Glomerulonephritis with crescents among adult Saudi patients outcome and its predictors.

The aim of this study is to investigate the clinical and pathological features and outcome of glomerulonephritis with crescents among adult patients. This is a retrospective study of all cases of crescentic GN seen over a 9-year period (2001-2010). Histological features were assessed, and renal function at baseline and end of follow-up period was recorded. Results among different etiological groups at baseline and end of follow-up period were compared. The mean age in the whole group was 35.6 years (16.2), with the lowest mean in the lupus nephritis (LN) group [27.7 years (9.9)] and the highest in the pauciimmune glomerulonephritis (PIGN) group (P = 0.001). There were 72 cases enrolled in the study. LN accounted for 49.3% of the cases, PIGN for 26.5%, other immune complex glomerulonephritis (ICGN) for 19% and post-infectious GN accounted for 6.3% The majority (85.7%) of the patients had renal impairment at presentation (mean serum creatinine levels were 247 (85) µmol/l, 412 (75) µmol/l and 230 (141) µmol/l in LN, PICN and ICGN, respectively (P = 0.05). Women accounted for 85.3, 76.5 and 36.2% of the patients in LN, PICN and ICGN, respectively (P = 0.025). By the end of the follow-up period of 26 (22.9) months, 25.8% of the patients were requiring dialysis (16.70% in the LN group, 50% in PIGN and 25% in ICGN (P = 0.05) and 21.7% had nephrotic range proteinuria (16.7, 1 and 33.3%, respectively (P = 0.4). Using logistic multivariate analysis, the only independent factors found to predict need for dialysis of prognosis were percent of sclerosed glomeruli (P = 0.05) and presence of ATN (P = 0.028). Baseline proteinuria or SCr, gender and number of glomeruli with crescents, on the other hand, did not impact prognosis. Using linear regression multivariate analysis, SCr, protein excretion and activity score at biopsy did not influence change in SCr or final SCr during the follow-up period. Using ANOVA to compare the groups of LN, PIGN and ICGN), we found significant differences only in gender between LN and ICGN (P = 0.035), in percent glomerular global sclerosis (between LN and PIGN (P = 0.007) and between LN and ICGN (P = 0.012) and in age (between LN and PIGN (P = 0.006). Almost half of our patients with CrGN were due to LN which is higher than that reported by others where PIGN was the more prevalent etiology. Patients with PICN were older and had worse prognosis. This could be explained by the higher number of globally sclerosed glomeruli in the PIGN group.

Predictors of mortality and end stage renal disease in Saudi patients with lupus nephritis.

The purpose of this study was to investigate the presentation and factors affecting outcome over a 9-year period in 99 consecutive Saudi patients with biopsy proven lupus nephritis (LN), 35.5% of whom had nephrotic range proteinuria, 46.8% had estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2) and 65.5% had histological class IV. The female:male ratio was 3.7:1. During the observation period, there were significant rises in eGFR (p = 0.005), C4 (p = 0.000) and significant decrease in 24-h urine protein (p = 0.028). No correlation was found between final eGFR and baseline 24-h protein, anti-DNA, C3 or C4. Female patients had a significantly higher rise in eGFR (p = 0.05).During follow-up (FU), 28.2% required dialysis. The survival rates at 5, 10 and 15 years were 92%, 77% and 77% respectively. Baseline C3 and C4 levels were significantly lower in the patients who died (p = 0.0001 and 0.02 respectively). Those who required dialysis were more likely to die (p < 0.000) (risk ratio = 4.46; 95% confidence interval 2.8-7.2). Hypertension at presentation was associated with lower baseline eGFR (p = 0.01) and final eGFR (p = 0.002) but did not affect the baseline proteinuria. Baseline eGFR of <60 ml/min/1.73 m(2) at presentation was associated with lower eGFR at end of FU (p = 0.000), higher activity score (p = 0.0001) and chronicity scores (p = 0.017).

Can renal scan findings predict biopsy-proven allograft rejection?

OBJECTIVES: To assess the usefulness of isotopic renogram in diagnosing acute renal graft rejection. MATERIALS AND METHODS: Degree of perfusion and allograft uptake of tracer were correlated with the clinical and biopsy diagnoses in 15 postrenal transplant patients with varying degrees of renal impairment. Renographic findings and perfusion calculations were done by a blinded observer. RESULTS: A strong correlation was found between renal histology and renal scan findings in 13 of 15 patients. Sensitivity and specificity of renal scanning in diagnosing acute rejection were 85% and 50% respectively (using renal biopsy findings as the gold standard). CONCLUSION: Our results demonstrate a strong correlation between blinded perfusion assessment and biopsy-proven acute rejection. We conclude, therefore, that single renal flow scan with DTPA (noninvasive/nonnephrotoxic) allows a physician to tailor therapy for acute renal graft dysfunction. We suggest that in cases with a renographic diagnosis of AR, the patient should receive standard antirejection therapy. Renal biopsy should be reserved for those instances when the renographic findings are not definitive and those when the patient fails to respond to a standard methylprednisolone therapy.

Post Transplant Acute Tubular Necrosis - How Long you can Wait?: A Case Report.

Delayed graft function (DGF) is a common clinical problem occurring after cadaveric renal transplantation. Acute tubular necrosis (ATN) is one of the main causes of the DGF. Protracted recovery from ATN may continue for several weeks. We describe a case of prolonged oliguric ATN that lasted for more than three months with complete recovery of renal function. We discuss the contributing factors to the lengthy course of ATN and the known prophylactic and treatment strategies.

Serotyping of Mannheimia (Pasteurella) haemolytica isolates from the upper Midwest United States.

Mannheimia (Pasteurella) haemolytica biotype A serotype1 (A1) is the primary bacterial agent responsible for the clinical signs and pathophysiologic events in bovine pneumonic pasteurellosis. The goal of this study was to determine the prevalence of other serotypes of M. haemolytica biotype A organisms obtained from the upper Midwest diagnostic laboratories. A total of 147 M. haemolytica isolates were collected from Minnesota, South Dakota, and Michigan. Isolates were tested against M. haemolytica antisera obtained from the National Animal Disease Center, Ames, Iowa. Results indicated that M. haemolytica serotype 1 represented approximately 60%, serotype 6 represented 26%, and serotype 2 represented 7% of the total examined isolates. In addition, 7% of the isolates were serotype 9, 11, or untypable. This finding suggests that M. haemolytica serotypes other than serotype 1 can be isolated from the lung lesions of diseased cattle and seem to be capable of causing the pathologic changes observed in the lung with pneumonic pasteurellosis.

Use of repetitive sequence-based polymerase chain reaction for molecular epidemiologic analysis of Streptococcus equi subspecies equi.

OBJECTIVE: To determine whether repetitive sequence-based polymerase chain reaction (rep-PCR) could be used to differentiate Streptococcus equi isolates, to examine S equi isolates from throughout the world, and to determine whether a horse had > 1 subtype of S equi during an outbreak of disease. SAMPLE POPULATION: An initial group of 32 S equi isolates, 63 S equi isolates from various geographic areas, and 17 S equi isolates obtained during outbreaks of disease. PROCEDURE: An aliquot of S equi genomic DNA was amplified, using enterobacterial repetitive intergenic consensus primers. Gel electrophoresis was performed on 1.5% agarose gels, and a computed-assisted program was used to compare rep-PCR results. RESULTS: Use of these primers to analyze 100 ng of S equi genomic DNA resulted in patterns of 6 to 14 bands. The 32 initial isolates were separated into 7 rep-PCR subtypes. There were 30 rep-PCR subtypes found among 29 S equi isolates obtained from Minnesota, Michigan, Canada, and Australia and 34 S equi isolates obtained from Kentucky and other sources. Furthermore, the same clone was identified in several horses during an outbreak of disease. Infected horses on the same farm all had a single clone of S equi. CONCLUSION AND CLINICAL RELEVANCE: Analysis of these results suggests that rep-PCR is useful for delineating S equi into rep-PCR subtypes. Results revealed that isolates with the same geographic source or similar date of collection did not always have the same rep-PCR subtype. A single clone of S equi usually predominated during an outbreak of disease.

Interferon-alpha in chronic hepatitis C infection in dialysis patients.

This study assesses the efficacy and adverse effects of interferon-alpha (IFN-alpha) administered at a dosage of 3 million units three times weekly for 1 year in 17 hemodialysis patients with hepatitic C virus (HCV)-associated chronic hepatitis (biopsy proven). The patients were prospectively followed up for a period of 18 months. Liver biopsy was repeated after 6 months of treatment in 13 patients. Patients were classified according to the histological activity index. Biochemical and virological responses were evaluated at the end (end-of-treatment response) and 6 months after completion of therapy (sustained response). HCV RNA became negative in 76% of the patients after 12 weeks of treatment, in 88% after 12 months of treatment, and in 71% of the patients 6 months after completion of therapy. HCV genotype 4 was found in 60% of our population. Alanine aminotransferase (ALT) levels were initially increased in only 6 patients and normalized in 4 of these patients after 12 weeks of therapy, with end-of-treatment and sustained biochemical responses of 83% and 67%, respectively. Of 13 patients who underwent liver biopsies after 6 months of therapy, 11 patients (85%) showed histological improvement. One patient could not tolerate therapy because of marked lethargy and myalgia; the other patients had minor side effects that did not require discontinuation of treatment. Two patients received a cadaveric renal transplant after 1 year of IFN treatment, and they continued to maintain biochemical and virological responses after a follow-up of 17 and 28 months, respectively.

Maintenance intravenous iron therapy in hepmodialysis patients receiving recombinant human erythropoientin.

Iron Supplementation is crucial in raising hematocrit as well as dosage saving for recombinant human erythropoietin therapy (rHuEPO) in maintenance hemodialysis patients. Intravenous iron has proved to be both safe and efficacious in this patient's population. However, the exact iron requirement has not been worked our. In this study we found that 1000 mg of element iron (given as iron saccharate) per moth was effective in maintaining hematocrit and hemoglobin at 33% and 110 gm/L respectively, and reducing the erythropoietin (EPO) dosage by about 20% in maintenance hemodialysis patients who were iron-replete. The serum ferritin increased from 219+/-144 to 320+/-234 microg/L (P< 0.05). There were no major side effects and patients tolerated the monthly iron therapy well. Our study suggests that intravenous iron saccharate (100 mg/month) is effective and safe in patients on maintenance hemodialysis receiving RHUEPO.

Effect of intravenous alfacalcidol on lymphocyte phenotyping in hemodialysis patients.

Chronic renal failure is associated with decreased production of active vitamin D and also results in altered lymphocyte population. We studied the effect of alfacalcidol on lymphocyte phenotype. There were 15 patients (10 males, 5 females) with a mean age of 54.3+/-14.4 years who had been on chronic maintenance haemodialysis for a mean period of 3.2+/-1.5 years. Intravenous alfacalcidol was given three times weekly during dialysis for a duration of 6 months. Our results show a significant increase in NK cells from 0.20+/-0.12 to 0.27+/-0.28 (P=0.001), without a significant change in CD2, CD19, CD4, CD8 population, and CD4/CD8 ratio.

Neurological disorders in renal transplant recipients.

The charts of 175 renal transplant recipients were retrospectively reviewed. The mean duration of follow up since the transplantation was 4.17 +/- 1.66 years. Apart from cyclosporin induced tremor, which occurred almost in all patients, 22 patients (12.5%) had neurological disorders during their follow up (mean annual incidence of 3%). Eight patients had epileptic seizures, seven had strokes, four had neurological infections, two developed a pseudotumor cerebri syndrome, two neuropathies, one myopathy and one conus medullaris infarction. This study demonstrates that neurological disorders are not uncommon in renal transplant recipients and that their mechanisms are variable and may be related to the underlying diseases such as hypertension and diabetes; to the operation itself; to the side effects of immunosuppression agents or rarely, they can accompany graft rejection.