Background. Infections caused by the pandemic H1N1 2009 influenza virus range from mild upper respiratory tract syndromes to fatal diseases. However, studies comparing virological and immunological ...profile of different clinical severity are lacking. Methods. We conducted a retrospective cohort study of 74 patients with pandemic H1N1 infection, including 23 patients who either developed acute respiratory distress syndrome (ARDS) or died (ARDS-death group), 14 patients with desaturation requiring oxygen supplementation and who survived without ARDS (survived-without-ARDS group), and 37 patients with mild disease without desaturation (mild-disease group). We compared their pattern of clinical disease, viral load, and immunological profile. Results. Patients with severe disease were older, more likely to be obese or having underlying diseases, and had lower respiratory tract symptoms, especially dyspnea at presentation. The ARDS-death group had a slower decline in nasopharyngeal viral loads, had higher plasma levels of proinflammatory cytokines and chemokines, and were more likely to have bacterial coinfections (30.4%), myocarditis (21.7%), or viremia (13.0%) than patients in the survived-without-ARDS or the mild-disease groups. Reactive hemophagocytosis, thrombotic phenomena, lymphoid atrophy, diffuse alveolar damage, and multiorgan dysfunction similar to fatal avian influenza A H5N1 infection were found at postmortem examinations. Conclusions. The slower control of viral load and immunodysregulation in severe cases mandate the search for more effective antiviral and immunomodulatory regimens to stop the excessive cytokine activation resulting in ARDS and death.
Acute renal impairment in coronavirus-associated severe acute respiratory syndrome.
Severe acute respiratory syndrome (SARS) is a newly emerged infection from a novel coronavirus (SARS-CoV). Apart ...from fever and respiratory complications, acute renal impairment has been observed in some patients with SARS. Herein, we describe the clinical, pathologic, and laboratory features of the acute renal impairment complicating this new viral infection.
We conducted a retrospective analysis of the plasma creatinine concentration and other clinical parameters of the 536 SARS patients with normal plasma creatinine at first clinical presentation, admitted to two regional hospitals following a major outbreak in Hong Kong in March 2003. Kidney tissues from seven other patients with postmortem examinations were studied by light microscopy and electron microscopy.
Among these 536 patients with SARS, 36 (6.7%) developed acute renal impairment occurring at a median duration of 20 days (range 5–48 days) after the onset of viral infection despite a normal plasma creatinine level at first clinical presentation. The acute renal impairment reflected the different prerenal and renal factors that exerted renal insult occurring in the context of multiorgan failure. Eventually, 33 SARS patients (91.7%) with acute renal impairment died. The mortality rate was significantly higher among patients with SARS and acute renal impairment compared with those with SARS and no renal impairment (91.7% vs. 8.8%) (P < 0.0001). Renal tissues revealed predominantly acute tubular necrosis with no evidence of glomerular pathology. The adjusted relative risk of mortality associated with the development of acute renal impairment was 4.057 (P < 0.001). By multivariate analysis, acute respiratory distress syndrome and age were the most significant independent risk factors predicting the development of acute renal impairment in SARS.
Acute renal impairment is uncommon in SARS but carries a high mortality. The acute renal impairment is likely to be related to multi-organ failure rather than the kidney tropism of the virus. The development of acute renal impairment is an important negative prognostic indicator for survival with SARS.
ABSTRACT
Aim: Living kidney donation provides the best source of kidney graft. The mortality and morbidity rates are small but the long‐term effects have not been studied. This is a report on our ...29‐year experience of living kidney donation.
Methods: All living donors were arranged to have follow‐ups. Defaulters were traced via a territory‐wide computer system.
Results: A total of 149 living kidney donor operations were performed. 136/149 records were available. 41 defaulted follow‐up. One donor died of multiple myeloma. The male to female ratio was 1.00 to 1.52. Mean age at donation was 33.94 ± 9.66 years. Mean follow‐up duration was 160.39 ± 87.96 months. Hypertension was diagnosed in 27 donors (19.9%). 22 donors (17.3%) had stage 3 chronic kidney disease (CKD). Glomerular filtration rate (GFR) dropped from 90.95 ± 15.62 mL/min per 1.73 m2 at time 0 to 66.29 ± 12.06 mL/min per 1.73 m2 at 2 years. GFR improved subsequently and remained stable for 25 years. Age at donation was associated with hypertension (HT) in univariate and multivariate analyses. HT was not associated with sex or GFRs over time. Using binary logistic regression, age at donation was associated with the development of stage 3 CKD and GFR before donation was associated with lower CKD risk. In multivariate analysis, only age at donation was associated with CKD. Other co‐morbidities included: hyperlipidaemia 16/136, diabetes mellitus 6/136, cardiovascular event 1/136, stroke 1/136 and cancer 5/136.
Conclusions: Living kidney donors had reductions in GFR post uninephrectomy with subsequent improvement. A significant proportion developed HT and stage 3 CKD. Age at donation was a strong determinant of development of HT and stage 3 CKD.
In this review, the authors describe their single‐centre experience with 149 live donors over 29 years. Hypertension developed in 19% of the donors with stage 3 CKD developing in 17.3%. Age was the main predisposing factor for the development of hypertension and CKD.
ABSTRACT
Aim: Nocturnal home haemodialysis (NHHD) was started in Hong Kong in 2006. The experience of 1 year of NHHD with an alternate night schedule in two local centres is reported.
Methods: The ...clinical parameters of 14 patients who had completed 1 year of NHHD were retrospectively analyzed. All patients were receiving an alternate night schedule (3.5 sessions/week) for 6–8 h/session.
Results: After 1 year of NHHD, haemoglobin levels increased from 9.6 ± 1.6 g/dL before NHHD to 11.4 ± 2.2 g/dL (P < 0.05) despite a reduction in erythropoietin dose requirement from 120.6 ± 44.3 to 59.4 ± 74.6 U/kg/week (P < 0.05). Four patients (29%) were able to stop taking erythropoietin after NHHD. Serum phosphate levels reduced from 2.33 ± 0.41 to 1.59 ± 0.29 mmol/L (P < 0.01) and calcium phosphate product decreased from 5.29 ± 0.96 to 3.74 ± 0.90 mmol2/L2 (P < 0.01). Phosphate binder dose was greatly reduced and eight patients (67%) were able to stop taking phosphate binders. The number of antihypertensive medications tended to reduced from 2.5 ± 1.3 to 1.6 ± 1.5 (P = 0.067) with four patients (29%) able to stop antihypertensives. Left ventricular mass index decreased from 186 ± 62 to 168 ± 60 g/m2 (P = 0.463) although this was not statistically significant. Weekly spKt/V during conventional haemodialysis was 3.63 ± 0.95 while that during NHHD was three times higher at 11.09 ± 6.44 (P < 0.01). The quality of life indexes also showed improvement.
Conclusion: This 1 year experience of alternate night NHHD demonstrates benefits in terms of anaemia control, erythropoietin requirement, serum phosphate and calcium phosphate product reduction, blood pressure control, haemodialysis adequacy and quality of life. NHHD with an alternate night schedule is a promising dialytic therapy for patients receiving chronic haemodialysis in this locality.
This paper demonstrates that nocturnal haemodialysis can be performed in Asia. The Hong Kong group have enthusiastically embraced this technology and demonstrate their progress.
Department of Medicine and Geriatrics, 1
Department of Pharmacy, 2 Princess Margaret Hospital,
Hong Kong, China
Correspondence to: K.H. Chu, Department of Medicine and Geriatrics, Princess
Margaret ...Hospital, Lai Chi Kok, Hong Kong SAR, China.
pmhrenal{at}gmail.com
Background: Peritoneal dialysis (PD)-related infections
are the major cause of technique failure. Exit-site infections (ESI) can be
prevented by local application of antibiotics. Mupirocin (M) is the most
extensively studied drug for this application. Long-term use can result in the
development of resistance. Gentamicin (G) is an attractive alternative, with
both gram-positive and gram-negative activities. We studied the comparative
efficacy of G cream versus M ointment in the prevention of PD-related
infections in a Chinese cohort.
Methods: This was a prospective study of adult PD
patients of the Princess Margaret Hospital, Hong Kong. Patients were excluded
if they had active infection, recent ESI or peritontiis, history of allergy to
either drug, or were unable to apply the drug or give consent. Patients were
taught to apply the drug daily to the exit site after routine exitsite care.
Records were tracked prospectively during hospital admissions and clinic
follow-ups.
Results: 95 patients were recruited; 14 discontinued
the study. The ESI rates were 0.38 and 0.20 episodes/patient-year for the G
group and the M group respectively ( p = 0.36). Gram-positive ESI
rates were 0.18 and 0 episodes/patient-year for the G group and the M group
respectively. Gram-negative ESI rates were 0.20 episodes/patient-year for both
groups ( p = 0.62). The overall peritonitis rates were similar in the
two groups ( p = 0.91).
Discussion: In addition to good perioperative care and
strict exit-site care, local antibiotic application can prevent ESI. Mupirocin
has been extensively studied and shown to be effective. Similar if not
superior effects of G cream have been demonstrated. In this study, neither
antibiotic gave significantly better results in the prevention of either ESI
or peritonitis.
Conclusions: Both gentamicin and mupirocin were
effective as prophylaxis for ESI. Longer study is required to determine the
long-term efficacy and the potential beneficial effect on the prevention of
peritonitis.
KEY WORDS: Exit-site infection; peritonitis; prophylaxis; gentamicin; mupirocin.
Received 28 February 2007;
accepted 14 May 2008.
Aim: Secondary hyperparathyroidism is common in chronic kidney disease. When medical treatment fails, subtotal or total parathyroidectomy with autoimplant is done but both are associated with a high ...recurrence rate. The third surgical strategy is total parathyroidectomy without autoimplant. We evaluate the outcomes of patients who had total parathyroidectomy with no autoimplant.
Methods: Thirteen patients who had total parathyroidectomy without autoimplant were prospectively studied from 1998–2002. Intact parathyroid hormone, biochemistry and bone mineral densities were measured at baseline and serially. All patients had bone biopsies done preoperatively and seven had repeat bone biopsies at a mean of 37.7 months postoperatively. Histomorphometric studies were done for all bone biopsies. Patients were observed for fractures.
Results: Five patients were on haemodialysis and eight on peritoneal dialysis. Mean duration of follow up was 68 months. Postoperatively, mean intact parathyroid hormone decreased precipitously and remained within or just above normal. Mean serum calcium phosphate product decreased and remained normal. Out of seven patients who had repeat bone biopsies, two showed reversal of hyperparathyroid bone disease to normal, two had mild hyperparathyroidism, while three had adynamic bone disease. One patient with adynamic bone disease subsequently developed biochemical recurrence of hyperparathyroidism. Serial bone densitometry showed remarkable improvement. There was no fracture.
Conclusion: In the studied series of total parathyroidectomy without autoimplant, adynamic bone disease occurred in three out of seven repeat bone biopsies while improvement occurred in the rest. Bone mineral density was much improved and there was no fracture.
Total parathyroidectomy without autoimplantation was effective for improvement of bone mineral density in dialysis patients. Although no fracture was documented, the authors still found a certain patients (3 out of 7) with adynamic bone disease at repeated bone biopsies.
We evaluated the effectiveness of local application of mupirocin ointment at the catheter exit site in preventing exit-site infection and peritonitis attributable to gram-positive organisms in ...continuous ambulatory peritoneal dialysis patients.
This prospective randomized controlled trial included 154 patients. They were randomly allocated to a mupirocin-treated group (group M) and a control group (group C). Group M included 73 patients (47.4%) who were instructed to apply mupirocin ointment to the catheter exit site once daily after the routine daily exit-site dressing. Group C included 81 patients (52.6%) who continued their usual daily exit-site care without applying mupirocin. The two groups were followed to see whether there would be any difference in the frequency of exit-site infection and peritonitis or in the infecting organisms.
Interim data were collected at 5 months after the start of the study. Those data showed a significantly lower incidence of exit-site infection and peritonitis attributable to gram-positive organisms in group M as compared with group C. The incidence of gram-positive exit-site infection in group C was 1 episode per 36.8 patient-months; in group M, the incidence was 1 episode per infinity patient-months (0 incidence in 5 months, p < 0.05). The incidence of gram-positive peritonitis in group C was 1 episode per 40.5 patient-months; in group M, the incidence was 1 episode per 365 patient-months (p < 0.05). Mupirocin treatment had no significant effect on the incidence of exit-site infection and peritonitis attributable to other organisms. Before mupirocin treatment, we saw a trend toward higher infection rates in diabetic patients and nasal carriers of Staphylococcus aureus as compared with non diabetic patients and nasal non carriers, although the differences were not statistically significant. Mupirocin brought the infection rate attributable to gram-positive organisms to an equally low level in diabetic and non-diabetic patients, and in nasal carriers and nasal non carriers of S. aureus. No adverse effect of local application of mupirocin was reported.
Local application of mupirocin ointment at the catheter exit site is a safe and effective method of preventing exit-site infection and peritonitis involving gram-positive organisms.
Disorders of bone mineral metabolism are common in advanced renal failure. These are associated with significant morbidity and mortality. We report our experience on the management of renal bone ...disease over a period of 25 years. Between 1982 and 2007, 192 patients had bone biopsies. We found that the epidemiology had changed over these 25 years. While hyperparathyroid bone disease remained the predominant histological type (86%), aluminium-related osteomalacia disappeared. Reduced exposure to aluminium due to decreased use of aluminium-based phosphate binder and better water treatment were among the likely causes. Newer forms of adynamic bone disease were non-aluminium-related and likely resulted from factors such as older patients, more diabetics and oversuppression of parathyroid hormone (PTH). Seventy-four patients underwent parathyroidectomy (PTx), which produced satisfactory control of calcium, phosphate and PTH levels with a mean follow-up of 5 years. Intact PTH (iPTH) levels were kept at 2-5 times of normal throughout the study. Post-PTx mean calcium × phosphate products showed remarkable improvement at 3.80-4.58 mmol
2/L
2. Thirty-two (47%) patients underwent PTx without autoimplantation. Post-PTx iPTH, calcium and phosphate levels were similar between the implantation and no implantation groups. Time to recurrence of hyperparathyroidism was earlier in the implantation group. No fracture was observed in either group after PTx. PTx without implantation should be considered for patients who have a low chance for kidney transplantation.
Mercury is a known cause of nephrotic syndrome and the underlying renal pathology in most of the reported cases was membranous nephropathy. We describe here 4 cases of minimal change disease ...following exposure to mercury-containing skin lightening cream for 2 - 6 months. The mercury content of the facial creams was very high (7,420 - 30,000 parts per million). All patients were female and presented with nephrotic syndrome and heavy proteinuria (8.35 - 20.69 g/d). The blood and urine mercury levels were 26 - 129 nmol/l and 316 - 2,521 nmol/d, respectively. Renal biopsy revealed minimal change disease (MCD) in all patients. The use of cosmetic cream was stopped and chelation therapy with D-penicillamine was given. Two patients were also given steroids. The time for blood mercury level to normalize was 1 - 7 months, whereas it took longer for urine mercury level to normalize (9 - 16 months). All patients had complete remission of proteinuria and the time to normalization of proteinuria was 1 - 9 months. Mercury-containing skin lightening cream is hazardous because skin absorption of mercury can cause minimal change disease. The public should be warned of the danger of using such products. In patients presenting with nephrotic syndrome, a detailed history should be taken, including the use of skin lightening cream. With regard to renal pathology, apart from membranous nephropathy, minimal change disease should be included as another pathological entity caused by mercury exposure or intoxication.
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