Results of renal angioplasty in nonspecific aortoarteritis (Takayasu disease)

PURPOSE

To evaluate the long-term results of percutaneous transluminal renal angioplasty (PTRA) in the management of renovascular hypertension caused by nonspecific aortoarteritis (Takayasu disease).

MATERIALS AND METHODS

The results of 96 stenoses in 66 patients were retrospectively studied. The indications for PTRA included hypertension uncontrolled by single-drug therapy, evidence of greater than 70% diameter stenosis in the renal artery with a peak systolic gradient of greater than 20 mm Hg, and clinically inactive disease.

RESULTS

Technical success was obtained in 91 (95%) stenoses in 62 patients. Clinical success was seen in 59 (89%) and included "cure" in 14 and "improvement" in 45 patients. The stenosis decreased from 88% +/- 6% (range, 70%-100%) to 11% +/- 12% (range, 0%-40%), systolic pressure gradient decreased from 95 mm Hg +/- 22 (range, 30-140 mm Hg) to 9 mm Hg +/- 8 (range, 0-30 mm Hg), blood pressure improved from 181 +/- 16 (range, 150-220)/115 +/- 10 (range, 90-146) to 136 +/- 25 (range, 130-210)/86 +/- 16 (range, 80-130) mm Hg, and the drug requirement decreased from 3.9 +/- .6 (range, 2-5) to 1.1 +/- .9 (range, 0-3) (P value for all < .001). Complications included transient intrarenal arterial spasm in three patients, groin hematoma in two patients, and ipsilateral renal vein injury in one patient. At 22 months +/- 17 (range, 4-84 months) follow-up, the restenosis rate, as determined by recurrence of hypertension and angiographic demonstration of restenosis, was 16%.

CONCLUSION

Despite some technical problems, PTRA is safe and effective in treating renovascular hypertension caused by nonspecific aortoarteritis. The complication rate is low.

Prospective randomized control trial of isoniazid chemoprophylaxis during renal replacement therapy

BACKGROUND

Infectious diseases remain among the major morbid events in patients with end-stage renal disease (ESRD) on renal replacement therapy (RRT). In developing countries, tuberculosis (TB) has been found to occur more frequently in these patients than in the general population. Efficacy of isoniazid (INH) chemoprophylaxis has been seen in other situations, such as human immunodeficiency virus infection. However, studies on INH prophylaxis in ESRD patients on RRT are limited.

METHODS

In this prospective randomized controlled trial, from April 2000 to June 2001, a total of 109 ESRD patients registered for renal transplant and accepted for maintenance hemodialysis in our hospital were included and followed up until June 2004 to assess the role of INH prophylaxis in preventing development of TB. At the time of acceptance for hemodialysis, 54 patients were assigned to receive daily INH for 1 year and 55 patients were assigned to the control group. Primary outcome was development of TB. Secondary outcome was INH hepatotoxicity. To evaluate the effect of INH prophylaxis on the development of TB, a Kaplan-Meier survival estimate was used to plot TB-free survival curve and log-rank test was used for comparison.

RESULTS

Overall, TB was diagnosed in 27 patients during RRT, with an incidence of 24.8%. TB developed in 9 (16.7%) patients in the INH group and in 18 (32.7%) patients in the control group. There was a significantly lower incidence of TB in the INH group as compared with the control group. The risk ratio of INH vs. control group for development of TB was 0.40 (95% confidence index [CI], 0.17-0.92; P=0.032). In the INH group 27 (50%) patients and in the control group 17 (30.9%) patients developed some hepatic dysfunction. However, significant hepatitis that required discontinuation of INH developed in only 9 (16.7%) patients in the INH group. Furthermore, significant hepatitis also developed in 6 (10.9%) patients in the control group. The majority of patients with significant hepatitis in both groups (INH as well as control) were subsequently found to be positive for hepatitis B and/or hepatitis C viral infection. Mild hepatitis (which did not require discontinuation of INH) was seen in 18 (33.3%) patients in the INH group and 11 (20%) patients in the control group. Viral hepatitis infection was not found in any of the milder cases of hepatitis in either group.

CONCLUSION

This study shows significant efficacy of INH chemoprophylaxis during RRT in preventing development of TB, when the INH was started during dialysis itself. INH chemoprophylaxis was safe and well tolerated in the majority of patients. However, mild hepatic dysfunction was common, both in the treatment as well as in the control group. As the incidence of viral hepatitis overall was high in our patients on RRT, it is difficult to identify INH-induced hepatitis in this clinical setting.

Renovascular hypertension resulting from nonspecific aortoarteritis in children: midterm results of percutaneous transluminal renal angioplasty and predictors of restenosis

OBJECTIVE

Nonspecific aortoarteritis is a major cause of renovascular hypertension in children. Stenosis of the renal artery is usually long and begins at the origin of that artery. We retrospectively studied the midterm results of angioplasty during treatment and defined the predictors of restenosis in 40 stenoses in 24 children.

MATERIALS AND METHODS

All patients had clinically inactive disease and hemodynamically significant stenosis causing hypertension. Midterm results were analyzed by the life table method. The effect of clinical, angiographic, and technical factors on the restenosis rate was tested by the Kaplan-Meir survival method.

RESULTS

Technical success was obtained without complications in 38 (95%) of the lesions in 22 (92%) of the patients. The stenosis decreased from 89 +/- 7% to 11 +/- 12%, the pressure gradient fell from 97 +/- 27 to 10 +/- 10 mm Hg, and blood pressure decreased from 174 +/- 14/112 +/- 11 to 141 +/- 13/88 +/- 11 mm Hg (p < .001). Clinical benefit was seen in all patients with technically successful angioplasty. During the follow-up period (33 +/- 22 months), restenosis was seen in eight lesions (20%). The predicted cumulative patency rate at 5 years was 71%. Adverse effects on the rate of restenosis were associated with male sex (p = .04), stenosis beginning at the origin of the renal artery (p = .01), and more than 20% residual stenosis after angioplasty (p = .02).

CONCLUSION

Our results show that hypertension in children with renal artery stenosis caused by nonspecific aortoateritis can be safely treated by renal angioplasty with excellent midterm results. A long stenosis beginning at the origin of the artery predisposes to restenosis, but repeat dilatation often produces lasting benefit.

Kawasaki disease: characteristics, diagnosis, and unusual presentations

Introduction: Kawasaki disease (KD) is one of the commonest pediatric vasculitides and is associated with a significant risk of development of coronary artery abnormalities if left untreated. Areas covered: In this review, we have highlighted the incomplete and unusual presentations of KD and also emphasize the controversies pertaining to 2D echocardiography in KD. A PubMed search was performed regarding diagnosis and unusual presentations of KD. Expert opinion: Diagnosis of KD is essentially clinical and based on recognition of typical clinical features that may appear sequentially and all signs and symptoms may not be present at one point of time. There is no confirmatory laboratory test for diagnosis of this condition. Further complicating the picture is the fact that incomplete and atypical forms KD may be seen in up to 50% patients. Although 2D echocardiography continues to be the preferred imaging modality for cardiac assessment in patients with KD, it has its limitations.

Platelets in Kawasaki disease: Is this only a numbers game or something beyond?

Kawasaki disease (KD) is a medium vessel vasculitis with predilection to cause coronary artery abnormalities. KD is now the most common cause of acquired heart disease in developed countries. Thrombocytosis is consistently found in patients with KD, usually in 2nd to 3rd week of illness. Thrombocytopenia has occasionally been reported in the acute phase of KD. An increase or decrease in platelet number in patients with KD was initially considered to be a benign phenomenon. However, recent literature on platelet biology in KD has suggested that platelets are not only increasing but are rather activated. This phenomenon has been found to increase the risk of thrombosis in these patients. Similarly a fall in platelet counts during acute stage of KD has also been found to be associated with increased severity of disease. In this review, we update on the current best understanding about pathogenic role of platelets in patients with KD.

Diagnosis of glomerular haematuria: role of dysmorphic red cell, G1 cell and bright-field microscopy

Differentiation between glomerular and non-glomerular haematuria by observation of the changes in red cell morphology using phase-contrast microscopy is a well established technique. However, the method is not widely accepted in clinical practice because of controversy regarding the minimum percentage of dysmorphic red cells required to diagnose glomerular aetiology, as well as the need for specialized microscopes. Recently, a glomerular-specific morphological alteration of red cells has been described, which has the form of a doughnut shape with one or more blebs and which is termed the "G1" cell. In the present double-blind prospective study 250 urine samples were examined without any knowledge of diagnosis. Haematuria was detected in 122 cases. The type of haematuria was characterized by counting dysmorphic cells and G1 cells separately, in each case using a phase-contrast microscope as well as an ordinary bright-field microscope with and without staining of urinary sediments. The results were later correlated with the confirmed diagnosis. The study showed that the G1 cell is more specific than the dysmorphic cell for the diagnosis of glomerular haematuria. Evaluation of both dysmorphic red cells and G1 cells can be done using bright-field microscopy with 100% specificity and sensitivities of 82 and 100%, respectively. It has been concluded that the ordinary bright-field microscope can be used for the diagnosis of glomerular haematuria with an efficiency similar to that of a phase-contrast microscope.

Lupus anticoagulant hypoprothrombinemia syndrome associated with systemic lupus erythematosus in children: report of two cases and systematic review of the literature

We report two children with systemic lupus erythematosus (SLE) having severe bleeding manifestations and lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) along with a review of published cases of childhood SLE and LAHPS. We report clinical and laboratory profile of two children diagnosed with childhood SLE and LAHPS. We also conducted literature search to identify similar published cases and a review was performed. An 8-year-old girl had presented with fever, arthralgia, alopecia, anasarca and bleeding from multiple sites. She was diagnosed to have SLE based on laboratory investigations which showed anemia, thrombocytopenia, low complements, positive anti-nuclear antibody (ANA) and double standard DNA (dsDNA) antibodies. She was also found to have prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), positive lupus anticoagulant (LA) and low factor II levels. She was diagnosed to have SLE with LAHPS and treated with intravenous methylprednisolone, intravenous immunoglobulin and cyclophosphamide with good outcome. Patient 2 was a 7-year-old-boy who was diagnosed to have SLE when he presented with fever, anasarca, malar rash, arthritis and bleeding from skin and mucosa. Laboratory investigations revealed anemia, proteinuria, low complements, positive ANA and anti-dsDNA titre. Coagulation studies showed deranged PT and aPTT, positive LA and low factor II levels. He was diagnosed to have SLE with LAHPS and was treated with intravenous methylprednisolone and oral mycophenolate mofetil. Review of literature of cases with childhood SLE and LAHPS showed that there are 32 cases have been reported till date which have been summarized. LAHPS is an uncommonly identified cause of bleeding in patients with SLE and must be suspected while evaluating these children.

A prospective analysis of testicular androgenic function in recipients of a renal allograft

Eighteen adult males with end stage renal disease (ESRD) were studied to determine the serum levels of gonadotropins (LH and FSH), prolactin (PRL) and testosterone. All of the patients were studied longitudinally while undergoing maintenance hemodialysis (HD) and six months after renal transplantation. Prior to transplantation, significantly high levels of gonadotropins and PRL were observed. During HD the serum testosterone levels tended to be subnormal in most of the uremic patients and low normal in some of the subjects. Renal transplantation led to a significant improvement (P < 0.05) in serum testosterone. Elevated gonadotropin and PRL levels observed in patients on HD returned to the normal range in most of the patients after successful renal transplantation.

Kawasaki Disease in Children Older Than 10 Years: A Clinical Experience From Northwest India

Background: Kawasaki disease (KD) is predominantly seen in young children (<5 years). Diagnosis of KD is often delayed in older children and adolescents, leading to a higher risk of coronary artery abnormalities (CAAs). There is a paucity of literature on KD in older children. Methods: Data were collated from a review of records of patients diagnosed with KD who were aged ≥10 years at the time of diagnosis, during the period from January 1994 to June 2019. Results: Eight hundred and sixty five patients were diagnosed with KD during this period. Of these, 46 (5.3%; 26 boys and 20 girls) were aged 10 years or older at the time of diagnosis. The median age at diagnosis was 11 years (range of 10-30 years). The median interval between the of fever and the diagnosis of KD was 12 days (range of 4-30 days). Eight patients (17.4%) presented with hypotensive shock. Coronary artery abnormalities (CAAs) were seen in six patients (13.04%), and three patients had myocarditis. Patients with CAAs were found to have significantly higher median platelet counts and higher median C-reactive protein levels. First-line treatment included intravenous immunoglobulin. Adjunctive therapy was given in five patients (infliximab in four patients and steroids in one patient). The median time between the onset of fever and the administration of IVIg was 13.5 days (range of 6-2). The total duration of follow up is 2,014.5 patient-months. Conclusion: Diagnosis of KD in children older than 10 years is usually delayed, and these patients are thus at a higher risk of CAAs.

Ureteric Complications of Renal Transplantation: The Impact of the Double J Stent and the Anterior Extravesical Ureteroneocystostomy

The urological complications of renal transplantation are well documented. In 1990, our experience of 507 consecutive renal transplants using the Leadbetter-Politano technique, which was unsplinted in the vast majority of patients, had a ureteric complication rate of 7.7%. Here, we report the long-term incidence and management of our ureteric complications in 1186 consecutive renal transplants done over the following 11 years using an extravesical onlay stented ureteroneocystostomy. We report a considerable reduction in the urological complications of renal transplantation to 3.8%. Furthermore, we were able to use percutaneous radiological techniques to salvage the majority (84.7%) of ureteric complications. Recourse to surgery was required rarely but enabled salvage of all treatment failures.

A pilot study on area under curve of mycophenolic acid as a guide for its optimal use in renal transplant recipients

Background & objectives:

The immunosuppressants administered to renal transplant subjects are usually monitored therapeutically to prevent graft rejection and drug toxicity. Mycophenolic acid (MPA) is an immunosuppressant. The present prospective study was undertaken to establish the utility of plasma level monitoring of MPA and to correlate it with clinical outcomes in renal transplant receipients.

Methods:

MPA plasma level at 2, 4 and 9 h and the area under concentration-time curve (AUC) were estimated using high performance liquid chromatography in 24 renal transplant recipients receiving immunosuppressant MPA plus tacrolimus and steroid.

Results:

There was wide inter-individual variation in MPA plasma level and the AUC. The incidences of gastrointestinal adverse drug events (diarrhoea and acidity) were significantly more in the high MPA AUC patients. Though biopsy proven acute rejection was not found, of the six subjects with lower MPA AUC (<30 mg.h/l), three were clinically diagnosed to develop tacrolimus nephrotoxicity. The Gastrointestinal Symptom Rating Scale (GSRS) and Gastrointestinal Quality of Life Index (GIQLI) scores represented better health related quality of life in lower MPA AUC than in the higher MPA AUC (>60 mg.h/l).

Interpretation & conclusions:

The present findings suggest the MPA AUC of 30 - 60 mg.h/l in the maintenance stage of renal transplant patients to have optimum clinical benefit and relegated adverse events profile indicating the usefulness of AUC of MPA with limited sampling strategy in optimizing its use.

Effect of bisphosphonates on bone mineral density after renal transplantation as assessed by bone mineral densitometry

INTRODUCTION

Steroid-induced osteoporosis is a major problem after organ transplantation. There is considerable evidence that bisphosphonates are effective in decreasing osteoporosis.

AIM

This prospective study was carried out to see the effects of bisphosphonates on bone mineral density (BMD) after successful renal transplantation.

MATERIAL AND METHODS

Fifty consecutive patients of successful renal transplantation were randomized into two groups. Group A (n = 27) received 35 mg/wk of Alendronate for 6 months after transplantation. Group B (n = 23) did not receive Alendronate and served as a control. Both groups underwent a pretransplant baseline dual-energy X-ray absorptiometry (DEXA) scan of their hips and lumber spines. Both groups received oral calcium and vitamin D supplement. Both groups were matched for the regimen and dose of immunosuppressive drugs. BMD was measured at 3 months and 6 months after transplantation.

RESULTS

Both groups showed a decline in BMD in early months posttransplantation. However, the 6-month DEXA scans showed a significant rise in BMD in group A as compared to group B.

CONCLUSION

Bisphosphonates appear to have a beneficial effect on steroid-induced bone loss.

Monitoring of anti-HLA and anti-Major histocompatibility complex class I related chain A antibodies in living related renal donor transplantation

This study was undertaken with the aim to analyze the clinical relevance of posttransplant anti-HLA and anti-major histocompatibility complex class I related chain A (MICA) antibodies in response to living related donor renal transplantation. A total of 185 consecutive post-renal transplant recipient serum samples were analyzed for the detection of anti-HLA and MICA antibodies using enzyme-linked immunosolvent assay techniques. Patients carrying both anti-HLA as well as anti-MICA antibodies (MICA(+)/HLA(+)) were the worst affected, showing significantly poorer graft survival compared with the MICA-/HLA-negative group (17% vs 89%, chi(2) = 19.63, P = .000). Similarly, patients with only MICA antibodies or those with only HLA antibodies also had significantly lower graft survival (P = .035 and P = .001, respectively) as compared to the nonsensitized group. The study illustrated that posttransplant monitoring antibodies to both MICA as well as HLA could be good predictors of renal allograft failure.

Lyme Disease: A Case Report with Typical and Atypical Lesions

Lyme disease is a multisystem infectious disease caused by the spirochete “Borrelia burgdorferi,” which is transmitted by “Ixodes” tick, with skin being the most common and earliest organ to be affected. Diagnosis of erythema chronicum migrans (ECM), which is the characteristic lesion of early disease, may help in early treatment and prevention of complications. Here, we are reporting a case of Lyme disease in a 10-year-old young boy from a non-endemic zone of Himachal Pradesh, who presented with typical as well as atypical ECM lesions. The clinical diagnosis was confirmed serologically, and the child was treated successfully with doxycycline.

Fungal panniculitis in renal transplant recipients

Panniculitis may result due to various etiologies. In post-transplant immunosuppressed patients infection is the foremost cause of panniculitis. We present 2 cases of fungal panniculitis in renal transplant recipients. The first patient presented with non-tender firm erythematous plaques on the left thigh. Biopsy showed panniculitis with cryptococci. Subsequent investigations revealed the presence of cryptococcal antigens in the blood, urine, and bronchoalveolar lavage fluid. There was no evidence of cryptococcal meningitis. The second patient complained of subcutaneous nodules on the trunk and right thigh. Biopsy of one of the nodules showed panniculitis with histoplasma. This patient had been treated earlier (inadequately) for disseminated histoplasmosis. Both the cases responded well to conventional amphotericin B therapy. Their renal functions remained stable.

Scintigraphic patterns of lymphocele in post-renal transplant

Lymphocele is a common cause of fluid collection in post-renal transplant patients. Most of these patients are routinely followed up with 99mTc diethylenetriaminepentaacetate renal dynamic scintigraphy. The present study retrospectively reviews the range of findings with renal dynamic scintigraphy in documented lymphoceles. A lymphocele was diagnosed when there was a pelvic collection on ultrasonography with a similar biochemical composition to plasma. Four types of scintigraphy patterns were noted in lymphocele in a total of 13 patients. In nine patients there was an initial photopenic area, which progressively filled up with tracer activity equal to that of the background level in delayed images. In two other patients, the activity in the initial photopenic area exceeded the background activity in delayed images. A persistently photopenic area was seen in early and delayed images in the two remaining patients. In addition, a rim of increased tracer activity was noted surrounding the photopenic area in four patients in the early images. In conclusion, an initial photopenic area (with or without a surrounding rim of increased tracer activity), which fills up with tracer in delayed images seems to be the most common pattern seen in lymphoceles in scintigraphic studies of renal transplants. The presence of a rim sign may add confidence to the reporting of a collection as a lymphocele.

Evaluation of lymphatic drainage in free flaps by lymphoscintigraphy: a preliminary study

Lymphatic drainage from free flaps was studied by lymphoscintigraphy in 14 patients in whom free vascularised flaps were used to cover defects caused by trauma or tumour ablation. Lymphoscintigrams were done after intradermal injection of Technetium-99m-Dextran in the flap and in the corresponding contralateral normal area. The retention of radioactivity at the injection sites after 1 h was computed and expressed as percentages of baseline activity at the time of injection. 25 studies were done in 14 patients at intervals varying from 9 days to 6 years postoperatively. In all cases, radioactivity was detected beyond the flaps in the lymphatic channels and draining lymph nodes. There was no significant difference (P = 0.27) between the retention of activity in the flaps (mean 88.68%; s.e.m. 1.25) and that in the corresponding contralateral control area (mean 86.88%; s.e.m. 1.35). This study shows that lymphatic drainage in a free flap is established early after surgery.

Heat shock protein (HSP) expression and proliferation of tubular cells in end stage renal disease with and without haemodialysis

BACKGROUND

Prolonged dialysis is associated with acquired cystic kidney disease (ACKD) and also higher incidence of renal cell carcinoma. Relationship among dialysis, tubular cell proliferation, development of cystic change and neoplastic transformation is not clearly known. Whether dialysis causes additional stress on tubular cells is also conjectural. Study of heat shock protein (HSP) expression which are rapidly synthesized in cells in response to a variety of stresses may be helpful in this regard.

METHODS

To evaluate dialysis induced early changes in end stage renal disease (ESRD), kidneys from eight adult autopsied patients were examined (group I) who were on weekly maintenance haemodialysis for 3-12 months. The heat shock protein (HSP 72/73) expression of tubular epithelial cells and their proliferating cell nuclear antigen (PCNA) labelling index (LI) were studied by immunohistochemistry using monoclonal antibodies. For comparison similar study was carried out in 10 cases of ESRD (Group II) of similar age and sex distribution who were not dialysed. The atrophic tubules were subtyped morphologically into (1) classic, (2) thyroid, (3) endocrine and (4) super tubules.

RESULTS

In the dialysed group (I) the percentage of hyperplastic super tubules (10.6 +/- 4.1%) was significantly higher than in the non-dialysed group (II) (5.2 +/- 1.3%) with a higher PCNA LI (6.8 +/- 2.04%) (group II 4.9 +/- 1.9%) (P < 0.01 to < 0.001). Though grossly not detected, but microscopic cysts and microadenoma like areas were seen in all the cases in group I with a mean diameter of 522.66 +/- 315.25 microns and 494.85 +/- 262.46 microns respectively. They were seen in one case of group II. PCNA LI of the cells in microadenoma (7.2 +/- 3.1%) and microcysts (6.6 +/- 2.6%) were similar to that of super tubules in group I. Quantitation of HSP expression by image analysis (optical density 2.309 +/- 0.155) showed a positive correlation (r = 0.7555) (P < 0.001) with PCNA LI in super tubules indicating a higher induction in the dialysed group.

CONCLUSIONS

This study suggests that haemodialysis may cause injury to tubular cells and aggravate stress on an already compromised situation of ESRD leading to increased cell proliferation and more hyperplastic supertubule formation which may be the forerunner of cyst formation as well as neoplastic transformation.