A case report of recurrent membranoproliferative glomerulonephritis after kidney transplantation due to ventriculoatrial shunt infection.

BACKGROUND: Transplant failure requires the consideration of numerous potential causes including rejection, acute tubular necrosis, infection, and recurrence of the original kidney disease. Kidney biopsy is generally required to approach these differential diagnoses. However, the histopathological findings on their own do not always lead to a definite diagnosis. Consequently, it is crucial to integrate them with clinical findings and patient history when discussing histopathological patterns of injury. The histopathologic finding of a membranoproliferative glomerulonephritis (MPGN) is one of the most challenging constellations since it does not refer to a specific disease entity but rather reflects a pattern of injury that is the result of many different causes. Whilst MPGN is occasionally classified as immune complex mediated, careful evaluation usually reveals an underlying disorder such as chronic infection, plasma cell dyscrasia, complement disorders, and autoimmune disease. CASE PRESENTATION: We describe the case of a 43-year-old woman who was referred to us because of a slowly rising serum creatinine 4 years after kidney transplantation. As in the native kidney, the biopsy revealed an MPGN pattern of injury. The cause of this finding had not been established prior to transplantation leading to a classification as idiopathic MPGN in the past. Further workup at the time of presentation and allograft failure revealed chronic infection of a ventriculoatrial shunt as the most probable cause. CONCLUSION: This case underlines the fact that MPGN is not a disease but a histopathological description. Consequently, the causative disorder needs to be identified to avoid kidney failure and recurrence after transplantation.

In-vitro comparison of the pullout strength of 3 different thoracic screw fixation techniques.

SUMMARY OF BACKGROUND DATA: Dvorak et al in 1993 and Husted et al in 2003 reported 2 different screw fixation techniques at the thoracic spine as alternatives to transpedicular screws. So far, there is no investigation comparing the pullout stability of all 3 possible screw fixation techniques. OBJECTIVE: To evaluate the stability of possible alternatives for transpedicular screw fixation. STUDY DESIGN: A biomechanical human cadaver investigation of the transpedicular and 2 different extrapedicular techniques was performed in the form of a comparative pullout test. MATERIALS AND METHODS: Eighteen human vertebral bodies from Th7 to Th9 were harvested from 6 donors, dissected from surrounding tissue, and matched to 3 different fixation groups. As alternatives for transpedicular screw fixation, an extrapedicular supratransverse screw insertion from posterolateral and a tricortical screw fixation technique, penetrating the transverse process and reentering the vertebral body at the pedicle base were evaluated biomechanically. A unilateral screw fixation was performed in one of the described techniques. Axial pullout strength was measured using a Zwick Z50 servoelectric testing machine. RESULTS: The average pullout strength of the pedicle screws was 400 N, whereas the supratransverse and the pertransverse screw fixation resisted 370 N pullout force on average. There was neither a statistic significant difference between the pullout forces of the 3 groups nor a significant correlation of pullout strength and bone mineral density measured by quantitative computed tomography. CONCLUSIONS: In-vitro pullout resistance of thoracic screw fixation does not differ significantly in intrapedicular and extrapedicular insertion techniques.

Hyponatremia and seizures caused by triamcinolone-induced adrenal insufficiency.

BACKGROUND: A 49-year-old woman presented to hospital with an 18-month history of hyponatremic episodes, nausea, vomiting, anorexia and fatigue. INVESTIGATIONS: Physical examination, laboratory tests including full blood count, measurement of electrolytes, hormones, autoantibodies, thyroid and renal function, corticotropin-releasing-hormone stimulation test, 24 h urinalysis and abdominal ultrasonography. DIAGNOSIS: Severe symptomatic hyponatremia in a patient with secondary adrenal insufficiency caused by treatment of lumbago with triamcinolone injections. MANAGEMENT: Hydrocortisone replacement therapy (15 mg daily) for 3 months, followed by a tapering schedule over 12-24 months.