A 55-year-old female underwent right nephrectomy for renal cell carcinoma (RCC). The histopathology showed clear cell carcinoma. There was no evidence of metastasis. After remaining asymptomatic for eight years, she developed pain in the right loin. Abdominal ultrasound, computerized tomography (CT) Scan and magnetic resonance imaging (MRI) were suggestive of a tumor mass in the right renal area, multiple tumor masses in the left kidney and a mass in the gallbladder. Cholecystectomy, left radical nephrectomy and right adrenal mass with excision of adjacent lymph nodes were performed. The histopathology from all sites was suggestive of RCC. She was maintained on hemodialysis. Two and half years later she died after surgical exploration for spinal cord decompression due to metastasis to the dorsal spine.
We describe here hydrothorax that occurred in a patient on continuous ambulatory peritoneal dialysis (CAPD) and highlight the problems of diagnosis and management. A 48 years-old man with history of obstructive uropathy secondary to urolithiasis was stared on CAPD when he reached end-stage renal failure. Two months later, he was admitted with two days history of shortness of breath on exertion and dry cough increasing in supine position. Chest examination was suggestive of right sided pleural effusion confusion confirmed by chest X-ray. Radioisotope Technetium 99m labeled albumin instilled through the peritoneal catheter was detected in the right pleural fluid confirming the peritoneo-pleural leak. The peritoneal dialysis (PD) was discontinued and the patient was switched to hemodialysis. The pleural effusion subsided and has not recurred for the following three years.
End-stage renal disease (ESRD), due to its high morbidity and mortality as well as social and financial implications, is a major public health problem. Outcome depends not only on different modalities of treatment like hemodialysis and peritoneal dialysis, but also on existing co-morbidities, age, duration on dialysis, supportive therapies and infection control strategies. Thus, a detailed study becomes necessary to improve health care delivery, provide medical care and to establish a geographical reference. The present study was undertaken to characterize the ESRD patients by their demographic and co-morbid conditions and relate this to the morbidity and mortality trends. The medical records of 110 ESRD patients seen over a five-year period (June 1995 to December 1999) in two tertiary-care hospitals in Riyadh, Saudi Arabia were studied retrospectively. There were 79 (64.5%) males and 31 (35.5%) females; their age ranged from 17 to 92 years (mean age 53.8 +/- 17.8 years). Diabetes was the commonest cause of ESRD seen in 26 (26.6%) followed by nephrosclerosis, unknown etiology, lupus nephritis, pyelonephritis and primary glomerulonephritis. Diabetes mellitus was the most prevalent co-morbidity seen during the study period and occurred in 65 patients (59%) followed by heart disease in 36 (32.7%), liver disease in 30 (27.3%), cerebrovascular accidents in 13 (11.8%) and neoplasm in 11 (10%). Seven (6.3%) patients only were smokers. Hemodialysis was the most frequent treatment choice as renal replacement therapy. Among the causes of hospitalization, cardiovascular conditions were the leading single cause (19.1%), followed by access related reasons and infections (11.5% each). The overall hospitalization rate was 11.2 days/year. The overall mortality rate was 8.07 deaths/year. The leading cause of death was cardiovascular in 15 (51.7%) followed by unknown/sudden death in eight (27.5%). Other causes of death included fluid overload, gastrointestinal hemorrhage, septicemia, liver disease and pulmonary embolism. Diabetes was the commonest co-morbid cause among the deceased. Old age, diabetes mellitus, prolonged duration on dialysis and cardiac diseases were the common causes of mortality. Our findings are consistent with worldwide reports. The study provides a reference data and will hopefully be helpful in improving the medical care.
144 patients (107 adults and 37 children) belonging to a homogenous North Indian population who were hospitalised for acute post-streptococcal glomerulonephritis have been followed up for a period of ten years. The majority of these belonged to the lower socio-economic group. Varying degrees of proteinuria was present in 88.2%, hypertension in 62.5%, renal insufficiency in 61% and hematuria in 51.4% of the patients at the onset of the disease. By the end of the two years, 25 patients were dead because of rapid progression to end stage renal failure and 6 patients had mild to moderate renal insufficiency. Of the 119 patients who were alive at the end of the two years, 32 patients (who had shown a clinical recovery) were not available for further regular follow up and were excluded from the long term study, 87 patients were followed up beyond 2 years. In addition to 6 patients who were already in renal insufficiency at two years, 6 more developed renal failure on further follow up. 3 out of these 12 patients progressed to end stage renal failure 5 to 10.5 years after the onset of the disease. Persistence of nephrotic state, hypertension and renal insufficiency following an acute attack, and the presence of glomerular crescents on renal histology were associated with a poor outcome. Whereas only 2 out of 37 children died of end-stage renal failure, the majority of the deaths were in the adults (26 out of 107). Thus, 17% of the patients of acute post-streptococcal glomerulonephritis progressed to end stage renal failure within 2 weeks to 2 years, another 2% within 10 years and more than 6% will ultimately progress failure beyond 10 years.
A 23-year-old Saudi female presented with nephrotic syndrome. On renal biopsy she had primary focal and segmental glomerulosclerosis which was resistant to steroids. Two years later she presented with absent left arm pulses and on investigation a diagnosis of left ventricular thrombosis and thromboembolism of left brachial artery was made. Low antithrombin III, high fibrinogen levels and diuretic therapy were the possible causative factors for hypercoagulable state. On anticoagulation therapy initiated with heparin and continued with warfarin for 8 weeks there was complete dissolution of intraventricular and improvement of left brachial artery thrombosis. An early diagnosis and treatment of this potentially serious complication of nephrotic syndrome are stressed.
A 30-year-old seventh gravida presented with acute renal failure at 28 weeks of gestation. All her previous pregnancies were normal. With a differentional diagnosis of acute pyelonephritis, acute interstitial nephritis (cefuroxime induced) or rapidly progressive glomerulonephritis, treatment with antibiotics, intensive hemodialysis (HD) and pulse methylprednisolone followed by oral prednisolone was initiated. She was maintained on HD 5-6 times per week aiming at serum urea level of less than 15 mmol/L. After six weeks on HD, she underwent a cesarean section at 34 weeks of gestation with delivery of a baby weighing 1.6 kg. Percutaneous left renal biopsy performed one week post-delivery showed anti-glomerular basement membrane (GBM) antibody-mediated crescentic glomerulonephritis. The anti-GBM antibody, which was negative during pregnancy, was found to be positive at this juncture and remained so until ten months post-delivery while on HD. The patient continues to be on regular maintenance HD.
Ten cases of acute renal failure (ARF) were seen in the period from July 1990 to August 1991 in the Nephrology Department of the SIMS Hospital, Srinagar. All were males in the age group of 18-28 years and in apparent good health when apprehended by the police. There was alleged history of physical torture of different types. All had been beaten on the buttocks, back and limbs; in addition, 2 cases had been given repeated electric shocks and 1 case put to 'sit-and-stand' exercise for about 3 h. The interval between the first day of torture till they came to our observation varied from 4 to 11 days. The main clinical features at the time of presentation were generalized aches and weakness (10), oligoanuria (9), vomiting (8), hypertension (6), acidosis (10), facial puffiness and pedal edema (6), fever and shivering (3), pulmonary edema (2), stupor (4), and hyperkalemia (5). All the cases had an established ARF (serum creatinine 668-1,997 mumol/l and serum urea 21.8-71.8 mmol/l) when first seen. Muscle enzymes, creatine phosphokinase, lactic dehydrogenase and serum glutamic oxaloacetic transaminase were all significantly raised indicating rhabdomyolysis. All showed evidence of myoglobin casts in urine. Nine had oliguric and 1 had nonoliguric ARF. All except the 1 case with nonoliguric ARF were managed with peritoneal dialysis and/or hemodialysis. All recovered. Early recognition of ARF is important since the main attention in such cases is directed towards the surgical aspect.
