Prevalence of BK virus among renal transplant recipients in a tertiary care hospital in Sri Lanka

Introduction: BK virus nephropathy (BKVN) is an important cause of graft failure in post renal transplant patients. Detection of BK virus replication early enables prevention of BK virus nephropathy. Understanding BK virus epidemiology in post renal transplant patients will be useful in implementing a routine screening programme. Objectives: Objectives were to determine the prevalence of BK virus viruria and viraemia among post renal transplant patients within the first two years of transplantation. Methodology: A hospital-based, descriptive cross-sectional study was conducted on 136 clinic and in-ward patients. Plasma and urine were tested for BK virus DNA using real time PCR. Serum creatinine done within two weeks of data collection was recorded. Results: The prevalence of BK virus viruria was 53.67% and viraemia was 11%. Viraemia >1000 copies/ml was associated with abnormal serum creatinine and higher median serum creatinine. No similar association was observed with viruria. Among patients with normal serum creatinine, virus was not detected in urine in 48.9% and plasma in 92.7%. Conclusion: The prevalence of BK virus is high in this study population. Significant viraemia was associated with elevated serum creatinine. Viruria or viraemia was not detected among a large number of patients with normal serum creatinine.

Crescentic glomerular nephritis associated with rheumatoid arthritis: a case report.

BACKGROUND: Rheumatoid arthritis is a systemic disorder where clinically significant renal involvement is relatively common. However, crescentic glomerular nephritis is a rarely described entity among the rheumatoid nephropathies. We report a case of a patient with rheumatoid arthritis presenting with antineutrophil cytoplasmic antibody-negative crescentic glomerular nephritis. CASE PRESENTATION: A 54-year-old Sri Lankan woman who had recently been diagnosed with rheumatoid arthritis was being treated with methotrexate 10 mg weekly and infrequent nonsteroidal anti-inflammatory drugs. She presented to our hospital with worsening generalized body swelling and oliguria of 1 month's duration. Her physical examination revealed that she had bilateral pitting leg edema and periorbital edema. She was not pale or icteric. She had evidence of mild synovitis of the small joints of the hand bilaterally with no deformities. No evidence of systemic vasculitis was seen. Her blood pressure was 170/100 mmHg, and her jugular venous pressure was elevated to 7 cm with an undisplaced cardiac apex. Her urine full report revealed 2+ proteinuria with active sediment (dysmorphic red blood cells [17%] and granular casts). Her 24-hour urinary protein excretion was 2 g. Her serum creatinine level was 388 µmol/L. Abdominal ultrasound revealed normal-sized kidneys with acute parenchymal changes and mild ascites. Her renal biopsy showed renal parenchyma containing 20 glomeruli showing diffuse proliferative glomerular nephritis, with 14 of 20 glomeruli showing cellular crescents, and the result of Congo red staining was negative. Her rheumatoid factor was positive with a high titer (120 IU/ml), but results for antinuclear antibody, double-stranded deoxyribonucleic acid, and antineutrophil cytoplasmic antibody (perinuclear and cytoplasmic) were negative. Antistreptolysin O titer <200 U/ml and cryoglobulins were not detected. The results of her hepatitis serology, retroviral screening, and malignancy screening were negative. Her erythrocyte sedimentation rate was 110 mm in the first hour, and her C-reactive protein level was 45 mg/dl. Her liver profile showed hypoalbuminemia of 28 g/dl. She was treated with immunomodulators and had a good recovery of her renal function. CONCLUSIONS: This case illustrates a rare presentation of antineutrophil cytoplasmic antibody-negative crescentic glomerular nephritis in a patient with rheumatoid arthritis, awareness of which would facilitate early appropriate investigations and treatment.

Serum cystatin C as a marker to identify patients with moderately impaired renal function.

The low molecular weight protein cystatin C produced by all nucleated cells and eliminated by glomerular filtration is of special benefit as a marker of renal function. A study was therefore undertaken to investigate whether serum cystatin C could be used as a marker to identify patients with moderately impaired renal function. A cross-sectional descriptive hospital based study was carried out and serum cystatin C was measured in fifty subjects aged 12 to 74 years with a 24 hr creatinine clearance estimation done at the same time. The gold standard creatinine clearance was used to compare the predicted glomerular filtration rate measured using serum cystatin C. Predicted glomerular filtration rate gave a sensitivity of 82% and specificity of 68% with a diagnostic cut-off value of 1.25mg/L cystatin C for identification of patients with moderately impaired renal function with a single random blood sample.

Epidemiology of chronic kidney disease in a Sri Lankan population.

CONTEXT: Chronic kidney disease (CKD) is characterized by progressive destruction of renal mass with irreversible sclerosis and loss of nephrons over a period of months to years, depending on the underlying etiology. AIM: To describe demographic patterns and identify common causes of CKD in patients admitted to ward 41 and 48B, National Hospital of Sri Lanka. SETTINGS AND DESIGN: A hospital based descriptive 3-month study was conducted at ward 41 and 48B, National Hospital of Sri Lanka. A case record form was used to record sociodemographic variables, stage of renal disease, and etiology of patients in established chronic renal failure. Sources of data included patient interviews, diagnosis cards and case records, ultrasound scan reports, and biopsy findings. RESULTS: One hundred and twenty-one patients were recruited with male to female ratio being 2.5:1 (86:35). Mean age of the population was 47.8 years (SD +/- 13.7). Common causes of CKD identified in these patients included diabetic nephropathy (37, 30.6%), hypertension (16, 13.2%), glomerulonephritis (12, 9.9%), and obstructive uropathy (10, 8.3%). The cause was unknown in 25.6% of patients with chronic renal disease. Fifty percent of patients were from the Western Province. The leading cause of CKD in patients from the Western Province was diabetic nephropathy (26, 37.7%). The etiology of CKD was unknown in majority of the patients (14, 27.4%) from other provinces. The difference in incidence of diabetic nephropathy in the Western Province as to other provinces was not statistically significant (P > 0.05). CONCLUSION: Diabetes is a major contributor to CKD reflecting changing disease epidemiology in Sri Lanka.

Patient mixed biphasic insulin in a diabetic clinic.

INTRODUCTION: Improved glycaemic control is possible with the use of multiple injections of premixed insulin. These are expensive, and not available in state hospitals. OBJECTIVES: To study the cost, patient acceptance and efficacy of a patient mixed and administered combination of soluble and lente (biphasic) insulin administered twice a day. PATIENTS: A cohort of 25 patients with poor glycaemic control on a single dose of 100 units or more of lente insulin. 25 patients matched for age and glycaemic control were used as a control. SETTING: The diabetic clinic of the National Hospital Sri Lanka. METHOD: A prospective study of a cohort of patients. RESULTS: Mean fasting blood glucose decreased from 8.3 mmol/l (SD 3.1) to 6.9 mmol/l (SD 2.3, p < 0.01) and mean blood glucose levels declined from 12.3 mmol/l (SD 4.1) to 10.1 mmol/l (SD 4.7, p < 0.01) in the biphasic group. Total mean insulin dose fell from 80 units (SD 12) to 61 units (SD 11) in the biphasic group, but increased in the control group from 82 units (SD 16) to 91 units (SD 13.1). The diabetes well-being score in the biphasic group was 91.5 (SD 35.3), while the control group had a score of 63.7 (SD 21.3 p < 0.01). Mean glycosylated haemoglobin (HbA1c %) was 8.1 (SD 2.7) in the biphasic group compared to 9.2 (SD 3.3) in the control group. CONCLUSION: Patient mixed and administered biphasic insulin on a twice daily basis is feasible, acceptable to patients, results in better glycaemic control and affords better patient satisfaction.