How Robust are our Methods of Detecting Impaired Glomerular Filtration Rate in the Intensive Care Unit?

BACKGROUND

Serum creatinine is not a sensitive marker to assess early loss of renal function in acute kidney injury. Timed creatinine clearance and several formula used to predict glomreular filtration rate have not been validated.

METHODS

In a prospective observational study in 50 adult patients admitted to the intensive care unit with apparent normal renal function, we assessed the glomerular filtration rate by the formula methods and timed creatinine clearance.

RESULT

The mean serum creatinine was 0.77mg/dl, SD ± 0.15 (range 0.5-1.14 mg/dl). The mean measured creatinine clearance was 87.15 ml/min/1.73m(2), SD ± 20.5 (range 56.9-137 ml/min/1.73m(2)). In 25 (50%) patients, one hour urinary creatinine clearance was <80 ml/min/1.73m(2) and in two (4%) patients, the creatinine clearance was <60 ml/min/1.73m(2). Spearman correlation coefficient and regression analysis revealed a statistically significant correlation for the Cockcroft-Gault and predictive equations when compared with measured creatinine clearance. The differences between the predictive equations and creatinine clearance, as illustrated by the ±95% confidence interval in the Bland-Altman graphs was very significant [Cockcroft- Gault = -40.3 to 17.7 ml/min/ 1.73m(2), Modification of Diet in Renal Disease equation = -46.2 to 30.6 ml/min/1.73m(2) and the simplified Modification of Diet in Renal Disease equation = -72.8 to 24.8 ml/min/1.73m(2)].

CONCLUSION

Formula methods and creatinine clearance are more sensitive than serum creatinine in detecting early phase of acute kidney injury. However, there is no agreement between these methods of glomerular filtration rate estimation.

Acute cortical necrosis in Falciparum malaria: an unusual manifestation

The spectrum of acute renal failure in Falciparum malaria varies from mild urinary abnormalities to acute renal failure. Acute tubular necrosis has been reported in 1% patients, and acute cortical necrosis has rarely been reported. We present a case of acute cortical necrosis in a young patient with Falciparum malaria who had a prolonged oligo-anuric course followed by partial recovery of renal function.

Successful medical treatment of emphysematous pyelonephritis in a renal allograft recipient

Emphysematous pyelonephritis in renal allograft recipients is a rare but serious complication. The management of this entity is a subject of controversy in live related donor programs where the absence of a second donor is a key factor influencing surgical removal of the graft. We present a case of emphysematous pyelonephritis in a renal allograft recipient managed successfully with medical therapy alone.

Lipid Profile In Transplant Patients: A Clinical Study

15 renal transplant recipients were studied for their lipid profile. The patients were on regular post transplant follow up and had non clinical or laboratory evidence of graft dysfunction, intercurrent infection or post transplant diabetes mellitus for at least 3 months prior to the study. The mean duration of transplant was 15 ± 9.5 months (range 3-32 months). Majority (86%) were on triple immunosuppression therapy and received a mean prednisolone dose of 10.5 mg. An equal number of healthy subjects were randomly selected and studied for their lipid profile and served as control for the study group. There was no significant change in the HDL-cholesterol level as compared with controls. However, these patients showed a significantly higher LDL-cholesterol and total cholesterol levels. Further, a significant inverse correlation was observed between triglycerides and total cholesterol levels and transplant duration.

LUPUS NEPHRITIS-A CRITICAL ANALYSIS OF 17 PATIENTS

Over a 3 year period from June 94 to June 97, out of 28 patients of systemic lupus, 17 were diagnosed as renal lupus. Demographic data showed 12 females and 5 males, mean age being 32.2 years (range 12 to 54 years). Mean time gap between presentation and definitive diagnosis was 32.4 days (7 days to 5 years). 2 patients (11.76%) presented renal lupus, one (5.88%) with acute interstitial lung disease and the remaining had the usual systemic manifestations of lupus. Anti dsDNA antibodies were positive in all patients while ANA was negative in 3 cases. Renal involvement consisted of rapidly progressive glomerulonephritis in 2 patients (11.76%), nephrotic syndrome in 4 (23.52%) and non nephrotic range proteinuria in 11 (64.70%) patients. Mean serum creatinine at presentation was 2.4mg/dl (0.8mg/dl to 8.9 mg/dl). Three patients were dialysis dependent. Renal histology on light microscopy comprised of class II lesions in one (5.88%), class III in 4 (23.52%), class IV in 11 (64.70%-including one with crescents) and class V in one (5.88%) patient. All patients with advanced class III/IV lesions were treated with corticosteroids and cyclophosphamide pulses. Except one patient who died of pyopericardium all others improved and their serum creatinine stabilised around 2.3 mg/dl (0.8 to 4.6 mg/dl). The study highlights the importance of early diagnosis and aggressive management in this potentially treatable disease.

Efficacy of enalapril in the treatment of steroid resistant idiopathic nephrotic syndrome

Fifteen patients of idiopathic nephrotic syndrome who failed to respond to 8 weeks of corticosteroid therapy formed the material for this study. There were 10 males and 5 females, age ranging from 4 to 56 years. Three patients had hypertension. Histological lesions were focal and segmental glomerulosclerosis (FSGS) in 8; membranous glomerulonephritis in 3; mesangial proliferative glomerulonephritis in 2 and membranoproliferative glomerulonephritis in 2 patients. Proteinuria ranged from 3.64 to 8.66 g/1.73 m2/day. Serum albumin ranged between 2.2 to 3.3 g/dl. Serum creatinine was elevated > 1.5 mg/dl in 3 cases. After discontinuing steroids, enalapril was started in a dose of 2.5 mg/day and increased by 2.5 mg/day every 3-4 days till the maximum tolerated dose but not exceeding 20 mg/day. Proteinuria, serum albumin and serum creatinine estimations were done every 4 weeks for six months and every three months thereafter. Patients were followed up for 6 to 30 months. Proteinuria decreased to < 1.5 g/1.73 m2/day in 12 patients (80%) and to < 0.5 g/1.73 m2/day in 10 patients (66.7%) by 8 weeks. There was no significant decrease in proteinuria in 3 (20%) patients; two of these were cases of FSGS and one of membranoproliferative glomerulonephritis. Oedema, hypoalbuminaemia and hypercholesterolaemia returned to normal in all patients who had a decrease in the proteinuria. There was no correlation between the histological lesion and response to enalapril. There was no rise in the serum creatinine level above the baseline in any of the patients. Except for cough in one patient, no other significant side effects were observed. We conclude that enalapril is effective in reducing proteinuria and thereby the morbidity in steroid resistant nephrotic syndrome irrespective of the underlying pathology.