Clinical Queries: Nephrology最新文献

A highly sensitive single antigen bead assay (SAB) by luminex is a very useful tool for post-transplant monitoring of HLA antibodies for diagnosing antibody-mediated rejection ABMR. Donor-specific anti-HLA antibodies that arise de-novo (de-novo DSA) after transplantation, indicate the highest risk for acute antibody-mediated rejection (AMR) and graft loss. The return of pre-existing antibodies after transplantation or the development of new de-novo anti-HLA or non-HLA DSA may also confer an increased risk for graft loss. A case with de-novo donor-specific antibody (DSA) against HLA-DQ antigens resulting in acute antibody-mediated rejection (ABMR) in a renal transplant patient is presented along with review of literature.

Wilms tumour is the most common malignant renal tumour in childhood. Approximately 5–7% of Wilms tumour patients present with bilateral disease, either synchronously or metachronously. However, its association with hypospadias is seen in only 1.8% cases. Synchronous bilateral Wilms tumour poses the special challenge of establishing local tumour control while preserving renal function. We describe the case of synchronous bilateral Wilms tumour associated with hypospadias in a 1-year-old male child. A review of the aetiology, demographics, diagnosis and imaging, staging and treatment of Wilms tumour with emphasis on bilateral disease will be presented.

Renal biopsy is usually obtained to establish a diagnosis, help guide therapy, and ascertain the degree of active and chronic changes. The routine evaluation of a percutaneous renal biopsy involves examination of the tissue under light, immunofluorescence, and electron microscopy. The indications for performing a renal biopsy vary among concerned physicians, being determined in part by the clinical features, signs, and symptoms. Among patients with the nephrotic syndrome and no evidence of systemic disease, renal biopsy is performed both to determine treatment and to make an unidentified diagnosis. The acute nephritic syndrome is often caused by a systemic disease that requires a renal biopsy to establish the diagnosis and guide treatment. Even in the absence of a systemic disease, the acute nephritic syndrome commonly needs a biopsy to ascertain a diagnosis and guide treatment. Among patients with unexplained acute kidney injury, a biopsy is obtained in those settings, in which the diagnosis is uncertain. Among patients with isolated glomerular hematuria, a renal biopsy is not routinely performed, unless there is evidence of progressive disease such as increasing proteinuria or a rising serum creatinine concentration. A renal biopsy is also generally not obtained in patients, who presents with low-grade proteinuria (less than 500–1000 mg/day), the absence of glomerular hematuria, usually normal renal function, and an absence of clinical or serologic evidence of a systemic disease that can cause glomerulonephritis. Prior to a percutaneous renal biopsy, a history, physical examination, and selected laboratory tests should be performed. Recommended laboratory tests include complete blood count, platelet count, prothrombin time, partial thromboplastin time, and bleeding time. Percutaneous renal biopsy is usually performed under real time ultrasonic guidance in local anesthesia with spring-loaded needle. Bleeding is the primary complication of renal biopsy. Nonpercutaneous renal biopsies (open, laparoscopic, and transjugular renal biopsy) are indicated in settings, in which a percutaneous renal biopsy cannot be performed (uncorrectable bleeding diathesis, failed attempts at percutaneous biopsy).

The pharmacology of the sirolimus and their use in renal transplant recipients are discussed here. In majority of the transplant centers, sirolimus whole-blood concentrations are measured by enzyme-linked immunoassays and high-performance liquid chromatography (HPLC) with ultraviolet or mass spectrometry detection. HPLC measures the parent drug and is very accurate but time-consuming. The recommended time for collection is 1 h prior to the next oral dose. Because of metabolic interactions, sirolimus should be given 4 h after cyclosporine, whereas sirolimus and Tacrolimus can be given simultaneously. The target sirolimus levels should be 5–15 ng/mL depending on immunologic risk, time of conversion and other immunosuppressive drugs. Sirolimus trough concentrations >15 ng/mL have been correlated with side effects such as hypertriglyceridemia, thrombocytopenia, and leukopenia. The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines for the care of kidney transplant recipients suggest monitoring sirolimus levels (2C). KDIGO recommend that if sirolimus is used, they should not be started until graft function is established and surgical wounds are healed (1B). KDIGO recommend that the combined use of sirolimus and calcineurin inhibitor (CNI) should be avoided, because they potentiate nephrotoxicity, particularly if used in the early period following transplantation. Conversion from CNI to sirolimus is generally not recommended when proteinuria >800 mg/day, acute rejection during the 3 months before conversion, estimated GFR < 40 mL/min, acute Banff 2A at any time post-transplant and dyslipidemia despite lipid lowering agents.

This study aims to document the incidence of hyperphosphatemia in dialysis patients and correlate it with malnutrition. The incidence and severity of malnutrition (low serum albumin) and hyperphosphatemia (increased serum phosphorus level) were correlated with serum calcium, serum alkaline phosphate, and serum parathyroid hormone levels in patients on dialysis. In India, approximately on an average, every 10th person has evidence of early stage of chronic kidney disease. There is high incidence of malnutrition in chronic kidney disease (CKD) patients on dialysis (stage 5D). There have been varying reports of incidence of hyperphosphatemia in dialysis patients in India. Patients on maintenance hemodialysis (MHD) also have high incidence of malnutrition. Indian patients on dialysis have been reported to have less incidence and severity of hyperphosphatemia. A total of 500 patients on MHD (122 female and 378 male patients, age range 9–89 years, and mean age 47.0 ± 15.25 years) were evaluated for hyperphosphatemia, malnutrition, and degree of renal failure. There was trend of more hyperphosphatemia in the group of patients with serum albumin level ≥3.0 g/dl, because these patients were taking adequate dietary protein intake. Patients with malnutrition (serum albumin level <3.0 g/dl) had less incidence and severity of hyperphosphatemia as compared to the group with serum albumin level ≥3.0 g/dl. Chronic kidney disease (CKD) patients on dialysis had high incidence of malnutrition. Hyperphosphatemia was seen even in patients with malnutrition despite lower dietary protein intake and low serum albumin levels.

Background

In India, epidemiologically, Plasmodium vivax predominates over Plasmodium falciparum malaria, and this produces a major public health problem due to the recent increase in severe vivax malaria. Malaria-related renal failure is usually ascribed to acute tubular necrosis (ATN) and interstitial nephritis, and rarely to cortical necrosis. Clinical features of hemolytic uremic syndrome (HUS) and thrombotic microangiopathy (TMA) on renal histology have not been described conclusively in relation to malaria.

Methods

This prospective observational study includes patients of vivax malaria with renal failure admitted to a tertiary care hospital during November 2011 to April 2012 with features of HUS (anemia, thrombocytopenia, and acute kidney injury). The diagnosis of P. vivax malaria monoinfection was established with detection of parasite in peripheral smear and malaria card test. Renal biopsies were performed after three weeks for nonrecovering renal failure and evaluated with light and immune-fluorescence microscopy.

Results

Five patients (2 males and 3 females) had clinical constellation of HUS associated with vivax malaria. All the patients required dialysis [1 peritoneal dialysis and 4 hemodialysis (HD)]. Renal biopsy performed in all the patients showed characteristic features of TMA like mucointimal proliferation, subintimal fibrin deposits with luminal thrombi along with ATN, and cortical necrosis. Three patients were dependent on dialysis [1 continuous ambulatory peritoneal dialysis (CAPD) and 2 HD]. The rest of the two patients had partial recovery at the end of 3 months. The patient on CAPD died due to pneumonia-related sepsis.

Conclusion

Clinical association of vivax malaria with TMA leading to HUS is novel and suggests parasite-related severe endothelial injury. Future studies are needed to demonstrate interaction of parasite with endothelium and factors related to it.

Tumor lysis syndrome (TLS) is well described treatment related oncologic emergency with hyperuricemia being a cardinal sign of it leading to acute uric acid nephropathy. But spontaneous occurrence of TLS has occasionally been described in the literature. This spontaneous tumor lysis syndrome (STLS) is unusual cause for acute kidney injury (AKI) and a very uncommon initial presentation of lymphoma. AKI occurring in the setting of STLS has very poor outcome as it was not possible to institute preventive measures leading to very high mortality. We report a case of non-Hodgkin's lymphoma presenting with severe hyperuricemia with AKI. Our case stresses the importance of rapid diagnosis and treatment of AKI due to STLS which helps in early renal recovery. With prompt and timely initiation of hemodialysis and other supportive measures, renal failure and prognosis can be improved.

Background

Infection is the most common cause of hospitalization, morbidity, and mortality in post-transplant recipients in developing countries like India. With the availability of potent immunosuppression the short-term graft outcomes have improved, but the risk of infections has increased, and the long-term graft and patient survival are poor. Infections are the leading cause of death with functioning grafts in the developing countries. By increasing the HLA match, we can decrease the need of more potent immunosuppression, thereby decreasing the risk of infection and improving graft and patient survival. Here we report a case where two-way kidney paired donation (KPD) transplantation was done for better HLA match to improve long-term graft survival.

Methods

Two-way kidney paired donation (KPD) transplantation was performed, where one compatible pair (patient: AB blood group 48 years male; Donor, 47 year wife) benefitted by better HLA match (9/14) and other pair (patient: O blood group 33 years female; Donor 47 year mother) benefitted by getting ABO compatible O group donor. Both patients had anatomic, functional, and immunologically comparable donors. Kidney transplant was performed simultaneously after legal permission from authorization committee.

Results

Outcome was similar for both patients. Mean serum creatinine is 0.95 mg/dl at 3 months follow-up without any complications.

Conclusion

National KPD program will expand the donor pool. Long-term outcome of compatible pairs with poor HLA matching can be improved with better HLA matching in KPD, which also increases the transplant rate of KPD program.

Cannabis is a collective term referring to the bioactive substances from cannabis sativa or cannabis indica. Ganja is a resinous extract of leaves and bracts of a female plant. Smoking of ganja is very rampant for a very long time in our country. Recently, use of synthetic drugs is increasing as compared to natural psychotropic substances because intensity is much higher than that induced by natural ones, together with easy access, affordability and avoidance of detection by many commonly used urine drug tests. Renal failure after cannabinoid use has never been reported; we here report a case of acute kidney injury after synthetic cannabinoid use.

Guillain–Barré syndrome is acute, frequently severe fulminant polyradiculoneuropathy characterized by areflexic motor paralysis with/without sensory disturbance. We report a rare case of post-renal transplant (RT) Guillain–Barré syndrome (GBS) in a 34-year-old male, who presented with sudden onset of ascending pattern paralysis of lower limbs (LL) without bowel/bladder involvement. The diagnosis was confirmed by neurological examination and nerve conduction velocity (NCV) studies. He was treated with IV immunoglobulin and recovered completely.