneal dialysis (PD) for a longer duration. Use of permanent catheters like Tenckhoff catheter can overcome many of the problems associated with the prolonged use of temporary catheters. Thirty one infants and children with mean (SD) age of 49.3(39.4) months were subjected to PD using surgically placed Tenckhoff catheter. Catheters were put under general anesthesia in 28 patients and under local anesthesia in 3 patients. The technique of catheter insertion has been described in detail. All the catheters, except one, functioned immediately after the insertion. There was no intraperitoneal hemorrhage, dialysate leak or poor catheter drainage. The mean (SD) duration of catheter placement for PD was 11.3 (16.1) days (range 2.90 days). There were 6 episodes of infections (19.2%), peritonitis in 4 (12.8%) and exit site infection in 2 (6.4%). In 2 patients, infection episodes did not respond to antibiotics and the catheter had to be removed. There was no mortality due to complications of PD procedure and catheter insertion. Acute intermittent PD using surgically placed Tenckoff catheter was done safely for prolonged duration and also had additional advantages of good catheter drainage and no intraperitoneal hemorrhage.

Prevalence of antibodies to hepatitis C virus in HBsAg negative hemodialysis patients.

The prevalence of hepatitis C virus (HCV) infection was estimated in a 14-month study using anti-C100-3 antibody assay in 31 HBsAg negative patients on maintenance hemodialysis (MHD) for > or = 3 months. One and three patients respectively had ALT elevation and anti-HCV positivity at entry. During MHD (mean period of follow up 9.9 mo), 11 (35.5%) patients had, on fortnightly estimation, ALT elevation which lasted for < or = 6 months in seven patients and for > 6 months in four. Fourteen (45.2%) patients had anti-HCV (including the three positive at entry). There was no significant difference in frequency of anti-HCV positivity in patients with normal and elevated ALT (57.1% and 42.9% respectively). The number of blood transfusions and duration of MHD were similar in anti-HCV positive and anti-HCV negative patients. We conclude that our MHD patients have a high frequency of hepatitis and anti-HCV positivity, and these may not be related to blood transfusions.