Calciphylaxis in uraemic and nonuraemic settings: clinical risk factors and histopathological findings.

BACKGROUND: Calciphylaxis is a life-threatening cutaneous ulcerative/necrotic disease characterized by vascular calcification/occlusion. It occurs most commonly in end-stage kidney disease (ESKD), known as uraemic calciphylaxis (UC) but can also occur in patients with chronic kidney disease (CKD) and normal kidney function (nonuraemic calciphylaxis; NUC). There are few large series of NUC in the literature. AIM: To compare the clinicopathological features of UC and NUC. METHODS: We retrospectively compared the clinicopathological features of 35 patients with NUC during the period 2010-2020 with those of 53 patients with UC (control group). Cases were classified as NUC in the absence of all of the following: ESKD, significant CKD (defined as serum creatinine > 3 mg/dL or creatinine clearance < 15 mL/min) and acute kidney injury requiring kidney replacement therapy or kidney transplantation. RESULTS: NUC represented 40% of the total cases, and there was a higher number of women (P < 0.01) and a higher median body mass index (P = 0.06) compared with the control UC group. Elevated parathyroid hormone was present in 44% of patients with NUC. Most of the tested patients were positive for lupus anticoagulants (56%). NUC biopsies showed a higher rate of extravascular calcium deposits (73% vs. 47%, P = 0.03). Dermal reactive vascular proliferation was the most common dermal change (32%). CONCLUSIONS: NUC is more common than previously reported and shows a higher predilection for obese postmenopausal women. Undiagnosed hyperparathyroidism shows a possible association with NUC. Lupus anticoagulants were positive in most patients. NUC biopsies are more likely than UC biopsies to display extravascular calcium deposition.

Functional Outcomes of Arteriovenous Fistulas Created by Nephrologist.

Background Nephrologists worldwide, after undergoing surgical training, have reported creating arteriovenous fistulas (AVFs). Objective To demonstrate the functional outcome of arteriovenous fistulas created by a trained Nepalese nephrologist. Method This was a cross sectional study. A convenient sampling method was used and all consecutive AVFs created by a single nephrologist from January 2016 to December 2018 were included to assess their functional status within 3 months of creation. Patients with incomplete data and no follow up for up to 3 months post surgery were excluded. Result One hundred sixty six (166) arteriovenous fistulas were created during the study period; mean age of the patients was 52 ± 14 years, 121 (75%) male and 65 (39%) were diabetic. The most common site of arteriovenous fistula creation was left radiocephalic (Lt RC) 69(41.5%), followed by left brachiocephalic (Lt BC) 66(39.7%). Other sites were left brachiobasilic (Lt BB) 10(6%), right brachiocephalic (Rt BC) 10(6%), right radiocephalic (Rt RC) 9(5.4%) and right brachiobasilic (Rt BB) 2(1.2%). 139 arteriovenous fistulas (83.7%) were functional within 3 months post creation. Functional outcomes of radiocephalic, brachiocephalic and brachiobasilic arteriovenous fistulas were 75.6%, 90.7% and 100% respectively at 3 months post creation. Lymphoceles developed in three Lt BC arteriovenous fistulas, thrombosis in two Lt BC arteriovenous fistulas and infection in two Lt BC arteriovenous fistulas with pseudoaneurysm formation. Conclusion The functional outcome of arteriovenous fistulas created by a trained Nepalese nephrologist is similar to that reported in the literature.

A large splenic cyst mimicking diabetic gastroparesis.

Splenic cysts are rare, many of which are asymptomatic and incidental finding. We report an interesting case of a large incidental splenic cyst in a young diabetic patient who presented with diabetic ketoacidosis and mimicking gastroparesis. The differential diagnosis and management of splenic cysts is discussed.

Marked hyperuricemia with acute renal failure: need to consider occult malignancy and spontaneous tumour lysis syndrome.

Spontaneous tumour lysis syndrome (TLS) is an extremely uncommon cause for acute renal failure (ARF). ARF presenting with hyperkalemia, hyperuricemia and hyperphosphatemia should lead to further work up for occult haematological malignancy. We describe two cases of lymphoma presenting with ARF secondary to spontaneous TLS. The ARF in the first case appeared to be due to intravenous volume depletion but eventually lead to the diagnosis of gastric lymphoma. The second patient is interesting as he is probably the first reported case of lymphoma with HIV infection presenting as spontaneous TLS. Early diagnosis and prompt renal replacement therapy does not necessarily reverse the ARF.

Curvularia geniculata fungal peritonitis: a case report with review of literature.

Peritonitis is the "Achilles heel" of patients on peritoneal dialysis. Fungal peritonitis though not that common is associated with increased morbidity and mortality. We report the first case in the literature of a patient who developed peritonitis caused by Curvularia geniculata. We discuss the reported cases of Curvularia lunata peritonitis in literature and emphasize the early removal of catheter and treatment with intravenous amphotericin B.

Hyponatremia in critically ill patients.

Disorders of sodium and water metabolism are frequently encountered in hospitalized patients. Hyponatremia in critically ill patients can cause significant morbidity and mortality. Inappropriate treatment of hyponatremia can add to the problem. The diagnosis and management of salt and water abnormalities in critically ill patients is often challenging. The increasing knowledge about aquaporins and the role of vasopressin in water metabolism has enhanced our understanding of these disorders. The authors have outlined the general approach to the diagnosis and management of hyponatremia. A systematic approach by clinicians, using a detailed history, physical examination, and relevant diagnostic tests, will assist in efficient management of salt and water problems.

Heme oxygenase modulates selectin expression in different regional vascular beds.

Heme oxygenase (HO) catalyzes the degradation of heme to biliverdin, iron, and CO. The inducible isoform (HO-1) has been implicated as a modulator of the inflammatory response. HO-1 activity can be induced by hemin and inhibited with zinc protoporphyrin IX (ZnPP). Using these reagents, we assessed the possibility that HO-1 modulates the inflammatory response by altering the expression of endothelial cell adhesion molecules. Endotoxin (lipopolysaccharide, LPS)-induced expression of P- and E-selectin expression was quantified in different vascular beds of the rat using the dual radiolabeled monoclonal antibody technique. Pretreatment with hemin attenuated, whereas ZnPP treatment exacerbated, the increased selectin expression normally elicited by LPS. Biliverdin, at an equimolar dosage, was as effective as hemin in attenuating LPS-induced selectin expression in the lung, kidneys, liver, and intestines. These findings indicate that the anti-inflammatory properties of HO-1 may be related to an inhibitory action of P- and E-selectin expression in the vasculature. Biliverdin (or its metabolite, bilirubin), rather than CO, may account for this action of HO-1 on endothelial cell adhesion molecule expression.

Percutaneous renal biopsy using Monopty needle.

Forty six percutaneous renal biopsies (thirty one native and fifteen transplant kidneys) were performed using the Monopty needle, compared with equal number of biopsies performed using the Travenol Tru-cut needle. The core length of samples obtained ranged from 3-16 mm using Monopty and 5-13 mm using Tru-cut. Adequate tissue was obtained in 65.5% and 80.4% of cases with the use of Monopty and Tru-cut respectively. Both the needles gave equal number of reuses. The use of Tru-cut needle was associated with serious complications like gross haematuria requiring blood transfusions and perinephric haematoma in ten cases whereas only two cases developed haematuria when the Monopty needle was used. In view of its greater safety we have switched over to using the Monopty needle for percutaneous renal bipsies.