Saprochaete capitata (Geotrichum capitatum), an emerging fungal infection in kidney transplant recipients.

We are reporting the case of an 82-year-old Yemeni patient, renal transplant recipient who was admitted to our institution and who subsequently developed disseminated infection with Saprochaete capitata. This pathogenic fungus is rarely reported in patients with solid organ trans-plants. Saprochaete capitata is an emerging fungal pathogen, ubiquitously spread in the environment. This is the second case to our knowledge of infection with Saprochaete capitata in a renal transplant patient. Our patient was treated for multiple nosocomial infections with prolonged antibiotic courses. He succumbed to the infection with Saprochaete capitate after several weeks spent in the intensive care unit.

Radiologic findings in infected and noninfected scleral buckles.

PURPOSE: To present the radiologic findings in scleral buckle infections and in the early postoperative period after scleral buckling. METHODS: Retrospective multicenter orbital computed tomography (CT) study of 14 patients and brain magnetic resonance (MR) in one patient with scleral buckle infections, some with the referring diagnosis of endophthalmitis, proliferative vitreoretinopathy, orbital cellulitis, or unilateral headache. The control population consisted of early postoperative prospective CT study of 38 consecutive patients with scleral buckle without clinical infection. RESULTS: Diffuse scleral thickening and preseptal soft tissue swelling were noted in acute scleral buckle infections. Scleral thickening decreased radiologically following prompt antibiotic therapy in five patients with acute infections. Silicone sponge had low attenuation without infection and high attenuation with infection. In chronically infected scleral buckle, the sclera was thickened around the buckle, with scleral melt under the buckle. MR showed increased signal intensity in the preseptal region in one patient with chronic fungal infection. In the controls, two had thickening of the sclera without soft tissue swelling. CONCLUSIONS: CT or MR can assist in the early diagnosis and management of scleral buckle infections.

Anterior ischaemic optic neuropathy after coronary artery bypass graft: the role of anaemia in diabetics.

PURPOSE: To ascertain factors associated with anterior ischaemic optic neuropathy (AION) following coronary artery bypass graft (CABG) in a Lebanese population. METHODS: A retrospective chart review of consecutive CABG performed over a 5-year period (1995-1999) in one medical centre. A comparison of clinical characteristics was carried out between AION cases and subjects free from AION. The variables analysed included history of diabetes as well as preoperative, intraoperative, or postoperative values of haematocrit, blood sugar, oxygen saturation, and arterial blood pressure. RESULTS: A total of 1,594 persons were included. Three subjects experienced acute visual loss from AION following CABG, all had diabetes mellitus, and two suffered from severe postoperative anaemia. Among diabetics (n=484), the risk of AION was significantly higher in subjects with postoperative haematocrit falling below 22 (28.6%) than the rest (0.21%) (P=0.001). Blood transfusion was given in two subjects with prompt visual recovery. CONCLUSIONS: Severe anaemia in patients undergoing CABG appears to be a risk factor for AION, especially in diabetics, and needs prompt correction to prevent or reverse the ischaemic ocular events.

A controlled sequential evaluation of open donor nephrectomy versus classical and modified laparoscopic donor nephrectomy: an update.

This study sought to determine the procedure of choice for kidney retrieval for transplantation by comparing open donor nephrectomy to laparoscopic donor nephrectomy and modified laparoscopic donor nephrectomy and by analyzing intraoperative donor and recipient graft function parameters. In this single-center, controlled, sequential analysis, 100 consecutive donor-recipient pairs were recruited, grouped according to surgical procedure, and operated upon between 1997 to 2004, as follows: group 1, open donor nephrectomy (n = 30), performed from 1997 to 2000; group 2, laparoscopic donor nephrectomy (n = 28), performed from 2000 to 2002; and group 3, modified laparoscopic donor nephrectomy (n = 42), performed from 2002 to 2004. Data were analyzed by type of operative procedure, graft function, length of hospital stay, and donor recovery time. Operative time was similar for all three surgical approaches. Warm ischemia times for open donor nephrectomy and modified laparoscopic donor nephrectomy were similar. Acute tubular necrosis occurred in 7% of patients in all groups. Donor recovery and lengths of hospital stay were significantly shorter for laparoscopic approaches. Donor complications were similar in numbers, differing only in complication type. Graft function and survival were similar for all three surgical approaches. We conclude that modified laparoscopic donor nephrectomy is the procedure of choice for living kidney retrieval.

A controlled sequential evaluation of laparoscopic donor nephrectomy versus open donor nephrectomy: an update.

INTRODUCTION: In this study, we compared laparoscopic (lap Nx) to open donor nephrectomy (open Nx) with specific emphasis on outcomes in the donor and recipient. METHODS: This single-center sequential analysis recruited 100 consecutive donor-recipient pairs operated on from 1997 until 2003. The open Nx (n = 30), were performed between 1997 and 2000; the lap Nx (n = 70) were performed between 2000 and 2003. Prospective records included operative data, anatomic details of the graft, hospital stay, and donor recovery. RESULTS: Donor characteristics and renal function were similar for open Nx and lap Nx. Operative parameters were similar except for the longer warm ischemia time in lap Nx versus open Nx (3.14 +/- 2.10 vs 1.5 +/- 0.5 minute, P < .001). Donor complications were equivalent in number, but differed in spectrum with a trend toward more intraoperative complications with lap Nx versus more postoperative complications for open Nx. Donor recovery, hospital stay, and return to work were improved in lap Nx versus open Nx (P < .001). Renal function of grafts after lap Nx were similar to open Nx: 2-year serum creatinine values of 1.26 +/- 0.21 versus 1.31 +/- 0.40, respectively. Graft survivals were similar. CONCLUSION: Compared to open Nx lap Nx offers major advantages to the donor, and yields similarly favorable results in graft outcomes. However, it is more surgically demanding. Consequently, lap Nx should be adopted as the procedure of choice for living kidney retrieval.

Predictors of bone mineral density in patients on hemodialysis.

Renal osteodystrophy is a universal complication of uremia. Renal failure patients are at risk for low bone mineral density (BMD) and fractures. Parathyroid hormone (PTH) plays a pivotal role in the pathophysiology of uremic bone disease. Histomorphometric studies suggest that the maintenance of PTH levels between two and four times the upper limit of normal is associated with the lowest prevalence of two common forms of osteodystrophy: osteitis fibrosa cystica and adynamic bone disease. The purpose of this study was to investigate whether the above recommendation for PTH levels in dialysis patients corresponds to a more optimal BMD with a special emphasis on diabetic versus nondiabetic subjects. Twenty-eight patients with chronic renal failure on hemodialysis underwent measurement of PTH levels, as well as BMD at the lumbar spine, hip, and forearm. They were divided into three groups based on the mean PTH level over the 5 years prior to having BMD measured. Osteoporosis was diagnosed in 55% of men and 87% of women on dialysis. Predictors of BMD were gender, duration on hemodialysis, and diabetes. Our study supports the histomorphometry-based studies suggesting that the maintenance of intact PTH levels two to four times the upper limit of normal may be associated with better skeletal health in uremic patients on hemodialysis, and that the diabetic subgroup is at particular risk for low BMD.

Tamoxifen and ovarian cysts: a prospective study.

PURPOSE: To prospectively follow a group of women with breast cancer on tamoxifen for the development of ovarian cysts. METHODS: 72 women were followed every 6 months with pelvic examination and vaginal ultrasound. Chi square and Student's t-test were used for statistical analysis. RESULTS: The duration of treatment was 31.5+/-20 months. The mean age was 51.2+/-9.8 years. 55.6% were post-menopausal. Out of 72 women, 18 (25%) developed ovarian cysts. The mean age of women who developed ovarian cysts was significantly lower than in those who did not (47.0+/-7.0 and 52.5+/-10.2 years, respectively, P=0.03), however, the mean duration of treatment was not significantly different (33.3+/-17.4 and 29.3+/-20 months, respectively, P=0.45). Out of 32, 14 (43.8%) pre-menopausal and out of 40, 4 (10%) post-menopausal women developed ovarian cysts (P=0.003). They developed the cysts after an average duration of 33.3+/-18 and 50.7+/-6.2 months, respectively (P=0.7). The average diameter of the cysts was 2.8+/-1.2 cm. All cysts were simple except for one pre-menopausal women. All the cysts in post-menopausal women resolved spontaneously. One pre-menopausal patient had a multi-loculated cyst, was operated and had a serious cystadenoma. In nine patients, the cysts resolved spontaneously and in three after discontinuation of tamoxifen, and one patient was lost to follow-up. All cysts were asymptomatic. CONCLUSION: Ovarian cysts frequently develop in women with breast cancer on tamoxifen. The majority of the cysts resolve spontaneously, therefore an expectant management with follow-up ultrasonography is recommended.

Perirenal fluid in renal parenchymal medical disease ('floating kidney'): clinical significance and sonographic grading.

AIM: To study the clinical significance and radiologic features of perirenal fluid in patients with renal parenchymal disease. MATERIALS AND METHODS: During the previous 5 years, nine patients were found to have perirenal fluid on sonography associated with renal parenchymal medical disease. The clinical, radiological, histopathological and laboratory data were analysed. RESULTS: The perirenal fluid is a spontaneous subcapsular transudate in patients suffering from a nephropathy with a sodium retention state, with or without renal failure. Three sonographic patterns of perirenal fluid were observed: grade 1 is a thin layer of perirenal fluid; grade 2 is a moderate amount of perirenal fluid collection with indentations of the renal parenchyma and strands in the fluid, grade 3 is a large fluid collection surrounding the kidney. CONCLUSION: The perirenal fluid represents a sign of sodium retention state and oedema in patients with intrinsic renal parenchymal medical disease which may be caused by several nephropathies.

Reversal of impaired calcium homeostasis in the rat diaphragm subjected to Monocrotaline-induced pulmonary hypertension.

Monocrotaline (MCT) pneumotoxicity is known to alter the structure of pulmonary vascular wall and impairs endothelial cell function resulting in pulmonary hypertension. Its effect on the diaphragm muscle has not yet been elucidated. This study examines the effect of MCT pneumotoxicity on calcium transport in the rat diaphragm. Pulmonary hypertension induced by MCT pneumotoxicity caused a significant increase (P < 0.001) in calcium accumulation in strips isolated from rat diaphragms. Treatment of rats having received MCT with Indapamide reduced calcium uptake by diaphragmatic strips to levels that are not significantly different from the control (P > 0.05). Treatment with Indapamide alone did not elicit any change in calcium accumulation in the diaphragmatic strips. Treatment of the animals with MCT, Indapamide or both did not produce any significant change (P > 0.05) in the cell volume of the diaphragmatic strips. Pulmonary hypertension increased calcium uptake by the muscle cells in the rat diaphragm which may alter diaphragmatic contractility; an effect that was prevented by Indapamide.

The relation between erythropoietin, hematocrit and hemoglobin in breast cancer patients on non-nephrotoxic chemotherapy.

Serum erythropoietin (EPO), hematocrit and hemoglobin levels were determined in 17 female patients with stage II breast cancer before, during and at the conclusion of non-nephrotoxic chemotherapy. Serum EPO levels were determined using the ELISA technique. No irradiation was given to any patient. The hemoglobin and hematocrit levels remained stable. However, a statistically significant increase in EPO was noted (p<0.05). The possible factors involved in this increase are reviewed, however the exact mechanism remains to be elucidated.

The relationship between serum levels of erythropoietin (EPO) and insulin-like growth factor-1 (ILGF-1) and hematocrit (HCT) in breast cancer patients receiving non-nephrotoxic chemotherapy.

OBJECTIVE: To evaluate the relationship between the hematocrit (HCT), serum erythropoietin (EPO) and insulin-like growth factor-1 (ILGF-1) levels in breast cancer patients receiving non-nephrotoxic chemotherapy. METHODS: Seventeen patients with stage II breast cancer were included. All received 6 cycles of non-nephrotoxic chemotherapy (cyclophosphamide, 5-fluorouracil and doxorubicin or methotrexate with or without tamoxifen). Insulin-like growth factor-1 and EPO levels were determined before and at the end of therapy. Serum EPO levels were determined by Enzyme linked- immunosorbant assay (ELISA) while those of ILGF- I by radioimmunoassay (RIA). RESULTS: A significant drop in mean HCT from 37.41%+/-0.77% to 35.18%+/-0.70%, associated with a significant decline in ILGF-1 levels from 92.1+/-15.48 ng/ml to 52.75+/-10.5 ng/ml at the end of the treatment was noted. This association became significant when patients receiving tamoxifen were excluded (r=0.69, p=0.02). The mean serum EPO levels increased significantly from 13.64+/-0.55 U/l to 19.44+/-3.18 U/l and correlated negatively with ILGF-1 level (r=-0.46, p=0.05). There was no significant relation between the serum EPO levels and HCT (r=-0.26, p=0.32). CONCLUSION: The current data show that ILGF-1 may play an important role in erythropoiesis and it correlates better than EPO with HCT in breast cancer patients receiving non-nephrotoxic chemotherapy.

Clinical and histopathologic findings in adults with the nephrotic syndrome.

The clinical and histopathologic findings in 225 Irish adults with nephrotic syndrome were reviewed. Membranous nephropathy was the most common lesion found (28%), followed by proliferative glomerulonephritis (17%), and focal sclerosing glomerulonephritis (16%). Minimal change disease was the least frequent cause for idiopathic nephrotic syndrome (12%). The major secondary cause of nephrotic syndrome was amyloidosis (13%). The patients were analysed for the predictive value of the level of renal function, presence or absence of hypertension, and the degree of proteinuria. It was not possible to determine the nature of the underlying lesion giving rise to the nephrotic syndrome using any of these variables. There was also no significant difference between primary and secondary glomerular disease with regard to these factors. It is concluded that renal biopsy remains the only definitive method of establishing the underlying lesion causing idiopathic nephrotic syndrome.

The management of hydrothorax in continuous ambulatory peritoneal dialysis (CAPD).

Four patients on continuous ambulatory peritoneal dialysis (CAPD) developed large, symptomatic pleural effusions after commencing peritoneal dialysis. Pleuroperitoneal fistula in each case was diagnosed by the presence of a high glucose content in pleural fluid, with a normal corresponding blood sugar, and was confirmed by isotope or contrast peritoneography. Two patients had their effusions drained percutaneously, and then underwent pleural sclerosis with intracavitary tetracycline. Two patients had a thoracotomy performed, of which no fistula was identified in one case, and the other patient underwent pleurectomy. All four patients successfully recommenced CAPD several weeks after therapy, without recurrence of effusions. We conclude that pleuroperitoneal connections associated with CAPD do not mandate cessation of peritoneal dialysis and conversion to maintenance haemodialysis. Definitive diagnosis requires aspiration of pleural effusions for glucose estimation. Contrast or isotopic peritoneography is helpful in localising the fistula, but in our experience did not alter management. Simple sclerotherapy is effective and avoids the need for a formal thoracotomy.