Low sensitivity of the exit site scoring system in detecting exit site infections in peritoneal dialysis patients.

INTRODUCTION: To evaluate the utility of the exit site scoring system in diagnosing exit site infections, we compared its scores to the well established exit site categories outlined by Twardowski and Prowant. METHODS: We examined the exit sites of 50 patients on peritoneal dialysis. Each exit site was given a score ranging from "zero" to "≥ 4" according to the exit site scoring system. Exit sites were simultaneously classified into one of the exit site diagnostic categories outlined by Twardowski and Prowant. The sensitivity and specifity of the exit site scoring system in diagnosing exit site infection was then calculated in reference to the exit sites classified as infected according to Twardowski criteria. RESULTS: The proportions of perfect, good, equivocal, and infected exit sites were 24%, 22%, 32%, and 22%, respectively. 21 exit sites had an exit site score of zero. Of those, 12 (57.1%) were perfect, 7 (33.3%) were good, 1 (4.8%) was equivocal, and 1 (4.8%) was actually infected. 21 exit sites had an exit site score ranging from 1 to 3 without purulent discharge. Of those, 4 (18.2%) were good, 15 (68.2%) were equivocal, and 3 (13.6%) were infected. The specifity of the exit site scoring system in diagnosing exit site infection was 100%, but its sensitivity was only 63.6%. CONCLUSION: The exit site scoring system is not a sensitive tool for diagnosing exit site infection mainly because it ignores evaluation of the sinus for granulation tissue. Exuberant granulation tissue in the sinus tract is not always accompanied by purulent drainage.

Mycophenolate mofetil versus azathioprine for maintenance treatment of lupus nephritis.

To compare the efficacy of mycophenolate mofetil (MMF) with that of azathioprine (AZA) drugs in the maintenance therapy of lupus nephritis (LN) patients, we studied 81 Sudanese patients with LN (32 in Class III, 34 in Class IV, and 15 in combined Class V + IV of the ISN/RPS 2003 Classification). All patients received induction therapy consisting of monthly intravenous pulse doses of cyclophosphamide (CYC) (500 mg/m 2 of body-surface area) for six months, plus three consecutive pulses of intravenous methylprednisolone 15 mg/kg/day of body weight (maximum 500 mg). Subsequently, 41 (50.6%) patients were randomized into a group that received oral MMF (22 mg/kg/day), and 40 (49.4%) patients randomized to a group that received oral AZA (2 mg/kg/day). All patients initially received oral prednisone (1 mg/kg of body weight daily) for four weeks. The baseline characteristics of the two groups were similar. Total remission rate was 75.3% (80.5% in MMF and 70% in AZA), complete remission rate of 54.3% (56.1% with MMF and 52.5% with AZA), and a partial remission rate of 21% (24.4% with MMF and 17.5% with AZA) over 29 months. During maintenance therapy, six patients died (four in the AZA group and two in the MMF group), and end-stage renal disease (ESRD) developed in five patients (three in the AZA group and two in the MMF group). During the 36-months of the study, both groups had comparable event-free survival rate for the composite end point of death or ESRD and rate of relapse-free survival. Furthermore, both groups had no significant differences in terms of frequency of hospitalization, amenorrhea, infection, nausea, and vomiting. We conclude that our study showed that short-term therapy with intravenous CYC followed by maintenance therapy with oral MMF or AZA had similar efficacy and safety for the treatment of patients with moderate to severe LN.

Patterns of "severe acute renal failure" in a referral center in Sudan: excluding intensive care and major surgery patients.

Acute renal failure (ARF) is a common health problem worldwide. There is limited data on the pattern of ARF in Sudan. Moreover, glomerular diseases, which are a well-known cause of ARF, have not been accurately and adequately diagnosed previously. A retrospective study on the patterns of ARF was carried out in a general nephrology referral center in Sudan during the period from February 2003-February 2004. Patients from intensive care units with ARF and those who developed ARF after massive surgery were excluded from the study. Renal biopsy was performed when indicated and studied with light and immunofluorescent microscopy. Eighty-nine patients (57 (64%) cases were males and mean age was 39+/-19.4 years) fulfilled the criteria for the diagnosis of advanced renal failure requiring renal function replacement therapy. Acute tubular necrosis (ATN) was diagnosed in 50 (56%) patients; 33 (66%) ATN patients had renal failure as a complication of volume depletion, fulminant infections (particularly malaria and typhoid fever) or snakebites and 12 (13.4%) patients ingested paraphenylene-diamine (PPD) (hair/Henna dye) in suicidal attempts. Eight (9%) patients of the total study group had glomerular diseases and 11 (12.3%) had obstructive uropathy associated with ARF; the cause of ARF could not be determined in 17 (19%) patients. Fifty-three (60%) patients recovered their renal function, six (6.7%) patients progressed to chronic kidney disease (CKD), 16 (18%) died and 14 (16%) were lost to follow-up. In conclusion, patients with ARF associated with ATN had a favorable prognosis except when ATN was associated with PPD poisoning.

Pattern of glomerulonephritis in Sudan: histopathological and immunofluorescence study.

The final diagnosis of renal disease can only be established with the study of renal biopsy using light microscopy, immunohistochemistry and electron microscopy. This study reports on the pattern of glomerulonephritis, diagnosed with light microscopy and immunofluorescence, in two major nephrology referral centers in Sudan. Renal biopsies from 86 consecutive patients were studied by light and immunofluorescence microscopy. The latter was introduced for the first time in the country. Focal and segmental glomerulosclerosis, membranoproliferative glomerulonephritis, minimal change disease and rapidly progressive glomerulonephritis accounted for 26.6%, 22.1%, 10.5% and 3.5% of cases respectively. Lupus nephritis was the commonest cause of secondary glomerulonephritis, accounting for 11.6% of cases. In contrast to the frequency seen in developed countries, IgA nephropathy was uncommon in our series and was seen in only 4.7% of cases. Primary renal amyloidosis was diagnosed in 3.5% of the patients. The pattern of glomerulonephritis in our series is similar to the reports from other developing countries with focal and segmental glomerulosclerosis being the commonest primary glomerulopathy and lupus nephritis, the commonest secondary glomerulopathy.