Acute renal failure secondary to tuberculosis: a diagnostic challenge.

Tuberculosis is a multiorgan disease with varied clinical presentations and is reemerging due to increasing immigration and globalization. We present the case of an immigrant female patient who developed acute renal failure with clinical and biochemical features suggestive of lupus nephritis but with a timely renal biopsy showing caseating granulomata in the renal parenchyma consistent with renal tuberculosis. Despite treatment with antituberculosis treatment and resolution of TB on repeat renal biopsy, she remained haemodialysis dependent. We discuss the diagnostic challenges faced in this presentation and also explore possible differential diagnoses. This rare presentation highlights the importance of renal biopsy in the diagnosis and treatment of acute renal failure and the atypical presentation of tuberculosis.

Disseminated lymphoma presenting as acute thigh pain and renal failure.

A 66-year-old diabetic man presented with severe right thigh swelling and pain together with acute renal failure. At autopsy, this was found to be due to disseminated high grade B cell lymphoma invading the psoas muscle and multiple organs, including the kidneys. The unique presentation of this case emphasizes the need for increased awareness of the variety of ways in which lymphoma can manifest itself.

Effect of cytomegalovirus prophylaxis with acyclovir on renal transplant survival.

It is recognized that cytomegalovirus (CMV) infection in transplant recipients may lead to graft loss. Prophylaxis with acyclovir has therefore gained widespread acceptance, but the debate on whether this intervention improves long term graft survival continues. All patients who received renal grafts at the National Renal Transplant Centre, Dublin, between January 1992 and December 1999 were retrospectively analyzed. During this time period, patients who were CMV positive and/or had received grafts from CMV-positive donors were administered prophylactic oral acyclovir 800 mg thrice daily, adjusted for calculated creatinine clearance, from the first day post-transplantation. This treatment was continued for three months unless the graft failed or the patient developed CMV disease or died. Graft and patient outcomes were compared in recipients who received acyclovir with those who did not. Over the study period, 935 patients received renal transplants in our center, of whom 487 were administered acyclovir. The incidence of CMV disease was 3.3 cases per 100 patients per annum in those who required prophylaxis. Despite prophylaxis, graft outcomes were found to be significantly worse (p value < 0.001) in the group that qualified for acyclovir. We conclude that acyclovir provides incomplete protection from the negative impact of CMV on graft survival.

Reduced graft function (with or without dialysis) vs immediate graft function--a comparison of long-term renal allograft survival.

BACKGROUND: Delayed graft function (DGF) is a common complication in cadaveric kidney transplants affecting graft outcome. However, the incidence of DGF differs widely between centres as its definition is very variable. The purpose of this study was to define a parameter for DGF and immediate graft function (IGF) and to compare the graft outcome between these groups at our centre. METHODS: The renal allograft function of 972 first cadaveric transplants performed between 1990 and 2001 in the Republic of Ireland was examined. The DGF and IGF were defined by a creatinine reduction ratio (CRR) between time 0 of transplantation and day 7 post-transplantation of <70 and >70%, respectively. Recipients with reduced graft function (DGF) not requiring dialysis were defined as slow graft function (SGF) patients. The serum creatinine at 3 months, 6 months, 1, 2 and 5 years after transplantation was compared between these groups of recipients. The graft survival rates at 1, 3 and 5 years and the graft half-life for DGF, SGF and IGF recipients were also assessed. RESULTS: Of the 972 renal transplant recipients, DGF was seen in 102 (10.5%) patients, SGF in 202 (20.8%) recipients and IGF in 668 (68.7%) patients. Serum creatinine levels were significantly different between the three groups at 3 and 6 months, 1, 2 and 5 years. Graft survival at 5 years for the DGF patients was 48.5%, 60.5% for SGF recipients and 75% for IGF patients with graft half-life of 4.9, 8.7 and 10.5 years, respectively. CONCLUSION: This study has shown that the CRR at day 7 correlates with renal function up to 5 years post-transplantation and with long-term graft survival. We have also demonstrated that amongst patients with reduced graft function after transplantation, two groups with significantly different outcomes exist.

Favorable graft survival in renal transplant recipients with polycystic kidney disease.

Graft survival in the autosomal dominant polycystic kidney disease (ADPKD) transplant population at our center was compared to other end stage renal disease (ESRD) transplant recipients (excluding diabetics). There were 1512 adult cadaveric renal transplants carried out at our center between 1989 and 2002. After exclusions, 1372 renal grafts were included in the study. Using Kaplan-Meier methods, patient and graft survival were determined and compared between the two groups. Mean age at transplant was significantly older for the ADPKD group of patients. The age adjusted graft survival at 5 years was 79% for ADPKD patients compared to 68% in the controls. Patient survival for ADPKD patients improved from 89% at 5 years to 95% when age adjusted. Using the Cox proportional hazards models to compare ADPKD with other causes of ESRD (including recipient age and other variables) in a multifactorial model, ADPKD was significant at the 5% level (p=0.036). This study demonstrates a graft and patient survival advantage in ADPKD patients when age-matched compared to other ESRD patients.

A longitudinal study of the yield and clinical utility of a specifically designed secondary hypertension investigation protocol.

OBJECTIVE: It has become common practice to use a day-case based approach to identify from the population of hypertensive patients those with an identifiable cause. We aimed to prospectively identify 96 consecutive hypertensive patients undergoing an algorithmic investigation protocol based around two day case hospital attendances. METHODS: The overall diagnostic yield and associated costs were recorded and the patients were observed for a mean of 2.5 years with ambulatory blood pressure (BP) monitoring every three months. RESULTS: A secondary cause of hypertension was identified in 18.1% of patients, three quarters of whom had renovascular disease. There was a fall in blood pressure with time (157/97 vs. 140/85) but this was associated with an increase in the amount of medication required (mean medication score 5.99 vs. 7.65). Improvement in BP occurred irrespective of whether or not a secondary cause was identified. Only 3.2% of patients were cured of their hypertension as a result of enrollment in the protocol. The cost of identifying each case of secondary hypertension was Euro 10, 196. CONCLUSIONS: A comprehensive protocol aimed at identifying secondary hypertension had a low yield, the majority of whom had renovascular disease. In light of recent data illustrating the lack of improvement in BP following dilatation or bypass of atherosclerotic renovascular disease, it is debatable whether searching for it is justifiable.

Pathogenesis of acute renal failure associated with the HELLP syndrome: a case report and review of the literature.

Acute renal failure is a rare but serious complication of pregnancy. We describe a 31-year-old woman with haemolytic anemia, elevated liver enzymes, low platelets (HELLP syndrome) who developed acute peripartum renal failure. Renal biopsy performed 2 weeks later because of persistent oliguria revealed thrombotic microangiopathy and acute tubular necrosis. This case highlights the probable pathogenesis of acute renal failure in HELLP patients and explains why it resolves in the majority of cases. A review of the literature that describes renal histology in HELLP patients is presented.

Cutaneous squamous carcinoma leading to acute abdomen after renal transplantation.

Skin carcinoma is the commonest malignant complication of renal transplantation. We report the first case of a renal transplant recipient who presented with ileal obstruction as a consequence of squamous cell carcinoma metastases to the small intestine. This complication highlights the unusual presentation of malignancies associated with prolonged exposure to immunosuppression and the need for extra vigilance in such cases.

A longitudinal study of the repeated use of alteplase as therapy for tunneled hemodialysis catheter dysfunction.

When hemodialysis catheters allow only poor or no blood flow, it has become established practice in many centers to instill a thrombolytic agent in an attempt to clear the catheter. The catheter survival advantage gained by repeated use of such treatment is not known. In a prospective study, we analyzed all uses of alteplase in the setting of inadequate catheter blood flow in a cohort of 570 catheters over a 2(1/2)-year period. The time from alteplase instillation to the next episode in which it was required or catheter removal for nonfunction or thrombosis was recorded. Survival analysis was used to estimate the additional catheter survival afforded by each treatment. After censoring for elective catheter removal, the overall catheter half-life was 10.2 months. Catheter malfunction or thrombosis was the most common indication for catheter removal (36.3% of all catheters removed). Alteplase instillation was necessary in 2.77% of dialysis sessions. The median time from the first to second treatment or catheter removal for nonfunction or thrombosis was 27 days (95% confidence interval, 15.7 to 32.3). Additional median survival advantage gained from each subsequent treatment ranged from 10 to 18 days. Treatment of recurrent catheter malfunction with alteplase allows for a median of only five to seven additional dialysis sessions before the treatment must be repeated or the catheter must be exchanged. Although associated with minimal disruption to the dialysis schedule, the ultimate clinical benefit and cost-effectiveness of such treatment is doubtful.