Survival analysis of Thai patients with IgM nephropathy, focal segmental glomerulosclerosis and membranous nephrotic syndrome.

Long term outcome of 124 Thai adult nephrotic patients was determined. Nephrotic syndrome affects the young more often than the old (median age 29 years). The most common pathology was IgM nephropathy (45.2%), membranous nephropathy (31.5%) and FSGS (23.4%). Sixty-four per cent of patients with IgM nephropathy respond to corticosteroid within 4-8 weeks while twenty three per cent were late responders. However, more than half of these patients were relapsers or steroid dependent. Response to corticosteroid occurred in 48.2 per cent of patients with FSGS while the response rate of patients with membranous nephropathy was only 23.1 per cent. Survival analysis revealed that five and ten years renal survival of IgM nephropathy was 98 per cent. Five and ten years renal survival of FSGS was 83.7 per cent and 76.8 per cent while those of membranous nephropathy was 95 per cent and 63.3 per cent. The response to corticosteroid was associated with better prognosis in FSGS. Our results show that patients with IgM nephropathy and membranous nephropathy have a generally good prognosis. Renal function is usually well preserved for at least ten years. The prognosis of patients with FSGS varied and correlated with the degree of steroid responsiveness.

Acute renal failure (ARF) in Thailand. Retrospective analysis in a medical center.

The changing trend of today's ARF in Thailand had led to requirement of epidemiologic data for management and planning. Retrospective review of adult inpatient records for 5 years of Ramathibodi Hospital was performed. Normal initial serum creatinine rising to double its value within one week and/or oliguria were the inclusion criteria. Data from another 3 university hospitals were used for comparison. AFR is the second most common renal disease at Ramathibodi Hospital with sepsis as the major underlying etiology. Among 396 cases of ARF, 194 were non-oliguric, 150 oliguric and 52 anuric. Non-oliguric cases needed lesser dialysis and had lower mortality. The number of AFR patients from 4 university hospitals varied from 0.14 to 0.18 per cent of hospital admission. If we consider the incidence of AFR in general hospital admission to be 0.1 per cent and the average hospital admission/year of Thailand was 3.25 million, there will be 3,250 cases/year or 55 cases/million/population year. If 4 dialyses/case was considered, 220 dialyses/ year/million population was required. We suggested that the hospitals of the province with population above 1 million should have a hemodialysis unit for both their local service and referral cases and all provincial hospitals should develop at least a peritoneal dialysis facility for increasing cases in ARF.

Nocturnal physiological and biochemical changes in sudden unexplained death syndrome: a preliminary report of a case control study.

Sudden nocturnal deaths among "healthy" workers in Southeast Asia have been termed "sudden unexplained nocturnal death syndrome (SUNDS)" or "sudden unexplained death syndrome (SUDS)". The pathogenesis is still unknown. The paucity of publications on nocturnal monitoring and scientific data stimulated us to perform this study, which included biochemical tests and physiological monitoring during the night in 11 males north-eastern Thai workers. Group 1 (G1) consisted of 5 subjects with neither a previous history of near-SUDS (NSUDS) nor a familial history of SUDS (FHSUDS). Group 2 (G2) consisted of 6 subjects with a family history of either SUDS or NSUDS. Two subjects in G2 presented with NSUDS. Two-day nocturnal monitoring included blood sugar, electrolytes, and respiratory parameters. 24-hour Holter ECGs were monitored for 2 days. The subjects underwent exercise stress tests on the 2nd day of this study. Significant nocturnal hypoxia was more common in G2 than G1 and this abnormality was aggravated by exercise. There were no significant findings in sleep apnea (apnea indices) or in nocturnal biochemical changes, eg blood sugar, electrolytes, thiamine. The recordings of the Holter-ECGs were within normal limits in both groups. We conclude that nocturnal hypoxia might be the primary abnormality in SUDS, and this abnormality was aggravated by the day-time exercise. The cause of nocturnal hypoxia requires further studies.

Pulmonary edema in severe falciparum malaria. Hemodynamic study and clinicophysiologic correlation.

This study was performed to extend the knowledge of the pathogenesis of PE in severe falciparum malaria. Sequential hemodynamic studies were conducted in 13 patients with severe falciparum malaria. Seven patients developed PE, while the other six patients had NPE. Two patients died, one in each group. Hemodynamic changes were found in both groups, including an initial reduction in SVR and PVR, along with an increased CI and variable values (normal and increased) of PCWP. All abnormalities persisted for at least two days; changes in PVR lasted especially longer (throughout five days). The initial hemodynamic changes cannot predict the development of PE; however, heavy parasitemia of more than 60 percent and severe hypoalbuminemia were found to be more common in PE than NPE. Of three patients with PE who had normal PCWP, one died, with postmortem findings of increased pulmonary capillary permeability. The increased PCWP which was found in the other four cases of PE was proven to be volume overload without evidence of CHF. It was concluded that the pathophysiologic changes in severe falciparum malaria were systemic and pulmonary vasodilation. The abnormal pulmonary vascular change was found to be the cause of PE. Volume overload and hypoalbuminemia could aggravate further pulmonary capillary leakage in these cases.

Dosing regimen of gentamicin during intermittent peritoneal dialysis.

The peritoneal clearance of gentamicin was studied in 11 chronic uremic patients who undergoing intermittent peritoneal dialysis. Gentamicin was significantly removed by peritoneal dialysis with a clearance value of 9.75 +/- 3.78 ml/min. The serum half life was 14.08 +/- 3.57 hr, a value significantly less than that of non dialysed end stage renal disease patients. The mean apparent volume of distribution of the drug in these patients was about 27% of body weight. The derived value for gentamicin peritoneal clearance and volume of distribution can be used to calculate maintenance dose during intermittent peritoneal dialysis. In order to achieve the peak level of 8 micrograms/ml, supplementary dose compensated for the loss during peritoneal dialysis is approximately 40% of loading dose 0.8 mg/kg every 12 hours.

Continuous peritoneal dialysis in acute renal failure from severe falciparum malaria.

Severe falciparum malaria complicated by acute renal failure resulted in very high mortality. Ten patients with acute renal failure from falciparum malaria (infected rbc up to 80%) were continuously dialysed using Tenckhoff peritoneal catheter. Five were oliguric and BUN was maintained between 60 to 80 mg/dl (21.4 to 28.6 mmol/l) by hourly 1 to 1.5 liter dialysate exchange during the acute phase. The peritoneal urea clearance (mean +/- SD) was 12.1 +/- 1.2 ml/min with urea nitrogen removal of 13.4 +/- 2.3 g/day. In nonoliguric cases dialysis was also needed for additional removal of waste products since the remaining renal function could not cope with the hypercatabolic state. Peritoneal glucose absorption (135 to 565 g/day) gave considerable caloric supply without volume load and also contributed to the prevention of hypoglycemia. Varying degree of acute respiratory failure developed in all patients with 5 cases (2 oliguric and 3 nonoliguric) progressing to pulmonary edema. Swan-Ganz catheterization and hemodynamic study suggested the role of increased capillary permeability and volume overload from endogenous water formation in the development of pulmonary complication. Continuous removal of fluid and waste products minimized these problems and may prevent the progression of respiratory failure. One patient died of severe sepsis and the other nine survived. This study showed the beneficial contribution of continuous peritoneal dialysis in the management of acute renal failure from severe falciparum malaria.

Gentamicin removal during intermittent peritoneal dialysis.

Gentamicin removal during intermittent peritoneal dialysis was studied in 13 uremic patients. The peak serum level after 80 mg of gentamicin intravenous drip was 6.00 +/- 1.3 micrograms/ml with a serum half-life of 13.6 +/- 4.07 h. The gentamicin dialysate level did not correlate with the corresponding serum concentration. The peritoneal gentamicin clearance (10.0 +/- 3.65 ml/min) correlated with the rate of protein loss, but not with the peritoneal clearances of urea and creatinine. When 4% glucose dialysate was used, the clearance of the drug increased considerably along with the ultrafiltration rate. Adding gentamicin (5 micrograms/ml) to the dialysate resulted in a sustained serum drug level. The mechanism of gentamicin transport through the peritoneal membrane is discussed. The study demonstrated significant removal of gentamicin during intermittent peritoneal dialysis.

IgA nephropathy associated with enteric fever.

3 cases of enteric fever (2 paratyphoid and 1 typhoid) associated with IgA nephropathy were reported. Salmonella Vi antigen was demonstrated in the glomeruli. The clinical syndrome disappeared after enteric fever was treated. Possible pathogenesis was discussed relating this intestinal infection to IgA nephropathy.

Effect of chlorpromazine on peritoneal clearances.

Chlorpromazine added to the dialysate improved the ultrafiltration and increased peritoneal clearances of urea and inulin. These results were postulated to be due to the narrowed stagnant dialysate fluid layer by the surface-active property of chlorpromazine. The study suggested another way to improve large solute (possibly uremic toxin) transport by using substances that facilitate convective transport. Intraperitoneal chlorpromazine increased the peritoneal dialysis efficiency.

Modified method of weighing for accurate fluid balance.

The modified method of weighing using an ordinary commercial weighing scale, an empty bottle and an intravenous set was presented. The method measures change in weight by varying the water content in the bottle that the subject carried during the weighing process. The technique was used for the study of evaporative water loss and may be tried in clinical practice when accurate fluid balance is required.

Epididymo-orchitis due to Pseudomonas pseudomallei.

We report the first case of epididymo-orchitis caused by Pseudomonas pseudomallei. The diagnosis was made by isolation of the organism from testicle pus and urine. Treatment was successful with chloramphenicol and co-trimoxazole.

Effect of dialysate temperature on peritoneal clearances.

Peritoneal dialysis was performed in 18 uremic patients using both room temperature (27-31 degrees C) and prewarmed (37 degrees C) dialysate. There were no significant differences between the two periods of the following parameters: urea clearance, creatinine clearance, inulin clearance, ratio of inulin to urea clearance, ratio of inulin to creatinine clearance, drainage volume, dialysate flow rate, ultrafiltration rate and total protein loss. Since the peritoneal dialysis efficiency was not improved by warming dialysate in this range of temperature, the warming procedure is not necessary in the countries where the average room temperature is 29 degrees C (27-31 degrees C). The exclusion of this procedure will decrease the work load and lessen the chance of dialysate contamination.

Cadmium-induced experimental Fanconi syndrome.

We have demonstrated that repetitive injections of cadmium into rats leads to the abrupt development of Fanconi syndrome after the renal cortical concentration of cadmium has increased approximately eighty-fold. The syndrome is temporally associated with a fall in both Na-K-ATPase activity and ATP levels, suggesting a possible causal relationship between altered proximal tubular transport and inhibition of the ATP-Na-K-ATPase transport system.