Cytomegalovirus-induced tubulointerstitial nephritis in a renal allograft treated by foscarnet therapy

We report a female patient suffering from cytomegalovirus (CMV)-induced tubulointerstitial nephritis in a renal allograft 70 days after a cadaveric renal transplantation. CMV-induced renal allograft injury reported in the literature mainly related to immune-mediated mechanisms. In our patient, acute tubulointerstitial nephritis, associated with histological evidence of CMV infection, was demonstrated in the renal allograft biopsy. There were no histological features of allograft rejection, cyclosporin nephrotoxicity nor 'CMV glomerulopathy'. She was successfully treated by foscarnet therapy and a reduction in immunosuppression. Her renal function returned to baseline afterwards.

Abbreviated tacrolimus area-under-the-curve monitoring for renal transplant recipients

The area under the concentration time curve (AUC) for oral tacrolimus (FK) may provide a more precise model for FK monitoring after renal transplantation. The purpose of this study is to identify a simple, cost-effective method for predicting FK AUC. FK concentrations were measured at 0, 1, 2, 4, 6, 8, and 12 hours after the morning dose. The predicted AUCs (AUC(p)s) derived from regression equations were used to estimate the actual 12-hour AUCs (AUC(12)s). The relationship between AUC(p) and AUC(12) was validated by determining the coefficient of multiple determination (R(2)), percentage of prediction error (PE%), and percentage of absolute prediction error (APE%). Eighteen stable Oriental renal transplant recipients (9 men, 9 women) with a mean age of 42.6 +/- 6 years and mean body weight of 62.7 +/- 10 kg were recruited for the study. The FK AUC(12), trough, 2-hour, and 4-hour concentrations were 125 +/- 24 h. ng/mL (range, 87.7 to 181.9 h. ng/mL), 6 +/- 1.3 ng/mL, 18.1 +/- 4.7 ng/mL, and 11 +/- 2.4 ng/mL, respectively. Trough FK concentration did not have a significant correlation with AUC(12) (r = 0.34; P = 0.17). AUC(p) obtained by a two-time point regression equation using 2-hour (C2) and 4-hour (C4) FK concentrations: (AUC(P) = 16.2 + 2.4*C2 + 5.9*C4) obtained an R(2), PE%, and APE% of 0.93, -0.2% +/- 5.2% (range, -13% to 9.3%), and 3. 6% +/- 3.7% (range, 0.02% to 13%), respectively. We conclude that a two-point sampling method using C2 and C4 may be a more cost-effective FK monitoring strategy than morning FK trough levels in transplant recipients.

Subcutaneous nodules attributed to nocardiosis in a renal transplant recipient on tacrolimus therapy

We report a renal transplant patient who suffered from disseminated nocardiosis after empirical tacrolimus rescue therapy for chronic allograft rejection. The nocardiosis presented initially as only mildly tender subcutaneous calf nodules without any other signs of inflammation nor constitutional upset, which later spread to the lung and brain causing bronchopneumonia and brain abscesses. The risk factors for nocardial infection in our patient include the use of potent immunosuppressive agents such as tacrolimus, poorly controlled diabetes mellitus and kidney dysfunction. She responded well to combination antibiotic therapy comprising parenteral meropenem, cefotaxime and oral minocycline. We conclude that in transplant recipients, especially those receiving newer and more potent immunosuppressive agents like tacrolimus, nocardial infection can present as apparently 'cold' subcutaneous nodules without any systemic upset. An associated brain lesion should be excluded even in patients without neurological symptoms.

Rhabdomyolysis and acute renal failure resulting from alcohol and drug abuse

Rhabdomyolysis is a common cause of acute renal failure (ARF) associated with drug misuse. Abuse of the gel formulation of temazepam has been a particular problem in the West of Scotland. We performed a retrospective review of dialysis-dependent ARF from rhabdomyolysis and drug misuse in the West of Scotland, 1986-1997. We identified 76 patients, of whom 87% were male. Seventeen cases occurred in the first 6 years, compared with 59 in the subsequent 6 years. Median age was 32. Thirty cases followed intravenous drug misuse, 46 followed oral drug misuse. The substances most frequently misused were alcohol (54%), heroin (24%) and parenteral temazepam (17%). The temazepam cases all followed the introduction of the gel formulation. Three out of 4 patients requiring limb amputation had injected temazepam. Of intravenous drug misusers tested, 72% were hepatitis-C-positive. Some 43% of patients had deprivation scores in the worst category. ARF due to rhabdomyolysis from substance misuse is increasing in our area. Alcohol is frequently responsible. The introduction of the gel formulation of temazepam has contributed to the increase. Those at risk in this study were young, male, had a high incidence of hepatitis C and lived in the most deprived areas.

Spontaneous renal allograft rupture attributed to acute tubular necrosis

A renal allograft recipient receiving triple immunosuppressive therapy developed spontaneous allograft rupture 5 days after her second cadaveric renal transplantation. Renal biopsy showed interstitial edema with severe acute tubular necrosis (ATN). There was no evidence of acute rejection or renal vein thrombosis. The ruptured renal graft was salvaged by an aggressive fluid resuscitation therapy and surgical hemostasis. The renal function was satisfactory on discharge. We conclude that renal allograft rupture can be the result of interstitial edema solely attributed to ATN in the absence of graft rejection. The ruptured graft kidney is potentially salvageable for those patients whose hemodynamic status can be stabilized by appropriate supportive therapy.

Comparison of double-bag and Y-set disconnect systems in continuous ambulatory peritoneal dialysis: a randomized prospective multicenter study

We performed a multicenter, single-blinded, prospective randomized study on the use of a double-bag disconnect system (B) versus a Y-set disconnect system (Y). The peritonitis rate, exit site infection, clinical outcome, and patients' acceptance to the procedure were assessed. A total of 120 new end-stage renal failure patients of three regional hospitals were randomized: 60 each to the B and the Y systems. The results of 60 patients on the B system and 51 on the Y system were analyzable. They were followed up for a median of 16 months. Peritonitis rates for the B and the Y systems were 33.5 and 29.4 patient-months per episode, respectively. Exit site infection rates for the B and Y systems were 17.4 and 16.0 patient-months per episode, respectively. Four catheters were removed in each group. Patients on the B system were hospitalized for 2.1 days per patient per year related to peritonitis and exit site infection, and those on the Y system were hospitalized for 1.2 days. There was no significant difference between the B and Y systems in the incidences of peritonitis (all causes and those due to coagulase-negative staphylococci), exit site infection, and in hospitalization days. However, there was a higher percentage of gram-positive infections in the Y system (52%) than in the B system (32%) and a lower percentage of gram-negative infections in the Y system (16%) than in the B system (32%). Patients on the B system had a better acceptance of the procedure than patients on the Y system, as assessed by a six-item, 10-point questionnaire (total score, 43.1 +/- 10.2 v 37.6 +/- 9.4; P < 0.005 at 1 month; 44.6 +/- 9.1 v 39.8 +/- 8.6; P < 0.01 at 6 months). From this study, it is concluded that the B and Y systems are similar in the incidences of peritonitis and exit site infection, although the B system is better accepted by patients. This is probably the first multicenter randomized study comparing the double-bag and Y-set disconnect system using only new patients who had never used other systems of continuous ambulatory peritoneal dialysis.

The aging effect on corneal curvature and the validity of Javal's rule in Hong Kong Chinese

PURPOSE

The current study compared the central corneal curvature and the refractive error of Hong Kong Chinese to study the validity of Javal's rule.

METHODS

Subjects without corneal pathology were recruited at different age ranges. Their refractive error and the corneal curvature were measured and compared for the right eye only. Two instruments were used for the measurement of corneal curvature including a conventional Bausch & Lomb (B&L) keratometer and a computer-assisted videokeratoscope (TMS-1).

RESULTS

Subjects age ranged from 21 years to 77 years were recruited and were categorized into five groups according to age. The Bausch & Lomb keratometer was found to provide corneal information similar to that from the TMS-1. The corneal astigmatism was found to change from with-the-rule to against-the-rule with advancing age. The spectacle astigmatism followed a similar trend. There was a hyperopic shift in the spherical component of the refractive error with aging as well. A regression equation: Spectacle astigmatism = 0.93 (Corneal astigmatism) + (-0.58D x 90) was found, which is similar to the simplified Javal's rule. There was a shift of 1.03D in hyperopia (spherical equivalent) for each decade.

CONCLUSIONS

Both the corneal and spectacle astigmatism demonstrated a shift from with-the-rule to against-the-rule with age. The simplified Javal's rule is more suitable for predicting the spectacle astigmatism from corneal astigmatism in Hong Kong Chinese.

Comparison of marginal sealing ability of new generation bonding systems

The purpose of this in vitro study was to evaluate the enamel and dentine marginal sealing ability of four new generation composite bonding systems. Two Class V preparations, which were solely in enamel and dentine/cementum, were made on the buccal surfaces of 96 freshly extracted molar teeth. The teeth were randomly divided into four groups of 24 and restored with composite resin (Silux Plus) utilizing the following bonding systems: Scotchbond Multi-purpose (SB), Fuji Bond LC (FB), Prime & Bond 2.0 (PB) and Bisco One-step (BC). The restorations were finished immediately after photo-polymerization and stored in saline at 37 degrees C for 1 week. Half of the specimens in each group were then thermally stressed for 500 cycles. All restorations were then subjected to dye penetration testing, sectioned and scored. Results revealed no statistically significant difference (P < 0.05) in dye penetration scores for the different bonding systems with the exception of leakage at the dentine margins of thermally stressed specimens where FB exhibited significantly better sealing ability compared with the other bonding systems and BC exhibited significantly less leakage than PB. The marginal seal of 'one-step' (PB and BC) and resin-modified glass-ionomer (FB) bonding systems appear to be as effective as 'two step' systems like SB. Thermal stresses had some influence on marginal seal but this was both product and tissue specific.

Ventricular tachycardia after oxytocin injection in patients with prolonged Q-T interval syndrome--report of two cases

Oxytocin is widely used in obstetric settings to stimulate uterine contraction and prevent postpartum hemorrhage. Its adverse effects which include transient hypotension and increase heart rate could be life-threatening in patients with fixed cardiac output or hypotension resulting from hemorrhage. We reported two cases suspected to have preexisting prolonged Q-T interval syndrome (PQTS) who developed ventricular tachycardia immediately after intravenous injection of oxytocin. Anesthetic management of and use of oxytocic agents in patients with PQTS were discussed.

Past and present levels of some radionuclides in fish from Bikini and Enewetak Atolls

Bikini and Enewetak were the sites in the Northern Marshall Islands that were used by the United States as testing grounds for nuclear devices between 1946 and 1958. The testing produced close-in fallout debris that was contaminated with different radionuclides and which entered the aquatic environment. The contaminated lagoon sediments became a reservoir and source term of manmade radionuclides for the resident marine organisms. This report contains a summary of all the available data on the concentrations of 137Cs, 60Co and 207Bi in flesh samples of reef and pelagic fish collected from Bikini and Enewetak Atolls between 1964 and 1995. The selection of these three radionuclides for discussion is based on the fact that these are the only radionuclides that have been routinely detected by gamma spectrometry in flesh samples from all fish for the last 20 y. Flesh from fish is an important source of food in the Marshallese diet. These radionuclides along with the transuranic radionuclides and 90Sr contribute most of the small radiological dose from ingesting marine foods. Some basic relationships among concentrations in different tissues and organs are discussed. The reef fish can be used as indicator species because their body burden is derived from feeding, over a lifetime, within a relatively small contaminated area of the lagoon. Therefore, the emphasis of this report is to use this extensive and unique concentration data base to describe the effective half lives and cycling for the radionuclides in the marine environments during the 31-y period between 1964 and 1995. The results from an analysis of the radionuclide concentrations in the flesh samples indicate the removal rates for the 3 radionuclides are significantly different. 137Cs is removed from the lagoons with an effective half life of 9-12 y. Little 60Co is mobilized to the water column so that it is depleted in both environments, primarily through radioactive decay. The properties of 207Bi are different at Enewetak and Bikini. At Enewetak the radionuclide is lost from the environment with an effective half live of 5.1 y. At Bikini only radioactive decay can account for the rate at which the radionuclide is lost from the lagoon. The difference in the binding properties of the sedimentary materials for 207Bi among the two Atolls is not understood.

The Northern Marshall Islands Radiological Survey: data and dose assessments

Fallout from atmospheric nuclear tests, especially from those conducted at the Pacific Proving Grounds between 1946 and 1958, contaminated areas of the Northern Marshall Islands. A radiological survey at some Northern Marshall Islands was conducted from September through November 1978 to evaluate the extent of residual radioactive contamination. The atolls included in the Northern Marshall Islands Radiological Survey (NMIRS) were Likiep, Ailuk, Utirik, Wotho, Ujelang, Taka, Rongelap, Rongerik, Bikar, Ailinginae, and Mejit and Jemo Islands. The original test sites, Bikini and Enewetak Atolls, were also visited on the survey. An aerial survey was conducted to determine the external gamma exposure rate. Terrestrial (soil, food crops, animals, and native vegetation), cistern and well water samples, and marine (sediment, seawater, fish and clams) samples were collected to evaluate radionuclide concentrations in the atoll environment. Samples were processed and analyzed for 137Cs, 90Sr, 239+240Pu and 241Am. The dose from the ingestion pathway was calculated using the radionuclide concentration data and a diet model for local food, marine, and water consumption. The ingestion pathway contributes 70% to 90% of the estimated dose. Approximately 95% of the dose is from 137Cs. 90Sr is the second most significant radionuclide via ingestion. External gamma exposure from 137Cs accounts for about 10% to 30% of the dose. 239+240Pu and 241Am are the major contributors to dose via the inhalation pathway; however, inhalation accounts for only about 1% of the total estimated dose, based on surface soil levels and resuspension studies. All doses are computed for concentrations decay corrected to 1996. The maximum annual effective dose from manmade radionuclides at these atolls ranges from .02 mSv y(-1) to 2.1 mSv y(-1). The background dose in the Marshall Islands is estimated to be 2.4 mSv y(-1). The combined dose from both background and bomb related radionuclides ranges from slightly over 2.4 mSv y(-1) to 4.5 mSv y(-1). The 50-y integral dose ranges from 0.5 to 65 mSv.

Pregnancy in renal transplant recipients: the Christchurch experience

AIM

Assess the pregnancies of our female renal transplant recipients and to document long term maternal and fetal outcome.

METHODS

Between 7 June 1972 and 31 December 1992 112 females had at least one renal transplant. Sixty-four of these 112 women were in the reproductive age and had a functioning graft.

RESULTS

Nine women had 16 pregnancies which resulted in 11 live births and three first trimester abortions. Two unplanned pregnancies were terminated. Mean age at transplantation was 17.2 yr [range 16-22.5 yr] and mean interval from transplant to pregnancy was 6.8 yr [range 1.8-9.0 yr]. Prednisone and azathioprine were used in all patients and cyclosporin in five. For seven of the successful pregnancies plasma creatinine remained < or = 0.10 mmol/L. One of these women developed allograft nephropathy 5 years after delivery and returned to dialysis 9 years later. For the other four successful pregnancies the preconception plasma creatinine was 0.12-0.14 mmol/L. The woman with two successful pregnancies had a halving of glomerular filtration rate during the second pregnancy, but it has remained stable for 15 years; one was poorly compliant with her immunosuppressive regimen and reached endstage renal failure two years after delivery; one developed cyclosporin nephrotoxicity, but 18 months later renal function was stable after a dosage reduction. Ten infants were delivered by caesarean section, four of them urgently. Three babies were preterm and five growth retarded. One died of sudden infant death syndrome at four months. All other infants developed normally.

CONCLUSION

There is no contraindication to pregnancy in female transplant recipients who have stable graft function and controlled blood pressure. Management of such pregnancies should be by shared obstetrical/nephrological/paediatric care.

Concentration of 210Po and 210Pb in the diet at the Marshall Islands

The concentrations of 210Po and 210Pb have been determined in many local foods consumed by societies residing on different atolls in the Marshall Islands. The average daily intake of these two naturally occurring radionuclides from local and imported food is estimated to be 2.18 and 0.36 Bq, respectively. Local foods contribute 87% of the 210Po and 47% of the 210Pb associated with the diet. The items contributing the majority of the activity to the diet are derived from the marine environment and include parts of fish, invertebrates, seabirds and eggs of seabirds. The committed effective dose from ingestion of 210Po and 210Pb is approximately 2 mSv/year (200 mrem/year). This pathway now contributes 83% of the natural background irradiation received by residents in the Marshall Islands. Because the naturally occurring radionuclides are omnipresent in terrestrial and marine foods at all atolls, the annual intake and computed dose can be considered as typical values for individuals with comparable diets and inhabiting other islands in the Pacific.

Magnetic resonance imaging of an osteoid osteoma of the proximal femur: a potentially confusing appearance

Osteoid osteomas are common benign pediatric bone tumors. However, radiographic diagnosis and location of the tumor nidus can be difficult. We recently diagnosed and treated an osteoid osteoma of the right proximal femur in a 9-year-old girl in whom the preoperative magnetic resonance images demonstrated a well-marginated lesion in the medullary canal but no tumor nidus. This was confusing and misleading. Correct diagnosis was made with a computed tomography (CT) scan. Care must be taken in interpretation of magnetic resonance imaging (MRI) in disorders in which secondary bone marrow changes occur to avoid erroneous diagnoses and possible incorrect operative procedures.

[Anesthesia for the low body weight neonates]

58 newborns weighting under 2500 gm were collected, who received surgery in the past five years (1985-1989) in Chang Gung Memorial Hospital, Taipei, and followed up the survivors until April 1990. We classified these 58 cases by physical status that 31 cases (53%) were in ASA II, 26 (45%) in ASA III, 1 (2%) in ASA IV; by body weight that 9 cases (16%) were under 1500 gm, 17 (29%) between 1501 and 2000 gm, 32 (55%) over 2000 gm; by gestational age that 26 cases (45%) were in term pregnancy, 14 (24%) in borderline prematurity, 16 (28%) in moderate prematurity, 2 (3%) in extreme prematurity. All these 58 cases were under endotracheal general anesthesia, the majority of surgery (32 cases) were abdominal procedures. They were all sent to pediatric intensive care unit after operation. The mortality rate was 42% (25 cases), 4 cases of those were dead within the post-operative 24 hours. In this study, the change of temperature during operative procedures was significantly correlative to the neonatal mortality (p less than 0.005).

Characterization of proteins encoded by the Epstein-Barr virus transactivator gene BMLF1

Epstein-Barr virus (EBV) encodes a gene product in the BamHI-M leftward reading frame 1 (BMLF1) that functions as a promiscuous transactivator acting upon many other enhancer-promoter combinations. This protein has been studied by producing a polyclonal rabbit antiserum directed against a LacZ-BMLF1 fusion protein that was synthesized in Escherichia coli. Western blotting was employed to demonstrate that this antiserum specifically detected the BMLF1 proteins in E. coli, monkey, mouse, or B cells transfected with this gene, and in EBV-positive B cells chemically induced to produce this protein. In these induced B cells, two major proteins of 50 and 60 kDa and several minor antigens were detected by these antibodies. Transfection of an expression vector containing the BMLF1 coding sequence resulted in the synthesis of only the 50 kDa proteins. These major products were phosphorylated in vivo and were localized to the cell nucleus. Only the larger 60-kDa antigen was specifically induced to be synthesized by a different EBV encoded transactivator, the BZLF1 gene product. Chemical induction of lymphocytes latently infected with EBV resulted in the synthesis of both the 60- and 50-kDa forms of the BMLF1 transactivator. Two major forms of this EBV-encoded transactivator have been detected. The 60-kDa form is presumably derived from the BSLF2-BMLF1 open reading frame while the smaller antigens, 50 kDa size, appear to be made only by the BMLF1 open reading frame. These two forms of the transactivator are differently regulated and the functional significance of this remains to be explored.