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.

Hepatitis G virus infection in lymphoma and in blood donors

AIMS

To determine whether the recently described flavivirus, hepatitis G virus (HGV), might contribute to the pathogenesis of lymphoma by testing for the presence of HGV RNA in sera from patients attending lymphoma clinics; to compare the incidence of HGV RNA in lymphoma patients with that in normal blood donors; and to look for potential risk factors for HGV infection and for evidence of hepatic disease in the HGV positive patients.

METHODS

Sera were examined from 76 patients with lymphoma and 100 blood donors for the presence of HGV RNA using reverse transcriptase polymerase chain reaction (RT-PCR).

RESULTS

HGV RNA was detected in 10% of patients' sera, but only in 1% of blood donor samples. HGV infection was found in patients with various different types of lymphoma, including Hodgkin's disease and non-Hodgkin's lymphoma. The majority (75%) of patients who were HGV PCR positive had undergone transfusion, but only 30% of those who were HGV PCR negative had received blood products. In addition, the number of donor exposures per HGV positive patient was approximately twice that of the HGV negative group.

CONCLUSIONS

The data suggest (1) that HGV is present in the normal blood donor population; (2) that patients with lymphoma are at risk of acquiring HGV because of their exposure to blood products; and (3) that persistent HGV infection does not appear to cause serious liver disease in these patients.

Ceruminous gland neoplasia

Ceruminous glands are modified sweat glands, confined to the skin lining of the cartilaginous part of the external auditory meatus. Tumours arising from these glands are extremely rare. Confusion exists regarding the nomenclature 'ceruminoma' and controversies prevail on the standard way of management. Treatment often involves a multidisciplinary approach, requiring reconstruction after extensive surgical resection. A case report of adenoid cystic carcinoma of ceruminous glands is presented along with discussion of the various pathological types and a review of management.

Absence status: an overlooked cause of acute confusion in hemodialysis patients

Epileptic seizures are a known complication of uremia, but non-convulsive seizures appear to be rare. We describe a patient with absence status presenting with acute confusion who responded well to intravenous diazepam. Attention is drawn to this rare cause of acute confusional state in the hemodialysis population.

Doppler ultrasound evaluation of hemodialysis vascular access

Brescia-Cimino arteriovenous fistulas (AVF) ad synthetic grafts are the usual forms of vascular accesses for hemodialysis. Although angiography has been the traditional means of imaging these vascular systems, colour Doppler flow imaging (CDFI) offers a non-invasive method of evaluating AVF dysfunction. We retrospectively evaluated 22 patients with clinical evidence of access dysfunction who were studied by CDFI and of whom 14 also underwent angiography. We analyzed the results of whom the 14 patients who had both CDFI and angiography as angiography was impossible in the remaining eight patients due to difficulty with cannulation. Eight patient had thrombosis on CDFI and angiopraphy in all eight patients confirmed these findings. CDFI showed six stenoses, all of which were proven on angiopraphy. Overall,, CDFI correctly identified all lesions that were seen angiographically ginging a sensitivity and specifificity of 100%. Moreover, CDFI detected two cases of pseudoaneurysms which were missed by angiography. CDFI provides an adequate means of evaluating AVF dysfunction and should be the initial imaging technique of choice.

Allogeneic bone marrow transplantation for systemic AL amyloidosis

Low-intensity chemotherapy is ineffective in most patients with AL amyloidosis, probably because clinical benefit requires regression of the amyloid deposits, and this occurs only very gradually after the underlying plasma cell dyscrasia has been suppressed. We report the first successful allogeneic bone marrow transplant (allo-BMT) for AL amyloidosis, which after 3 years was associated with complete clinical recovery. This supports the idea that there may be a brief window of opportunity in patients with AL amyloidosis during which dose-intensive chemotherapy is feasible and most likely to produce clinical benefit.

Hereditary multiple glomangiomas

Hereditary multiple glomangiomas are an interesting rare problem which can either present as multiple painful cutaneous lesions or, rarely, a cosmetic challenge due to site, size or number of lesions. It may also pose a diagnostic dilemma, which can only be settled by biopsy. Malignant change in glomangioma is extremely rare and only a few cases are well documented in literature. A case report of this condition, along with extensive review of the literature, is presented. The prognosis of various forms of glomangiomas and efficacy of diagnostic and therapeutic tools is discussed.

The use of an all oral chemotherapy (idarubicin and etoposide) in the treatment of acute myeloid leukaemia in the elderly: a report of toxicity and efficacy

Acute myeloid leukaemia (AML) is predominantly a disease of the elderly but such patients are not always appropriate candidates for intensive intravenous (i.v.) based treatment regimens. The development of the anthracycline idarubicin which is highly effective in the treatment of AML and is active when given orally has made it possible to design anti-leukaemic regimens which may be given orally and be particularly useful in those elderly patients with AML considered unsuitable for standard intensive aggressive treatments. We have assessed an oral regimen combining idarubicin 30 mg/m2 and etoposide 80 mg/m2 for 3 consecutive days as initial treatment in 28 elderly patients with AML (median age 69 years, range 56-81) who were not considered suitable for more intensive i.v. chemotherapy schedules. Following informed consent, two patients died before treatment began and one patient withdrew prior to treatment. Twenty-five patients underwent one to four courses of treatment. The schedule was well tolerated with minor nonhaematological toxicity. The first course was given in hospital, eight of 21 subsequent courses of treatment were given entirely as an out-patient. Eleven patients responded to treatment with nine (36%) achieving complete remission (CR). The median survival for all patients was 3 months, but for the nine who achieved a CR it is 9 months with six patients still alive, five in first CR and one in second CR. We conclude that a combination of idarubicin and etoposide given orally as first-line treatment in elderly patients with AML is safe and effective. In some patients this means treatment and follow-up can be given entirely on an out-patient basis.

Focal segmental glomerulosclerosis associated with nephrotic syndrome in cholesterol atheroembolism: clinicopathological correlations

To better characterize the heavy proteinuria occasionally described in cholesterol atheroembolic renal disease (CAE), we reviewed the clinical features and histological findings of 24 patients found at renal biopsy to have CAE. Twelve (50%) had a typical clinical presentation soon after an invasive vascular procedure. Eight (33%) underwent biopsies to evaluate proteinuria and four (17%) with insidiously developing renal failure to exclude rapidly progressive glomerulonephritis. All had usual and similar risk factors for CAE; 71% were male, 96% had peripheral vascular disease, 79% had recently undergone an invasive vascular procedure, 74% were hypercholesterolemic, and all were hypertensive. Proteinuria was higher and serum creatinine lower in the proteinuria group. In the nine (38%) nephrotic patients, serum creatinine measurements were lower (2.7 +/- 1.2 v 5.6 +/- 2.4 mg/dL), duration of renal disease to biopsy longer, and time from biopsy to dialysis greater (23.5 +/- 14.8 v 0.03 +/- 0.098 mo, P < 0.05 for all). Focal segmental glomerulosclerosis (FSGS) was observed in 15 (63%) of the biopsy specimens. Although FSGS itself did not occur more commonly in nephrotic patients, these patients did have a higher fraction of segmentally sclerosed glomeruli (0.158 +/- 0.097 v 0.026 +/- 0.050, P < 0.01). A variant of FSGS, the cellular lesion with epithelial cell prominence and capillary loop collapse, was observed in 7 of 9 (78%) patients with nephrotic-range proteinuria, but in only 3 of 12 (25%) patients with lesser degrees of protein excretion (P < 0.05). The cellular lesion was accompanied by higher mean proteinuria, 7.6 +/- 4.3 versus 2.1 +/- 2.4 g/24 hr (P < 0.01). In a larger group of patients with a similar age range as the CAE group who were identified by search of a computerized biopsy database, membranous nephropathy was the only other form of idiopathic glomerulonephritis that occurred with CAE. One of 82 (1.2%) patients with membranous nephropathy also had CAE, compared with 20 of 102 (19.6%) with FSGS (P < 0.0002, chi2). Thus, the finding of FSGS with CAE was not coincidence. Mean follow-up was 20 +/- 26 months (range, 0 to 103 months). Six patients (25%) were followed-up at least 3 years after renal biopsy. These findings indicate that extended survival in CAE is not rare and that heavy proteinuria occurs as part of a chronic disorder with distinctive histological features. Cholesterol atheroembolism with FSGS should be considered in the differential diagnosis of nephrotic syndrome in elderly patients with advanced atherosclerosis.

Low-dose filgrastim significantly enhances neutrophil recovery following autologous peripheral-blood stem-cell transplantation in patients with lymphoproliferative disorders: evidence for clinical and economic benefit

PURPOSE

To assess the clinical and economic benefit of low-dose (50 microg/m2) filgrastim after peripheral blood stem-cell transplantation (PBSCT) in a randomized, placebo-controlled double-blinded study.

PATIENTS AND METHODS

Thirty-eight patients with lymphoproliferative disorders were randomized to receive low-dose filgrastim (19 patients) or placebo (19 patients) beginning on the first day after stem-cell reinfusion and continuing until absolute neutrophil count (ANC) was greater than 0.5 x 10(9)/L. All patients received greater than 2.5 x 10(6) CD34+ cells/kg, which was mobilized with chemotherapy and filgrastim 300 microg from the fifth day. An economic analysis was performed based on the outcome in the two groups.

RESULTS

Neutrophil engraftment was significantly more rapid in patients who received filgrastim with a median number of days until ANC was greater that 0.5 x 10(9)/L of 10 (9 to 13) versus 14 (9 to 19; P < .0001). The time to reach an ANC greater than 1 x 109/L was 12 (9 to 14) versus 16 days (10 to 25; P < .0001). The total number of patients who required intravenous antibiotic therapy was lower in the filgrastim-treated group (68%) compared with the placebo group (89%); also, the median number of days with fever and the duration of antibiotic therapy were shorter, although these differences did not reach statistical significance. However, although only three of 19 (16%) patients who received filgrastim required amphotericin, 11 of 19 (58%) who received placebo did require it, and amphotericin usage was significantly less in the filgrastim group (P = .029). Finally, in-patient stay was significantly shortened in those who received filgrastim from 16 (13 to 23) to 13 days (11 to 18; P = .0003).

CONCLUSION

Low-dose filgrastim significantly reduces neutrophil engraftment time post-PBSCT and also reduces in-patient stay and costs, which makes it economically viable for patients who are undergoing high-dose chemotherapy.

Plasma exchange with solvent/detergent-treated plasma of resistant thrombotic thrombocytopenic purpura

A patient with unremitting thrombotic thrombocytopenic purpura (TTP), with circulating von Willebrand factor (VWF) multimers of unusually high molecular weight, and refractory to standard plasma exchange therapy, was treated with solvent detergent (S/D) plasma. The patient achieved a sustained clinical and haematological remission, with normal VWF multimeric profile. Spontaneous remission of this patient's condition could not be excluded but would appear unlikely. S/D plasma was efficacious and potentially safe for repeated large-volume plasma exchange with respect to viral safety and reduction of anaphylactoid reactions. We have assayed coagulation factors and physiological inhibitors of haemostasis in S/D plasma, which were comparable to normal plasma except in the distribution of VWF multimers. The use of S/D plasma, previously reported in paediatric chronic relapsing TTP, should be assessed in further cases of adult TTP in the context of a clinical trial.

Henderson-Hasselbalch equation is inadequate for the measurement of transmembrane diffusion of drugs and buccal drug absorption is a useful alternative

1. The transmembrane diffusion of weakly acidic or basic drugs is being commonly assessed from their degree of ionization or ratio unionized/ionized forms (ratio U/I) as calculated from Henderson-Hasselbalch equation (HHEq). 2. Buccal drug absorption (BA) at pH 5-9 has been proposed as an in vivo model for passage of drugs across lipid membranes. 3. Area under the curve (AUC) of BA against pH 5-9 of 18 basic drugs has been reported to be significantly related to their pH dependent renal excretion. 4. We have calculated, using HHEq, ratios U/I of 10 weak bases at pH 5-9 and 10 weak acids at pH 4-8, whose percentage BA at these pH levels was available in the literature. 5. These ratios were not related to their %BA at corresponding pH levels. 6. Therefore it is proposed that HHEq is inadequate in the anticipation of transmembrane diffusion of drugs and AUC of %BA of drugs at pH 4-9 is a useful alternative.

Functional hyposplenism following allogeneic bone marrow transplantation

AIMS

To investigate the incidence of functional hyposplenism in a group of patients who had undergone allogeneic bone marrow transplantation (BMT).

METHODS

Splenic function was assessed by counting the number of gluteraldehyde fixed red blood cells containing pits or indentations as examined by interference phase microscopy. Normal values are < 2% whereas splenectomy patients have values of 25 to 40%.

RESULTS

Twenty eight BMT recipients (17 men, 11 women) were studied at varying periods post-transplant and the results compared with 20 healthy volunteers and 10 patients who had undergone splenectomy or had splenic atrophy because of haematological conditions. Of the 28 BMT recipients, one had undergone a prior splenectomy; of the remaining 27 patients, four (15%) had evidence of functional hyposplenism with between 5.0 and 34.0% pitted cells. Of these four patients, one had active extensive chronic graft versus host disease (GvHD) which has been previously reported to be associated with functional hyposplenism following transplantation. Only one of the four patients had peripheral blood red cell changes typical of hyposplenism.

CONCLUSION

These results confirm that extensive chronic GvHD is associated with hyposplenism. Intermediate degrees of functional hyposplenism may also occur following BMT in the absence of chronic GvHD and in the absence of haematological features of hyposplenism on routine blood films. This may be of significance in mediating the susceptibility to infection with encapsulating bacteria seen following allogeneic BMT.