Clinical Profile and Outcome of Posterior Reversible Encephalopathy Syndrome in Hemodialysis Patients.

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiologic entity characterized by headache, altered level of consciousness, seizures, visual disturbances, and reversible vasogenic subcortical edema. Hypertension and renal failure are well known principal risk factors for the development of PRES. However, risk factors and outcome of PRES has not been studied in patients on maintenance hemodialysis (MHD). The objective of this study is to characterize the factors predisposing to the development of PRES in patients on MHD. We performed a retrospective analysis in patients of MHD who were diagnosed with PRES between August 1, 2013, and July 31, 2015. Those with a history of cerebrovascular accidents/stroke, and epilepsy were excluded. We analyzed the clinical details, course, and laboratory data. One year follow-up data were noted in recurrence of PRES and mortality. A total of 18 patients were included for the final analysis. Of these, 13 (72%) patients were males. Majority of these patients were young and mean age was 21.1 years (6-50 years). Most of the PRES episodes developed shortly after initiation of MHD with mean duration of 2 months after initiation of MHD (1 month-3 years). All 18 patients had resistant hypertension. Eight (45%) patients had infection at the time of PRES episodes. Four patients had catheter-related bloodstream infection, 1 had pneumonia and 3 patients were recently diagnosed with pulmonary tuberculosis. Four (22%) patients developed recurrence of PRES and all these episodes developed within 2 months of index event. Seven (39%) patients underwent renal transplantation, and all received triple immune suppression and had uncontrolled hypertension in the perioperative period. However, none of these patients developed PRES after transplantation. All these patients had been maintaining stable graft function in the follow-up. All episodes of PRES were of generalized tonic-clonic seizure type and 6 of them presented as status epilepticus. None of them had any neurological sequel and no mortality at the end of 1 year. PRES is not uncommon in patients on MHD. Uncontrolled hypertension and infection are common predisposing factors. Renal transplantation is safe and not adversely affected by prior episodes of PRES in MHD.

Rituximab in the treatment of refractory late acute antibody-mediated rejection: Our initial experience.

Antibody-mediated rejection (AMR) is not uncommon after renal transplantation and is harder to handle compared to cell-mediated rejection. When refractory to conventional therapies, rituximab is an attractive option. This study aims to examine the effectiveness of rituximab in refractory late acute AMR. This is a retrospective study involving nine renal transplant recipients. Four doses of rituximab were administered at weekly interval for 4 weeks, at a dose of 375 mg/m2. The mean age of patients was 35.3 ± 7.38 years. The median period between transplantation and graft dysfunction was 30 ± 20 months. Mean serum creatinine at the time of discharge after transplantation and at the time of acute AMR diagnosis was 1.14 ± 0.19 mg/dl and 2.26 ± 0.57 mg/dl, respectively. After standard therapy, it was 2.68 ± 0.62 mg/dl. One patient died of Pseudomonas sepsis and three patients progressed to end-stage renal disease (ESRD). Four biopsies showed significant plasma cell infiltrations. Mean serum creatinine among non-ESRD patients at the end of 1 year progressed from 2.3 ± 0.4 to 3.8 ± 1.2 mg/dl (P value 0.04). eGFR prior to therapy and at the end of 1 year were 34.4 ± 6.18 and 20.8 ± 7.69 ml/min (P value 0.04), respectively. Only one patient showed improvement in graft function in whom donor-specific antibody (DSA) titers showed significant improvement. Rituximab may not be effective in late acute AMR unlike in early acute AMR. Monitoring of DSA has a prognostic role in these patients and plasma cell rich rejection is associated with poor prognosis.

Idiopathic nodular glomerulosclerosis: Report of two cases and review of literature.

Nodular glomerulosclerosis, a pathological finding characterized by areas of marked mesangial expansion with accentuated glomerular nodularity can be seen in a number of conditions including diabetic nephropathy, amyloidosis, light chain deposition disease, fibrillary and immunotactoid glomerulopathy, collagen type III disease, nodular membranoproliferative glomerulonephritis, and Takayasu's arteritis. Idiopathic nodular glomerulosclerosis is a diagnosis of exclusion and is reported in patients with hypertension, smoking, chronic obstructive pulmonary disease, obesity, metabolic syndrome, etc. We report two cases of idiopathic nodular glomerulosclerosis, one in obese hypertensive male and the other in nonhypertensive, nonobese female patient.

Successful catheter reinsertion in a case of Paecilomyces varioti peritonitis in a patient on continuous ambulatory peritoneal dialysis.

Peritonitis is one of the most common and important complications in patients on continuous ambulatory peritoneal dialysis (CAPD). Fungal peritonitis isreported in 4-8% of peritonitis episodes. Fungal peritonitis due to Paecilomyces species is not common. We report a case of CAPD peritonitis due to P. varioti. We immediately removed the CAPD catheter and IV amphotericin was administered for 4 weeks along with temporary hemodialytic support followed by successful catheter reinsertion.

Catatonic signs in neuroleptic malignant syndrome.

The study assessed catatonic signs in neuroleptic malignant syndrome (NMS). Records of inpatients meeting both stringent research criteria and DSM-IV criteria (n = 11) or only DSM-IV criteria (n = 5) for NMS were identified. The records were systematically rated on a 23-item rating scale for the presence of catatonic signs. Scores for NMS severity were related to the number of catatonic signs. Fifteen patients met both research criteria for catatonia and DSM-IV motor criteria for organic catatonia. The severity scores of NMS correlated with the number of catatonic signs (Spearman rho = +.71, P < .005). We conclude that multiple catatonic signs are present in NMS and the severity of NMS predicts the number of catatonic signs.

Is Lorazepam a treatment for neuroleptic malignant syndrome?

The authors assessed the ability of lorazepam and other benzodiazepines to affect the course of neuroleptic malignant syndrome (NMS). Records of inpatients who met both stringent research criteria and criteria under the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) (n=11) or DSM-IV criteria alone (n=5) for NMS were identified. All received lorazepam or related benzodiazepines within 24 hours of NMS onset or hospital admission. The records were reviewed for resolution of clinical signs of NMS. Rigidity and fever abated within 24-48 hours, while secondary features of NMS were relieved within 64 hours. These results compared favorably with prior reports of 5-day to 10-day recovery periods. Benzodiazepine administration appeared to be well tolerated. Lorazepam and related benzodiazepines may reduce recovery time in NMS.