Utility of bronchoalveolar lavage in the diagnosis of pulmonary infections in immunosuppressed patients.

AIM: To evaluate the utility of bronchoalveolar lavage (BAL) in immunocompromised patients. MATERIAL AND METHODS: We studied BAL cytology and microbiological culture in 16 kidney transplant recipients (Group A), 14 dialysis patients (Group B) and eight HIV positive patients (Group C) suspected of having pulmonary infections. A group of 21 individuals without pulmonary diseases were studied as controls. RESULTS: A comparison of the cytological profile in controls and study groups showed that percentages of lymphocytes and neutrophils were significantly increased in all three patient groups as compared to controls, BAL bacterial cultures were positive in 4, 3 and 4 cases of Group A, B and C, respectively. Direct examination of BAL cytosmears helped in detecting cytomegalovirus inclusions, acid fast bacilli and Pneumocystis carinii in 3, 2 and 5 cases of Group A, B and C, respectively though microbial cultures were negative. The sensitivity of BAL cytology was found to be 76.3%, whereas that of microbial culture was only 31.5%. The diagnostic yield of BAL was 68.75%, 71.42% and 100% in the Groups A, B and C, respectively, while it was 76% when all three groups were considered together. BAL cytology yielded the diagnosis in 47.36% of cases, a combination of BAL cytology and culture in 23.68% and culture alone in 5.3% of cases. CONCLUSIONS: BAL is useful relatively non-invasive investigative tool in the rapid diagnosis of infections in immunocompromised patients. BAL cytology was found to be more useful than microbial cultures.

Male reproductive function in uraemia: efficacy of haemodialysis and renal transplantation.

OBJECTIVE: To evaluate the impact of maintenance haemodialysis and live-related renal transplantation on the reproductive potential of men with end-stage renal disease. PATIENTS AND METHODS: The plasma levels of testosterone, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) were determined, and semen analysed, in 19 men (22-41 years old) with advanced uraemia after 6 months of dialysis and again 6 months after renal transplantation. Eight patients who had azoospermia or severe oligospermia underwent testicular biopsy after 6 months of dialysis and again 6 months after the transplant. RESULTS: Following dialysis, levels of testosterone were low in 17 patients and levels of LH and FSH were elevated in 15 and eight patients, respectively. Four patients each had azoospermia and severe oligospermia. The testicular tissue was hypospematogenic in three patients, showed late-maturation arrest in four and germ cell aplasia in one. After renal transplantation, testosterone and LH levels returned to normal in 15 and 13 patients, respectively, while FSH levels became normal in only two patients. The recovery of testosterone and LH levels after transplantation was statistically significant. Semen quality improved in 13 patients, with the improvement in sperm density and motility being statistically significant. Testicular histology revealed normal spermatogenesis in four patients, while three continued to show late-maturation arrest. The wives of five of the transplanted patients conceived. CONCLUSIONS: The impairment of testicular function seen in advanced uraemia is not reversible by maintenance haemodialysis. In contrast, after successful transplantation, steroidogenic function became almost normal while spermatogenic function showed a striking if incomplete recovery.

Effect of low dose recombinant human omega erythropoietin (rHuEPO) on anaemia in patients on hemodialysis.

The effect of low dose rHuEPO therapy in ESRD patients on regular dialysis therapy was assessed in a prospective study in 22 patients. Routine hematological and biochemical tests, bone marrow aspiration, serum iron and ferritin studies were performed. The quality of life was also assessed. rHuEPO was administered in a dose of 25 units/kg i.v. post dialysis 3 times a week for 8 weeks, followed by 36 units/kg for further 4 weeks. Significant rise (p = 0.0001) in Hb & PCV with rise in reticulocyte count (0.016) was noted. Serum ferritin was a better index of iron status of the body. Significantly improved anemia and quality of life of ESRD patients on hemodialysis was seen in 95% of the patients.

Left ventricular function in end stage renal disease--non-invasive assessment in patients on maintenance hemodialysis.

Non-invasive assessment of left ventricular function was performed by echocardiography and radionuclide ventriculography in 17 end-stage renal disease patients on maintenance hemodialysis. Patients with diabetes mellitus, ischemic heart disease and pericardial or valvular heart disease were excluded from the study. Parameters studied on echocardiography were left ventricular internal diameter in diastole (LVIDd), left atrial diameter (LAD), Aortic root diameter (ARD), Left ventricular posterior wall thickness in systole (LVPWs), End diastolic volume (EDV), End Systolic volume (ESV), fractional shortening percentage (FS%) and ejection fraction (EF). Parameters studied on radionuclide ventriculography were Peak ejection rate (PER), Peak filling rate (PFR) and Ejection fraction (EF). Significantly abnormal values for echocardiographic parameters LVIDd, LVPWs, EDV, ESV and FS% were found. On evaluation by MUGA scans, it was observed that the PER was significantly decreased while the PFR and EF did not change significantly.

Dyslipoproteinemia in renal transplantation.

Twenty-seven live related donor renal allograft recipients were evaluated for dyslipoproteinemia. Twenty-two patients received dual immunosuppression with prednisolone and azathioprine. Five patients received cyclosporin as well. Total cholesterol (Tch), triglycerides (TG), HDL cholesterol (HDLch), LDL cholesterol (LDLch) and VLDL cholesterol (VLDLch) levels were estimated. Fifteen (56%) patients showed significant lipoprotein abnormalities. Renal allograft recipients showed significantly lower levels of Tch (p < 0.05) and LDLch (p < 0.05) and higher levels of TG (p < 0.005) and HDLch (p < 0.05). Diet and beta blockers did not influence lipoprotein levels. A significant negative correlation was noted between post-transplant duration and Tch, TG and VLDLch levels. Increased TG levels were associated with increase in weight and higher daily prednisolone dosage at the time of evaluation. The study confirms the existence of dyslipoproteinemia in renal allograft recipients.

Measurement of serum thyrotropin levels using sensitive immunoradiometricassays in patients with chronic renal failure: alterations suggesting an intact pituitary thyroid axis.

Serum thyroid stimulating hormone (TSH) levels were measured in 127 patients with varying grade of chronic renal failure (CRF). Sensitive immunoradiometricassays (IRMA) were used so that small changes in TSH levels if any, could be appreciated, and to see if such alterations exhibit some relationship with those in thyroid hormone levels. Mean serum TSH levels in the patient group of 2.33 microU/ml (0.07-7.3) was significantly higher in comparison to 1.73 microU/ml (0.25-4.6) in normal subjects (p < 0.001). However, they were not significantly different when measured by radioimmunoassay (RIA) as compared to normals. Serum triiodothyronine (T3), thyroxine (T4) and free triiodothyronine (FT3) levels of 72 +/- 32 ng/dl, 7.4 +/- 2.6 micrograms/dl and 2.9 +/- 0.9 pg/ml were significantly lower than in normal subjects, whereas serum free thyroxine (FT4) showed a slight though not significant elevation. When patients were divided in three subgroups according to the degree of renal insufficiency, TSH levels showed a gradual rise with corresponding depression in their T3, FT3 and T4 levels. In 19 patients who were on hemodialysis (HD) and subsequently received successful renal transplantation, most of the thyroid function parameters returned towards the normals with TSH undergoing significant depression from their pretransplant levels as well as from normal levels. The results indicated that a slight but significant elevation in TSH levels could be revealed by sensitive IRMA in patients with CRF. Rising TSH levels with increasing renal insufficiency and its inverse relationship with T3 and T4 levels suggest maintenance of pituitary thyroid axis.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of direct radionuclide cystography with micturating cystourethrography for the diagnosis of vesicoureteric reflux, and its correlation with cystoscopic appearances of the ureteric orifices.

Forty-eight patients with strong clinical suspicion of vesicoureteric reflux (VUR) as the cause for their renal disease; were subjected to direct radionuclide cystography and roentgenographic micturating cystourethrography for its detection. Forty-four of them underwent cystoscopy under local anaesthesia to document the position and appearance of the ureteric orifices. Of the 92 kidney-ureter 'units' available for study, 20 had reflux positive on micturating cystourethrography and 22 had direct radionuclide cystography positivity. Two of the three units picked up on direct radionuclide cystography but missed on micturating cystourethrography were severe refluxes up to the renal pelvis. On the other hand, one unit missed on direct radionuclide cystography but picked up on micturating cystourethrography was a lower ureteric reflux. The sensitivity and specificity of direct radionuclide cystography to detect VUR as compared to micturating cystourethrography is 95% and 95.8% respectively. The localization and appearance of ureteric orifices which were classified as per Lyon's classification greatly enhanced the predictive value of determining past or present VUR. Patients with golf-hole orifices placed laterally had 100% incidence of reflux. Thus, combining direct radionuclide cystography with cystoscopy may enhance the predictive value for diagnosis of VUR even higher than a micturating cystourethrography study.

Effect of iron deficiency anaemia and its treatment on single dose phenytoin bioavailability.

Iron deficiency is a common nutritional deficiency, which leads to structural functional and enzymatic changes in the body that may affect the pharmacokinetics of drugs. The present study in 7 normal volunteers and 8 adult male patients with iron deficiency anaemia (IDA) was done to investigate the effect of iron deficiency and its treatment with total dose iron (TDI) on the bioavailability of a single dose of phenytoin. Phenytoin bioavailability was investigated before and 3 and 28 days after TDI. The bioavailability parameters Cmax, tmax, AUC and 2 h phenytoin concentrations were not significantly different in anaemic patients as compared to normal volunteers before or after treatment, except for an increase in tmax 28 days after TDI treatment.

Fine needle aspiration cytology (FNAC) in the evaluation of acute renal allograft rejection.

310 Fine needle aspirations biopsies (FNAB) were performed in sixty-five live related renal donor transplant recipients in a prospective study over 2 years. 82.8% of FNAB were adequate for opinion and there were no complications after the procedure. Methodology used and interpretation of FNACs was as described by Von Willebrand and Hayry. The procedure of FNAC had a sensitivity of 83.3%, specificity of 98.3% and accuracy of 96.1%, and statistically significant (p < .001) correlation was noted between FNAC and Needle biopsy. The increment in lymphoblasts, lymphocytes and score above 3 was suggestive of acute cellular rejection. Increment in monocytes and macrophages above 1% in addition to other cells, was suggestive of acute vascular rejection. FNAC was found to be a safe, simple and easy procedure with high specificity and sensitivity.

Food reduces isoniazid bioavailability in normal volunteers.

Food and drug interaction is a major variable in bioavailability of drugs. Isoniazid is the most common antitubercular drug used in India. We studied the effect of standard Indian breakfast and lunch on the bioavailability of isoniazid in a single dose crossover study in normal male volunteers. The standard breakfast and lunch significantly reduced plasma AUC, Cmax and Kabs values of isoniazid. Isoniazid, thus, should not be administered with food.

Total and free thyroid hormone levels in chronic renal failure.

The levels of serum total thyroxine (TT4), triiodothyronine (TT3), free T3, (FT3) free T4 (FT4) and thyrotropin (TSH) were measured in 127 clinically euthyroid patients with varying grades of chronic renal failure (CRF); and 97 healthy individuals. They were grouped as: Group I containing 93 patients on conservative management; Group II containing 34 patients on regular dialysis therapy; and Group III (normals). Group I patients showed significant decrease in TT3, TT4 and FT3 levels (p less than 0.001) as compared to Group III, whereas FT4 and TSH values in group I were not significantly altered. TT3, TT4 and FT3 levels reduced as the severity of renal damage increased. Variations in TT3, TT4, FT3, FT4 and TSH levels in Group II patients were similar to those in Group I, except for a decrease in TSH levels (p less than 0.05) as compared to normals. Several thyroid function tests are abnormal in CRF patients, however, finding of normal FT4 and TSH levels would indicate functional euthyroid status.