Modulation of ouabain sensitive sodium potassium pump of erythrocytes from patients with chronic renal failure: role of acute hemodialysis.

Significantly higher levels of plasma urea creatinine and potassium were observed in patients with renal failure compared to normal controls. The RBC sodium concentration was raised whereas the RBC potassium concentration was decreased in chronic renal failure. These alterations in the RBC Na+ and K+ concentrations were associated with decrease in ouabain sensitive sodium efflux rate and ouabain sensitive sodium efflux rate constant. However, there was no significant impact of acute hemodialysis on the intracellular electrolytes levels, ouabain sensitive sodium efflux rate and ouabain sensitive sodium efflux rate constant. These findings suggest an intrinsic alteration in the transport capacity of Na(+)-K+ pump which could account for the rise in intracellular sodium and fall in intracellular potassium content in the RBCs of chronic renal failure patients.

The high incidence of tuberculosis among renal transplant recipients in India.

Tuberculosis is an important infection encountered after renal transplantation in third-world countries. Over an 8-year period, 36 cases of tuberculosis were encountered in 305 renal transplant recipients (11.8%) with grafts functioning for more than 3 months followed up at our center. The infection was limited to the thoracic cavity in 41.7% and a single extrapulmonary site in 11.1%, and it was disseminated in 27.8% cases. In 19.4% of cases, the disease appeared as pyrexia of unknown etiology and the diagnosis was confirmed by a good therapeutic response to antitubercular therapy. Tuberculosis was diagnosed within 1 year of transplantation in 58.3% of cases. There was no significant difference in the incidence of tuberculosis in patients on different immunosuppressive regimens. The Mantoux test was positive in 33.3% patients. A total of 23 patients were treated with isoniazid and rifampicin, with the addition of a third drug for the first 2 months. Treatment was continued for 9 months in 11 cases with isolated pleuropulmonary disease and for 12-15 months in the other 12 patients. The other 13 were on cyclosporine and were given isoniazid, pyrazinamide, and ethambutol for 18 months. Two patients died of fulminant disease and five more died from unrelated causes. No recurrence of disease has been noted in any of the patients after a mean follow-up of 14.6 months. We conclude that the incidence of tuberculosis in renal allograft recipients in third world countries is much higher than that seen in the western world. Most of the cases are encountered in the first posttransplant year. Tuberculosis must be considered seriously in all patients who have prolonged fever of undetermined etiology. Treatment with isoniazid and rifampicin for 9 months is adequate for patients with localized pleuropulmonary disease. In patients on cyclosporine to whom rifampicin cannot be given because of economic considerations, treatment with isoniazid, pyrazinamide, and ethambutol should be given for 18 months.

SILENT MYOCARDIAL ISCHEMIA IN HEMODIALYSIS PATIENTS - FACTOR FICTION?

Thirty eight patients underwent Holter ECG monitoring for a 48 hour period covering dialysis and intermediate period to detect incidence of myocardial ischemia manifesting as ST segment changes. Seventeen patients (44.7%) had 165 episodes of dynamic ST segment changes lasting from 1 to 177 minutes, with maximum ST depression of 4 mm. The mean age of patients was 45 ± 14 years and 14 (82.6%) of them were males. Ten (58.8%) patients had hypertension, and 5 (29.4%) patients each had diabetes mellitus and pre-existing coronary artery disease. Six (35.3%) patients with dynamic ST segment changes had ventricular ectopics ranging from isolated ventricular premature contractions to episodes of ventricular tachycardia. No significant hypotension or angina was documented during these episodes of ST segment deviation. We concluded that hemodialysis plays an important role in the genesis of the above ECG changes.

Role of reactive oxygen species in renal damage in experimental leprosy.

Renal involvement is known to occur in leprosy. In the present study the possible role of reactive oxygen species (ROS) in causation of renal damage in mice infected with Mycobacterium leprae has been investigated. At least six animals from each group (control and infected) were killed at 0 day, 3, 6 and 9 months postinfection. The results showed a significant increase in the chemiluminescence (CL) response of peritoneal macrophages which was maximum between 3 and 6 months. No significant increase was observed in CL response of blood neutrophils. A significant increase in lipid peroxidation was observed at 3 and 6 months as evident by an increase in malondialdehyde levels. The increased ROS production might be the cause of lipid peroxidation. The renal damage is alos evident by decrease in the activity of renal brush border membrane enzymes, namely, alkaline phosphatase, leucine aminopeptidase and r-glutamyl transpeptidase. Thus ROS might play a role during early stages of M. leprae infection but in the later stages other immunological mechanisms may overpower the effect of ROS.

Differences in the care of ESRD patients worldwide: required resources and future outlook.

RRT has crossed the threshold of clinical applications, and its value as an effective modality for management of ESRD is fully established. However, RRT has emphasized the wide gap between developed and developing countries. Most of the developed nations are able to provide sufficient funds, directly or indirectly, for RRT and have organized cadaver donor networks. However, providing RRT is particulary difficult in the developing countries where national incomes are not sufficient to cover even the basic requirements of their citizens. Although some developing countries are making active efforts to establish cadaver donor transplant programs, these are virtually nonexistent in the majority at this time. The abject poverty in the developing world and the increasing success rate of transplantation following the discovery of cyclosporine have led to the commercialization and sale of kidneys for transplantation, an unethical practice which must be curbed. There is a near unanimity of opinion that renal transplantation is far cheaper than prolonged dialysis, and the benefit to the recipient is enormous in terms of the years of life saved and the quality of life. Until such time as cadaveric donor programs become a reality in the developing countries, short periods of dialysis followed by transplants with living-related donor kidneys appear to be the most cost-effective treatments of ESRD.

Gastrointestinal complications after renal transplantation. 10 Year data from a North Indian Transplant Center.

Gastrointestinal complications are responsible for substantial morbidity and mortality among renal allograft recipients in developing countries. During a 10 year period, 166 (62.6%) of 265 allograft recipients developed gastrointestinal complications. This figure reflects the high incidence of infectious complications, especially acute diarrheas. Also notable was the incidence of esophageal candidiasis (7.2%), ischemic colitis (2.6%), and gastrointestinal and peritoneal tuberculosis (3.0%). Almost one quarter of the complications developed in the first 6 months after transplantation. Mortality was the highest with acute ischemic colitis (100%), pancreatitis (60%), and upper gastrointestinal hemorrhage (40%). Improvements in standards of living and sanitary conditions, pre transplant evaluation and assessment of risk factors, prophylaxis with anti ulcer drugs, early diagnosis, and appropriate treatment are needed to decrease the frequency and severity of gastrointestinal complications in renal allograft recipients.

Primary IgA nephropathy: a preliminary report.

A total of 106 renal biopsies were examined. Each biopsy was processed for routine paraffin sectioning and frozen sectioning. Direct immunofluorescence was done by the conventional method. The immunofluorescence patterns were correlated with histopathological changes and clinical presentation. Fourteen biopsies revealed weak to strong IgA staining and out of these, 11 seemed to fulfil the criteria of primary IgA nephropathy. These cases were diagnosed in a brief period of eleven months and there had not been any earlier published series from India.

Evaluation of three serological tests for detection of anti-candidal antibodies in diagnosis of invasive candidiasis.

Immunoblot detection of antibody against 47 KD cytoplasmic antigen of Candida albicans was evaluated in diagnosis of invasive candidiasis and compared to whole cell agglutination and gel diffusion tests for detection of anticandidal antibody in 64 patients. The patients included 17 with culture proved candidemia, 34 with significant candiduria (more than 10,000 colony forming units per ml of urine) and 13 with nonsignificant candiduria. Antibody against 47 KD antigen was found to be the best indicator for diagnosis of invasive candidiasis even in patients with malignancy. The sensitivity of this procedure was 82.4%, specificity 86.7%, positive predictive value 77.8%, negative predictive value 89.7% and efficacy 85.1%. The gel diffusion procedure lacked in sensitivity whereas whole cell agglutination lacked in specificity. Detection of antibody against 47 KD antigen proved to be a valuable adjunct in the diagnosis of invasive candidiasis.

Hyponatremia in sick children seeking pediatric emergency care.

This prospective study evaluated the frequency, clinical characteristics and causes of hyponatremia (serum sodium < 130 mEq/L) in 727 children upto 12 years of age, who were brought for emergency care, and needed hospitalization. Hyponatremia was found in 29.8% and was more frequent in summer (36%; 123/341) than in winter (24%; 94/386) (p < 0.001). Acute lower respiratory infections (pneumonia) and acute diarrhea each accounted for 20% cases of hyponatremia; others were accounted for by meningitis/encephalitis (12%) septicemia (8%), and renal, heart and liver diseases (6-7% each). Clinical evaluation and concurrent plasma and urinary osmolality and urine sodium suggested that hyponatremia associated with pneumonia, meningitis/encephalitis, septicemia, seizures and miscellaneous diseases was of hypotonic-euvolemic (dilutional) type in more than 80% patients while in all children with acute diarrhea it was of hypovolemic type. The study has shown that hyponatremia occurs frequently in sick children requiring emergency care, especially in summer months, and should receive appropriate attention in the management plan.

Hyponatremia in sick children: a marker of serious illness.

To study the association between hyponatremia (serum sodium < or = 130 mEq/L) and the final outcome of the illness, we correlated serum sodium concentration at the time of hospitalization with the length of hospital stay and mortality in a prospective study of 727 sick children aged upto 12 years, who sought emergency care. The mean +/- SE duration of hospital stay (7.7 +/- 0.4 days) among 217 children with serum sodium < or = 130 mEq/L was about 30% longer than that of 510 children with serum sodium > or = 131 mEq/L (5.9 +/- 0.3 days) (p < 0.01). This remained unaffected by the sex and the age group, but was further prolonged in children with hypotonic--euvolemic type of hyponatremia as compared to those with hypovolemic hyponatremia. The mortality rate in 510 children with normal serum sodium concentration (> or = 131 mEq/L) was 5.3%. In contrast, it was 17% in 47 children with serum sodium < 125 mEq/L (Relative Risk 3.2; 95% Confidence Interval 1.6-6.7) and 9.3% in 170 children with serum sodium between 126-130 mEq/L (Relative Risk--1.8; 95% Confidence Interval 1.1-3.7) (p < 0.01). Hyponatremia in acutely ill children at admission indicates a poor prognosis.