Fluid therapy in pediatric victims of the 2003 bam, Iran earthquake.

INTRODUCTION: On 26 December 2003, at 05:26 hours, an earthquake of magnitude 6.6 (Richter scale) caused a disaster in the Bam region of Southeastern Iran, which had a population of approximately 102,000. In this study, the clinical and laboratory features and therapeutic interventions in pediatric (three months to 14 years) crush victims were analyzed. Determination of the type and amount of fluid therapy for prevention of acute renal failure (ARF) was the main aim of this study. METHODS: The clinical and laboratory data and therapeutic interventions provided to 31 pediatric crush victims were collected. Early and vigorous fluid resuscitation was immediately performed. Resuscitation of the children from hypovolemic shock was initiated by interavenous (IV) administration of normal saline until the signs and symptoms of shock disappeared. For victims with crush injuries, an alkaline intravenous solution, up to 3 to 5 times more than maintenance doses was provided. In this study, there were two groups with decreasing severity of injury: (1) crush injury (CI), with or without ARF; and (2) non-crush injury (Non-CI). According to the above mentioned classification, there were 15 and 16 patients in group I and II, respectively. RESULTS: The mean time spent under the rubble was 2.2 +/-2.5 hours and 0.5 +/-0.5 hours in Groups I and II, respectively. Seventy-five percent of ARF patients (n = 8), were admitted to the hospital the day of the earthquake (Day 0) and the day after earthquake (Day 1). In non-ARF patients (n = 7), 85.7% of the victims were admitted on Day 0 and Day 1. In Group II (ARF and non-ARF), all patients were admitted within three days after the earthquake. Although ARF did not develop in any of the children without CI, it was observed in eight of 15 patients with CI. There was no significant difference between CI with ARF (n = 8) and CI without ARF (n = 7) patients, in terms of the admission date, time of admission, hospitalization duration, and time under the rubble (TUR). Admission SGOTs were significantly different between these two groups. The ratio of the amount of delivered IV fluid (DL) to expected (EX) was based on weight of children was the only fluid therapy parameter in which there was a statistically significant difference between ARF and non-ARF groups. It was 3.6 +/-0.99 in ARF and 4.8 +/-0.74 in Non-ARF group (p = 0.01). CONCLUSIONS: Early intravenous volume replacement may prevent both ARF and dialysis need that may develop on the basis of rhabdomyolysis. In adults, six liters or 12-14 liters of fluids for prophylaxis of ARF in crush syndrome, were suggested. In children, it seems that DL/EX ratio (delivered to expected ratio) is the best marker for evolution of IV fluid therapy in pediatric patients. In children with crush injuries, DL/EX ratio of >4.8 was sufficient for the prevention of ARF.

Impact of hepatitis B and hepatitis C virus infections on patients and allograft outcomes in renal transplant recipients: a single center study.

BACKGROUND: Hepatitis C virus (HCV) and hepatitis B virus (HBV) infections occur frequently among end-stage renal disease (ESRD) patients. We analyzed our data to address concern that these patients are at increased risk for mortality or allograft dysfunction after renal transplantation compared with noninfected patients. PATIENTS AND METHODS: We retrospectively compared outcomes and survivals among 1350 patients who received renal allografts from 1990 to 2006. RESULTS: Fourteen patients were positive for both hepatitis B surface antigen (HBsAg) and HCV antibody (anti-HCV; group 1); 23 were HBsAg-positive and anti-HCV-negative (group 2); 29 were HBsAg-negative and anti-HCV-positive (group 3); and 1284 were negative for both markers (group 4). With respect to mean serum creatinine, there were significant differences between groups 1 and 4 (P < .01), and groups 2 and 4 (P < .01), but no significant difference between groups 3 and 4. With respect to graft survival, there were significant differences between groups 1 and 4 (P < .01), and between groups 2 and 4 (P < .01). There was no significant difference for survival among groups. CONCLUSIONS: HBV or HCV infections are not a contraindication to kidney transplantation in Iranian patients; they had no effect on patient survival. However, allograft outcomes were worse among HBV- or HCV-infected patients.

Pregnancy after renal transplantation: ten-year single-center experience.

There has been an increase in the number of pregnancies among renal transplant recipients. Our experience included 61 pregnancies in 53 patients from January 1997 to April 2007, with 6 patients having multiple pregnancies. Patients were studied for clinical, obstetrical, and perinatal outcomes. The mean patient age was 24.5 years (range, 19-38). They all received living donor kidneys. The mean transplantation-pregnancy interval was 2.7 years (range, 1.7-5.3 years). Immunosuppressive drugs consisted of cyclosporine (CsA), mycophenolate mofetil (MMF), and prednisolone (pred) in 38 patients (72%); CsA, azathioprine (AZA), plus pred were used in 15 patients (28%). Pregnancy complications were chronic hypertension in 21 patients (40%), anemia in 28 (52.6%), and urinary tract infection in 18 (34%). Twelve patients (22.6%) received blood transfusions. Pre-eclampsia was diagnosed in 14 cases (26.4%) and renal dysfunction in 11 (20.7%) with pre-eclampsia assumed to be the main cause. Three patients (5.6%) had graft losses as a result of hemorrhagic shock, sepsis, and eclampsia. Premature rupture of membranes occurred in 6 cases (11.3%), and preterm delivery occurred in 14 cases (26.4%). Eleven (20.7%) newborns were small for gestational age. One club foot and one large facial hemangioma occurred in 2 infants, respectively. One case of neonatal death was registered as a result of excessive prematurity. One mother died due to sepsis. Cesarean section was performed in 24 patients (45.2%), the main indications being related to hypertension and fetal distress. There were no significant differences between MMF-treated and AZA-treated patients with respect to clinical, obstetrical, and perinatal outcomes. This group of patients was characterized by a wide range of antenatal and perinatal problems that must be managed in specialized tertiary units to achieve the best results. MMF may be as safe as AZA in pregnancy.

Antineutrophil cytoplasmic antibody-associated glomerulonephritis in chronic graft-versus-host disease after allogenic hematopoietic stem cell transplantation.

Graft-versus-host disease (GVHD) is one of the most frequent complications that occur after hematopoietic stem cell transplantation (HSCT). Recently, renal involvement, including membranous nephropathy, focal segmental glomerulosclerosis, and minimal change disease, has been described as a manifestation of chronic GVHD. This case report describes a patient who developed antineutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis after HSCT. Following preparation with chemotherapy, a 29-year-old man with chronic myeloid leukemia underwent allogenic peripheral blood stem cell (PBSC) transplantation, after which first acute and then chronic GVHD developed. Treatment with prednisone resulted in improvement in the patient's GVHD. After the termination of steroid therapy and about 10 months after PBSC transplantation, nephritic syndrome appeared and the patient's serum creatinine value increased to 1.7 mg/dL. Laboratory evaluation revealed perinuclear antineutrophilic cytoplasmic antibody (p-ANCA) in the serum. Histological examination of renal biopsy tissue showed focal segmental proliferative glomerulonephritis with glomerulosclerosis in 20% of available glomeruli, large cellular crescents in 6% of glomeruli, and no staining of immunoglobulins or complement along the capillary walls. Electron microscopy revealed no immune deposits. After treatment with prednisone 60 mg/d, diltiazem 120 mg/d, and enalapril 10 mg/d, the proteinuria gradually decreased, and p-ANCA was undetectable. These findings suggest that in this patient the ANCA-associated glomerulonephritis was associated with renal involvement that occurred during the course of chronic GVHD.