An unusual presentation of fungal brain abscess in immunocompetent host.

Focal area of necrosis, with a surrounding membrane within the brain parenchyma, usually resulting from an infectious process or rarely from a traumatic process known as brain abscess. We report a case of young female, who presented with multiple abscess in left frontal and right occipital region of brain, she was otherwise immunocompetent, lacking any known risk factor for opportunistic infection. And this fungal abscess manifest with unusual presentation of bilateral lower limb weakness along with seizures and fever. This infection leads to acute kidney injury (AKI), necessitating kidney replacement therapy (RRT) in term of intermittent hemodialysis (IHD). After drainage of abscess and antifungal therapy, she responded well, her acute kidney injury resolved and she showed clinical and radiological improvement.

Community acquired acute kidney injury in South Asia: Causes and outcome. A Meta-Analysis.

OBJECTIVE: To collect all studies on acute kidney injury, even with their limitations, done in South Asia to draw a picture about the types of acute kidney injury prevalent in the region. METHODS: The meta-analysis was conducted in June 2022 and comprised search on PubMed, Medline, Cochrane Library and Google Scholar databases for studies on acute kidney injury done in South Asia regardless of time limit, and published in the English language. Combinations of key words used were 'community acquired acute kidney injury' or 'acute renal failure' with using individual names of 'different countries' in South Asia. Data was extracted and analysed. RESULTS: Of the 31(67.4%) studies subjected to detailed analysis, 17(54.83%) had been done in India, 10(32.25%) in Pakistan, 2(6.45%) in Nepal, and 1(3.22%) each in Bangladesh and Sri Lanka. Overall, there were 16,584 patients with acute kidney injury. There were 16(51.61%) studies focussing on community-acquired acute kidney injury, while 15(48.38%) also included hospital-acquired acute kidney injury. Also, 17(54.83%) studies were prospective and 14(45.16%) were retrospective. Pattern of defining and classifying acute kidney injury varied in the studies. Need for renal replacement was not mentioned universally. Complete recovery reported varied 40-80% and mortality 2.2-52% in the studies analysed. CONCLUSIONS: The number of acute kidney injury patients was considerable. Despite variations in definitions, study designs and outcomes, the meta-analysis provides useful information about the pattern of presentation and d major causes of community-acquired acute kidney injury in South Asia. .

Moya Moya Disease: A rare disease with a common presenting symptom in a chronic kidney disease patient.

Moya Moya Disease (MDD) is a rare cerebrovascular pathology. It is non atherosclerotic cerebrovascular disease characterized by bilateral internal carotid stenosis or occlusion, and abnormal vascular network at the base of the brain. Here we report a case of young female who presented in emergency with complaints of jerky movements of limbs for six months and history of recently developed unusual high blood pressure which was followed by uremic symptoms. Her workup revealed severe renal dysfunction required kidney replacement therapy (KRT) i.e., hemodialysis. During hospital stay her mental status deteriorated with a drop in GCS. Brain imaging performed and she found to have MMD. Her clinical course continued to deteriorate despite of extensive work up and aggressive management, she died eventually.

Efficacy of multiple Biomarkers: NGAL, KIM1, Cystatin C and IL18 in predicting pregnancy related acute kidney injury.

Objective: Several biomarkers like NGAL, KIM-1, IL-18, and Cystatin C has been previously reported as reliable marker to predict AKI. However, their predictive accuracy varies widely. We aim to observe the efficacy of multiple markers, NGAL, KIM-1, Cystatin C and IL-18, in obstetric population who are at risk of developing AKI. Methods: This prospective study was carried out between June 2021 to March 2022 at Department of Obstetrics & Gynecology Unit II, Ruth Pfau KM Civil Hospital and Sindh Institute of Urology & Transplant (SIUT), Karachi Pakistan. On women brought to OBGYN-ER with the diagnosis of hemorrhage (antepartum and postpartum), hypertension (pre-eclampsia and eclampsia) and sepsis. The urine samples and 3cc blood was collected at the time of admission, blood sample processed for biochemistry at time of admission and repeat blood samples for serum creatinine at 24 and 48 hours. Urine was stored at -80ºC and later evaluated for NGAL, KIM-1, Cystatin C and IL-18. Serum Cystatin C was also processed for the time zero sample. The biomarkers were tested using ELISA assays. Results: A total of 149 women were included in the study, 83% of these women were non-booked. Twenty-six (17%) women developed AKI. Serum Cystatin C, urinary Cystatin C and urinary NGAL were found significantly raised in women who developed AKI. While KIM-1 and IL-18 were not raised to statistical significance in this population. However, urinary KIM-1 along with urinary Cystatin C were significantly raised in women with positive quick sequential organ failure assessment (qSOFA). Conclusion: This study validates the use of serum and urinary Cystatin C and urinary NGAL as highly predictable biomarkers for the development of AKI and nullifies urinary IL-18 and KIM-1 in this regard.

Epidemiological trends in community acquired acute Kidney Injury in Pakistan: 25 years Experience from a Tertiary Care Renal Unit.

BACKGROUND: Epidemiological studies of community acquired acute kidney injury (AKI) are sparse especially from South Asia and none has published from Pakistan. Reported incidences from different countries vary with use of different criteria of defining AKI. There is also variation found in different class of income countries, hospital based versus community based AKI. METHODS: The current study was carried out in all adult AKI patients developing community acquired AKI and coming to a tertiary care renal institution from January 1990 to December 2014. This is a retrospective data collection from patient's records and AKI was defined according to KDIGO guidelines. Trends among different groups which are classified in medical, obstetrical and surgical were observed and presented. RESULTS: In medical AKI there has been found a rise in toxic rhabdomyolysis, vivax malaria and dengue infection during later part of study. In obstetrical AKI observed continuous rise in numbers contributing to total AKI during these years. Surgical AKI included obstructed cases during initial ten years and only surgical trauma during later 15 years. Older age on presentation in medical AKI, and thrombocytopenia, deranged coagulation, deranged liver function, hyperkalemia, requirement of mechanical ventilation and multi organ failure in all groups remained predictors of higher mortality. CONCLUSION: From Pakistan epidemiology for community acquired AKI has never been published on a large scale and this study would remain source of great information in this regard over coming years.

Prevalence of Fibromyalgia in chronic kidney disease pre-dialysis patients: Experience from a Tertiary Care Renal unit in Pakistan.

BACKGROUND AND OBJECTIVE: Fibromyalgia syndrome (FMS) is a well-established medical problem which gives rise pain at various sites, fatigue, sleep disturbances, poor memory and definitely affects quality of life. Its prevalence in chronic kidney disease (CKD) is scarcely reported, thus we aimed to assess this condition and report its prevalence in our population. METHODS: The current study was carried out in all adult CKD stage III and IV patients registered from January 2020 to July 2020 at outpatient department of a tertiary care renal institution in Karachi, Pakistan. This is a cross sectional study where prevalence of FMS was assessed by interviewing and examining patients according to established criteria for FMS. All data and laboratory parameters were recorded on a proforma and statistical analysis was done on SPSS version22.0. RESULTS: During the study period of six months, 161 patients with CKD stage III and IV were registered. Among these 81 male and 80 were females. Mean age was 47.12±9.27 (range 21-60) years. There were 22 (13.66%) patients found to have FMS. Mean Widespread Pain Index (WPI) score was 5.68±4.36 (range 1-16), while severity scale (SS) 2a was 3.17±1.78 (range 1-9) and SS2b 2.04±0.96 (range 1-5) was recorded. CONCLUSION: From Pakistan prevalence of FMS has never been published. As this syndrome affects quality of life of patients, its recognition and proper management is immensely required.

Hemolytic Uremic syndrome associated with pregnancy: Outcome from acute Kidney Injury.

OBJECTIVE: To report here, case series of women developing acute kidney injury (AKI) in association with hemolytic uremic syndrome (HUS) during pregnancy or within days postpartum. METHODS: Subjects for the study reported here comprised of a cohort of 49 women referred from OBGYN and diagnosed having AKI and HUS. AKI was defined according to RIFLE criteria and HUS on basis of hematological, biochemical and histological features. All patients had normal size kidneys on ultrasonography and no previous co- morbidity. RESULTS: From January 2000 - January 2020, 49 such women were admitted/ referred to this facility. The mean age of these patients was 29.02±5.258 years. Two had HUS during pregnancy while rest during postpartum. Majority of women had more than one insults these include hemorrhages, intrauterine deaths, operative measure (lower segment caesarean section). Renal replacement was required in all women. Complete renal recovery was observed in 14 patients, while one died during acute phase of illness. CKD-V developed in 17 patients, 16 patients lost long term follow up, but were dialysis free till last follow up and one left against medical advice during acute phase of illness. Treatment with plasmapheresis revealed significantly better renal recovery (p value 0.03) in this group of patients. CONCLUSION: AKI with background of Hemolytic Uremic Syndrome (HUS) may remain irreversible in many of these young women. Plasmapheresis should be offered to patients with established diagnosis of HUS.

A rare presentation of Kikuchi Disease with Hemolytic Uremic Syndrome.

Kikuchi disease (KD) or also known as Kikuchi Fujimoto disease is named after scientists Kikuchi and Fujimoto who describe the disease in Japan in 1972. KD originally reported from Asia but later case reports from different regions of world have been published. It is a benign condition of necrotizing histiocytic lymphadenitis which mimic like Lymphoma, diagnosis of KD is based on histo-pathological findings from lymphnodes. It is a rare condition and mostly case reports have been published, it can have an association with other pathologies. We aim to report a case where KD has been found in a young woman in association with hemolytic uremic syndrome and acute kidney injury.

Acute Kidney Injury in association with Acute Pancreatitis.

OBJECTIVE: To report case series of patients with acute kidney injury (AKI) developing in association with acute pancreatitis (AP). METHODS: All patients coming to Sindh Institute of Urology and Transplantation (SIUT), who developed AKI in association with acute pancreatitis, were included in the study. AKI was defined with sudden rise in creatinine and decline in urine output with normal size kidneys and no previous co morbid. AP defined as patients with abdominal pain and > 3 times rise in serum amylase and /or lipase and radiology suggestive of AP. RESULTS: Between 2000- 2017, 24 patients were found to have AKI in association with AP. Among these 13 were female, mean age was 36.875±10.152 years. Oligoanuria was present in 83%, 46% were icteric on presentation, 42% had circulatory failure, 33% had respiratory failure, 17% had abnormal Glasgow Coma Scale. Renal replacement was required in 79% patients. Complete renal recovery was observed in 54% patients, while 37% died during acute phase of illness. Multi-organ failure showed high prediction of mortality. CONCLUSION: Being a tertiary renal care unit only patients with renal failure were referred to our hospital, thus exact prevalence of AKI in AP is not known. Multi organ failure (MOF) has shown high mortality in this case series.

From diamonds to black stone; myth to reality: Acute kidney injury with paraphenylene diamine poisoning.

AIM: We report here, a case series of patients with acute kidney injury (AKI) after ingestion of paraphenylene diamine (PPD) a derivative of analine. It is used as a colouring agent to dye hair, fur and plastic and in photographic films. METHODS: Subjects for the study reported here comprised a cohort of 100 patients coming to this institution with AKI following PPD poisoning. AKI was defined according to RIFLE criteria and PPD poisoning on the basis of history and presenting features. All patients had normal sized kidneys on ultrasonography and no previous co- morbidity. RESULTS: One hundred patients with AKI after PPD exposure were brought to this institute between May 2010 and February 2015. Among these, 56 were females, with mean age of 23.11 ± 7.94 years. Cause of AKI was toxic rhabdomyolysis as indicated by marked rise in muscle enzymes with mean lactate dehydrogenase and creatinine phosphokinase levels of 6665.22 ± 6272.04 and 194 486.66 ± 301 905.80, respectively. Hepatotoxicity with raised aspartate aminotransferase and alanine aminotransferase was a main feature of the studied population. Renal replacement was required in 97% of patients. Complete renal recovery was observed in 77 patients, while 16 died during the acute phase of illness. Respiratory failure and recurrent hyperkalaemia were the main causes of mortality. CONCLUSION: Easy availability and low cost of PPD has lead to a remarkable increase in the use of this substance, especially for suicidal purposes. Awareness of its effects among health professionals, as well as at a societal and government level, is needed at this time.

Plasmodium Vivax causing acute kidney injury: A foe less addressed.

OBJECTIVE: To report patients developing acute kidney injury (AKI) after Vivax malaria. METHODS: An observational cohort of patients identified as having acute kidney injury (AKI) after Plasmodium vivax infection. AKI was defined according to RIFLE criteria with sudden rise in creatinine or decline in urine output or both. All patients had normal size non obstructed kidneys on ultrasonography, with no previous co morbids. Malarial parasite Vivax was seen on blood peripheral film in all patients. RESULTS: From January 1990 - December 2014, total 5623 patients with AKI were registered in our institute, of these 671 (11.93%) developed AKI in association with malarial infection, furthermore, Vivax was species in 109 patients. Average age of patients was 33.49±14.67 (range 8-78 years) with 66 male and 43 female. Oligo-anuria and vomiting were most common associated symptoms with fever. Renal replacement therapy required in 82 (75.22%) patients. Complete recovery was seen in 69 (63.30%), while 14 (12.84%) expired during acute phase of illness. Jaundice, thrombocytopenia, central nervous system involvement, mechanical ventilation requirement and hematuria were the factors significantly associated with high mortality. CONCLUSION: Malaria still causing significant morbidity and mortality in our part of world. Vivax malaria can present with hemolysis, thrombocytopenia and kidney failure in remarkable number of patients.

Evaluation of contributing factors of post transplant erythrocytosis in renal transplant patients.

OBJECTIVE: To evaluate the prevalence and contributing factors causing post transplant erythrocytosis in renal transplant patients. METHODS: This retrospective study was conducted on live related renal transplant patients at SIUT. The records of all transplant recipients transplanted between April 2008 and December 2008 and who had at least 24 months follow up were studied. Patients in whom haematocrit exceeded 51% and those who received treatment for it were classified into post transplant erythrocytosis group. RESULTS: Out of 200 renal transplant patients who had functioning graft at the time of analysis, 40 (20%) developed post transplant erythrocytosis (HCT > or = 51%) after a mean interval of 9.5 +/- 2.5 months. Patients with erythrocytosis were mostly males (95% in PTE group vs 73.75% in non PTE group), had a shorter period on dialysis before undergoing renal transplantation (9.28 months in PTE group vs 14.56 months in non PTE group) and had relatively better graft function at the onset of erythrocytosis as judged by serum creatinine (S. Creatinine of 1.06 +/- 0.29 mg/dl in PTE group vs 1.37 +/- 0.51 mg/dl in non PTE group). No thrombotic complications were observed. All patients with erythrocytosis were treated with enalapril (ACE inhibitors) and 28 out of 40 required phlebotomy in addition to ACE inhibitors. The mean HCT at the time of last follow up in treated patients was 48.61 +/- 1.85%. CONCLUSION: Post transplant erythrocytosis generally occurs in male patients with good graft function, thrombotic complications are of rare occurrence and response to ACE inhibitors is good.

Pattern of renal diseases observed in native renal biopsies in adults in a single centre in Pakistan.

AIM: In the absence of a national renal biopsy registry, there is a paucity of information on the pattern of renal disease observed in native renal biopsies in adults in Pakistan. METHODS: A retrospective review of native renal biopsies performed in adult patients was undertaken at the Sindh Institute of Urology and Transplantation (SIUT) during the period from July 1995 to December 2008. Renal biopsies were studied by light, immunofluorescence and electron microscopy. The renal biopsy diagnoses were categorized into the following groups: glomerulopathies (GN), tubulointerstitial diseases (TID), renal vascular diseases (VD), and hereditary diseases (HD). RESULTS: A total of 1793 adult patients were included in the study. GN was the commonest diagnosis representing 83.9% of all biopsies. Primary GN (PGN) accounted for 86.9% and secondary GN (SGN) for 13%. When PGN was further analyzed, focal segmental glomerulosclerosis (FSGS) was the leading histopathological diagnosis, found in 29% of PGN, followed by membranous GN (MGN), seen in 23.5% of cases. Among SGN, lupus nephritis (44.1%) was the commonest, followed by amyloidosis (42.1%) and diabetic nephropathy (8.1%). TID comprised 11.6% of all renal biopsy diagnoses. VD and HD were less frequent, found in 3.9% and 0.4%, respectively. CONCLUSION: The pattern of biopsied renal pathology is similar to that reported recently from other parts of the world with similar biopsy indications.

Prevalence and risk factors of renal tubular acidosis after kidney transplantation.

OBJECTIVE: To asses the prevalence of post-transplant renal tubular acidosis (RTA) and its associated risk factors. METHODS: A cross-sectional study was conducted on 100 live related renal transplant recipients, with a transplant duration of more than one year and an estimated GFR > 40 ml/min/1.73m2. Patients with acute graft rejection within last 6 months, unstable graft function, acute urinary tract infection and diarrhoea were excluded. Renal Tubular Acidosis (RTA) was diagnosed on the basis of plasma bicarbonate, venous pH, urine and serum anion gap measurements. RESULTS: Out of 100 patients (74 male, 26 female) RTA was observed in 40 (29 male, 11 female). Patients with RTA had a lower GFR (65.87 +/- 12.35 versus 74.23 +/- 14.8 ml/min/1.73m2, P = 0.004) and higher number of previous acute rejections. Lower bicarbonate was associated with higher serum chloride (108.2 +/- 3.19 versus 105.72 +/- 3.9 mEq/L, P = 0.001) and higher potassium concentration (3.95 +/- 0.53 vs 3.61 +/- 0.46 mg/dl, P = 0.001). Higher phosphorous level (3.46 +/- 0.71 in RTA vs 3.19 +/- 0.59 mg/dl in non-RTA, P = 0.045) but lower total serum calcium concentrations were found in patients with RTA. Intake of angiotensin converting enzyme inhibitors (ACE 1) was associated with the development of RTA. Calcineurin inhibitor (CNI) therapy was not associated with an increased likelihood of RTA. While no difference was noted in sex, age, pre-transplant dialysis duration, post transplant period, body mass index and serum albumin levels. CONCLUSION: There is a high prevalence of RTA in renal transplant recipients. In most of the patients, this is subclinical and does not require treatment.

Use of isoniazid chemoprophylaxis in renal transplant recipients.

BACKGROUND: The use of isoniazid (INH) as chemoprophylaxis for tuberculosis (TB) in renal transplant recipients has not been widely studied or reported from a country where TB is endemic. We are reporting here the results of the largest ever-reported randomized, prospective study of the use of INH in renal transplant recipients. METHODS: Four hundred consecutive live related renal transplant recipients between April 2001 and September 2004, from this single center, were randomized to receive or not receive INH for 1 year after transplantation. RESULTS: There were 12 dropouts. Of the remaining 388, 181 recipients received INH for 1 year post-transplant and 207 did not. The primary disease, comorbidities, HLA (human leucocyte antigen) match, immunosuppression, episodes of rejection, the use of anti-rejection agents, a past history of TB in the donor, the recipients and in family members living in same house and a history of TB in the family were factors compared in the two groups. The only significant difference between the two groups was that there was an increased family history of TB in recipients who received INH (P = 0.01). One recipient from the INH group and 16 recipients from the non-INH group developed TB (P = 0.0003). Discontinuation of INH for hepatotoxicity was not required in any patient. CONCLUSION: These results provide evidence that the use of INH following renal transplantation should be considered mandatory in geographical areas where the prevalence of TB is high. Furthermore, these results have important implication in patients from such areas who are immunosuppressed following other kinds of transplantation and for those who are immunocompromised for any other reason.