Drug-Induced Hematological Cytopenia in Kidney Transplantation and the Challenges It Poses for Kidney Transplant Physicians.

Drug-induced hematological cytopenia is common in kidney transplantation. Various cytopenia including leucopenia (neutropenia), thrombocytopenia, and anemia can occur in kidney transplant recipients. Persistent severe leucopenia or neutropenia can lead to opportunistic infections of various etiologies. On the contrary, reducing or stopping immunosuppressive medications in these events can provoke a rejection. Transplant clinicians are often faced with the delicate dilemma of balancing cytopenia and rejection from adjustments of immunosuppressive regimen. Differentials of drug-induced cytopenia are wide. Identification of culprit medication and subsequent modification is also challenging. In this review, we will discuss individual drug implicated in causing cytopenia and correlate it with corresponding literature evidence.

Factors Affecting Inpatient Mortality in Elderly People with Acute Kidney Injury.

BACKGROUND: Acute Kidney Injury (AKI) is common in elderly people (EP). There is paucity of data on predictor of mortality in EP with AKI. OBJECTIVE: This study was done to know more about factors associated with inpatient mortality in EP with AKI. METHODS: We retrospectively reviewed medical records of patients aged 65 years or above hospitalized with a diagnosis of AKI at Aga Khan University Hospital, Karachi, between January 2005 and December 2010. Binary logistic regression models were constructed to identify factors associated with mortality in EP with AKI. RESULTS: 431 patients had AKI, with 341 (79.1%) having stage I AKI, 56 (13%) having stage II AKI, and 34 (7.9%) having stage III AKI. Out of 431 patients, 142 (32.9%) died. Mortality increased with increasing severity of AKI. Mortality was 50% (17/34) in AKI stage III, 44.6% (25/56) in AKI stage II, and 29.3% (100/341) in AKI stage I. Factors associated with increased inpatients mortality were presence of stage III AKI (OR: 3.20, P = 0.04, 95% CI: 1.05-9.72), presence of oliguria (OR: 3.42, P = 0.006, 95% CI: 1.42-8.22), and need for vasopressors (OR: 6.90, P < 0.001, 95% CI: 2.42-19.65). Median bicarbonate 18 versus 17 between those who survived and those who died was associated with less mortality (OR: 0.94, P = 0.02, 95% CI: 0.89-0.99). History of hypertension (OR: 0.49, P = 0.03, 95% CI: 0.25-0.95) and high admission creatinine (OR: 0.68, P = 0.01, 95% CI: 0.50-0.91) were also associated with less mortality. CONCLUSION: Mortality in EP increases with increasing severity of AKI. Presence of stage III AKI, oliguria, and hemodynamic instability needing vasopressor are associated with increased mortality. Increased median bicarbonate, presence of hypertension, and high admission creatinine were various factors associated with decreased inpatient mortality. Increasing age and need for dialysis did not increase mortality in elderly population.

Dual Kidney Transplantation: A Review of Past and Prospect for Future.

Kidney transplantation (KT) is one of the treatment options for patients with chronic kidney disease. The number of patients waiting for kidney transplantation is growing day by day. Various strategies have been put in place to expand the donor pool. Extended criteria donors are now accepted more frequently. Increasing number of elderly donors with age > 60 years, history of diabetes or hypertension, and clinical proteinuria are accepted as donor. Dual kidney transplantation (DKT) is also more frequently done and experience with this technique is slowly building up. DKT not only helps to reduce the number of patients on waiting list but also limits unnecessary discard of viable organs. Surgical complications of DKT are comparable to single kidney transplantation (SKT). Patient and graft survivals are also promising. This review article provides a summary of evidence available in the literature.

Spontaneous Bacterial Peritonitis and Anasarca in a Female Patient with Ovarian Hyperstimulation Syndrome Complicated by Respiratory and Kidney Failure.

Ovarian hyperstimulation syndrome (OHSS) was first described in 1960. It may occur as a complication of gonadotropin hormone therapy during assisted pregnancy or for primary infertility. A 26-year-old female patient with polycystic ovarian syndrome and primary infertility was treated to conceive. She received intravenous gonadotropin-releasing hormone (GnRH) along with follicle-stimulating hormone in an outside private clinic. She presented to the emergency department with abdominal and chest pain, loose stool, vomiting, shortness of breath and decreasing urine output. She was found to have edema, ascites, effusion and acute kidney injury (AKI). Considering the symptoms preceding the drug history and anasarca, a diagnosis of severe OHSS was made. Ascites was further complicated by spontaneous bacterial peritonitis (SBP), which had already been reported before. We speculate that low immunity due to decreased immunoglobulin in patients with OHSS makes them prone to SBP. In our case, septicemia secondary to SBP and fluid loss due to capillary leakage from OHSS resulted in AKI and respiratory failure. This critically ill patient was treated in a special care unit, and she fully recovered with supportive measures. Severe OHSS may present as anasarca including ascites which can develop SBP leading to sepsis and multiorgan failure.

Recurrent Brachiocephalic Vein Stenosis as a Cause for Persistent Left-sided Transudative Pleural Effusion in a Hemodialysis Patient.

BACKGROUND: Effusion is common in dialysis patients. The most common causes include fluid overload due to renal failure and nonrenal causes like congestive heart failure and infection. We here report a case of left side transudative effusion due to brachiocephalic venous stenosis. METHODS: A 34-year-old female who had chronic kidney disease V during transplant work-up was found to be having left arm swelling and left transudative effusion. Work-up for transudative effusion did not show any cardiac cause or liver problem. Her dialysis duration was optimized from 2 times a week to 3 times a week for 4 hr and her dry weight was adjusted. Despite adequate dialysis for 1 month, effusion on the left side persisted. She had a previous venoplasty for a stenosis in brachiocephalic vein but restenosis occurred again. RESULTS: Brachiocephalic vein stenting was performed which successfully lead to resolution of left arm swelling and left effusion. She was later on successfully transplanted. CONCLUSIONS: Brachiocephalic stenosis can cause ipsilateral transudative effusion. Venoplasty and stenting of the brachiocephalic vein lead to complete resolution of effusion.

Acute kidney injury in lymphoma: a single centre experience.

Background. Acute kidney injury (AKI) is a common but least studied complication of lymphoma. Objective. To determine the frequency and predictors of AKI in lymphoma and to study the impact of AKI on hospital stay and mortality. Methods. Retrospective review of medical records of hospitalized lymphoma patients aged ≥14 years between January 2008 and December 2011 was done. Results. Out of 365 patients, AKI was present in 31.8% (116/365). Multivariate logistic regression analysis showed that independent predictors for AKI included sepsis (odds ratio (OR) 3.76; 95% CI 1.83-7.72), aminoglycosides (OR 4.75; 95% CI 1.15-19.52), diuretics (OR 2.96; 95% CI 1.31-6.69), tumor lysis syndrome (OR 3.85; 95% CI 1.54-9.59), and R-CVP regimen (OR 4.70; 95% CI 1.20-18.36). AKI stages 2 and 3 was associated with increased hospital stay (OR 2.01; 95% CI 1.19-3.40). Conclusion. AKI was significantly associated with sepsis, aminoglycoside, diuretics, presence of tumor lysis syndrome, and use of R-CVP regimen. Presence of AKIN (Acute Kidney Injury Network) stages 2 and 3 AKI had increased hospital stay. AKI was also associated with increased mortality.