New protocols for treatment of class IV lupus nephritis with emphasis on rituximab as the sole maintenance therapy

Objective: A safe and effective treatment for lupus nephritis [LN]

Design: An 8-year prospective study

Setting: Hospital-based

Subjects: Three groups of patients with class IV LN; comparison of 2 new treatment-protocols for class IV LN with a retrospective group of patients who had received the standard treatment for LN

Intervention: The 2 treatment groups had received an induction phase of monthly intravenous Cyclophosphamide, Mycophenolate [MP] and Prednisone [P]. The maintenance phase in the first group was only MP and P, while patients in the second group had received only yearly Rituximab infusions

Main outcome measures: Morbidity and mortality

Results: Patients in the first group did not have significant relapses, yet had 10 episodes of infections during the maintenance phase. In the second group, there were five treatment failures, yet none had renal deterioration, infections or death. In the third group, seven relapses occurred during the induction period and three in the maintenance one. Moreover, complications included 1 death of disseminated sepsis, 12 cases of chronic renal failure, three kidney losses, 16 episodes of major infections, two cases of aseptic necrosis, two cases of gonadal failure, two cases of hemorrhagic cystitis and 2 cases of retinal deposits

Conclusions: Rituximab infusions, used once yearly, are effective and a safe maintenance therapy for most patients with LN after a short course of three anti-proliferative agents. In those who failed to respond, MP and P are more effective and safer than the standard protocol

Unstable angina as the first manifestation of a relapse in polyarteritis nodosa

Coronary involvement with polyarteritis nodosa [PAN] has been identified in post-mortem studies, yet rarely in clinical practice. We report a 38-year-old woman who presented with unstable angina for two days. She had a history of PAN and had received immunosuppressive therapy for two years, six years ago. Her initial ECG showed ST depression in most leads. Troponins were not elevated. Coronary arteriography revealed multiple aneurysms and stenotic lesions without obstruction. She also had anemia and progressive renal failure, indicating acute flare of PAN. She was treated with infusions of heparin, nitroglycerin, and oral Clopidogrel. Moreover, she received three daily infusions of 1 g solumedrol, followed by tapering dose of prednisone and three monthly 1 g Cyclophosphamide infusions, followed by Mycophenolate 1 g twice daily. She improved and remained stable for the next two years

Acute appendicitis induced by cholesterol crystal-embolism

Cholesterol crystal embolism [CCE] or athero-embolism is a disorder caused by embolization of cholesterolcontaining material, from the aorta and/or its great arteries, to various tissues in the body. We report a 74-year-old man who developed CCE as manifested by livedo reticularis, ischemic toes and protracted renal failure, one month after a femoral approach for coronary angioplasty. One month later, he developed acute abdomen due to acute appendicitis with peritonitis as confirmed by CT scan, laparoscopy and histopathology. It revealed an inflamed appendix, yet with a patent lumen. Its submucosal artery was occluded by multiple biconvex clefts indicating previous deposition of cholesterol crystals. The patient improved after appendicectomy, yet had required maintenance hemodialysis for his protracted renal failure

Renal disease in bodybuilders

We report our experience with the development of focal segmental glomerulosclerosis [FSGS] in two adult bodybuilders who had consumed high protein diet, anabolic steroids and growth hormone for years in their attempt to gain more muscular appearance. The first patient presented with severe renal failure [serum creatinine 700 umol/l] and kidney biopsy showed advanced FSGS. The second had moderate renal disease [serum creatinine 170 umol/l] and hypercalcemia [3.8 mmol/l] due to his high intake of milk instead of water to promote more protein intake. His kidney biopsy showed early FSGS with diffuse interstitial fibrosis associated with extensive calcium deposition in the tubules. Both patients were instructed to avoid such attitude and were treated conservatively. However, the first patient required kidney transplantation four months later. The second one improved gradually, over the past two months, with decrease of serum creatinine to 96 umol/l. He is currently on telmisartan 40 mg daily to decrease his glomerular pressure. In conclusion, athletes and bodybuilders should consider the risks involved with the use of high protein diet, anabolic steroids and growth hormone alone or in combination to avoid the development of serious renal disease such as FSGS

Postmortem biopsies: the experience in Kuwait

To report our 4-year experience in postmortem needle biopsy of liver, heart, kidney and lung tissues when formal autopsy could not be performed. Subjects and In the period from January 2000 to December 2003, postmortem biopsies were done at Al-Amiri Hospital, Kuwait, in 19 cases where the original diagnosis or cause of death was not clear. The procedure was performed by a dedicated trained medical team using a biopsy needle or limited incisions guided by the knowledge of the clinical presentation and results of laboratory and radiological investigations. The actual diagnosis was established in 8 cases by postmortem histological findings and corrected in another 9 cases. In the remaining 2 cases with systemic sepsis, autopsy only confirmed the antemortem clinical diagnosis. Our study shows that needle biopsy is an adequate technique for postmortem examination and should be considered as the minimum alternative to conventional autopsy

epidemiological profile of anemia, blood transfusions and iron overload in paitients on maintenance dialysis

Anaemia contributes considerably to morbidity and impairs the quality of life in patients on maintenance dialysis [MD]. This study analyzed the epidemiological profile of anaemia, transfusional requirements [TR] and iron stores in patients on MD in Kuwait during 1989-1990. In those years, recombinant erythropoietin [rHuEPO] therapy had just been initiated. One hundred and eighty-nine patients were studied. Forty four [28.8%] patients were found to be severely Anaemic and/or required excessive blood transfusions, 25 of whom were receiving maintenance haemodialysis [MHD]] for <18 months. During the first 18 months of dialysis, 33% of MHD] patients were found to be iron depleted i.e. serum ferritin [SF] <30 micro g/l, compared to only <2% of MHD patients on longer duration of dialysis, and 0% of those on maintenance peritoneal dialysis [MPD]. Twenty six [13.8%] patients were Iron overloaded [10] [SF>1100 micro g/I] of whom 24 were receiving MHD]. Iron stores correlated positively with duration on dialysis only In those who exhibited excessive TR Our study emphasize the need for periodic assessment and replenishment of iron stores especially during the early months of MHD. Early application of iron monitoring and use of rHuEPO will limit the need for blood transfusions and prevent the development of 10 in this patient population