Assessment of Risk of Exposure to Leishmania Parasites among Renal Disease Patients from a Renal Unit in a Sri Lankan Endemic Leishmaniasis Focus

Leishmania donovani causes both cutaneous and visceral leishmaniasis (CL and VL) in Sri Lanka, where chronic kidney disease (CKD) and kidney transplant recipients’ (KTR) geographical areas overlap. This study aimed to determine the risk of exposure to Leishmania infection among renal patients. This cross-sectional study in a renal unit assessed clinical symptoms and signs of CL and VL in recipients of blood/kidney or immunosuppressives. Sera were tested with Leishmania-specific DAT and rK-39 ELISA. There were 170 participants. A total of 84.1% (n = 143) were males (CKD: 101, KTR; 42, mean age 45) and 27 were females (females: CKD: 23, KTR: 4, mean age 39 years). Recipients of blood transfusion/s within last 2 years: 75.9% (CKD: 115, KTR: 14), on immunosuppressive therapy: 34.1% (CKD: 13, KTR: 45). Two CKD patients repeatedly showed clear positive titres (1: 12,800 and 1: 3200) with Leishmania-DAT and another two (CKD) became marginally positive with rK39-ELISA. Prevalence of anti-Leishmania antibodies: 2.4% (4/170). All four patients were clinically asymptomatic and were recipients of recent blood transfusions. Attributable risk of exposure to Leishmania infection through blood transfusions was 0.032, OR 2.99 (95% CI = 0.16 to 56.45, p = 0.47). Therefore, routine screening of kidney/blood donors and CKD and KTR patients in Sri Lanka may not be necessary

Patient characteristics and questionnaire results of working history, n = 11.

<p>Patient characteristics and questionnaire results of working history, n = 11.</p

Morphological and clinical findings in Sri Lankan patients with chronic kidney disease of unknown cause (CKDu): Similarities and differences with Mesoamerican Nephropathy

<div><p>In Sri Lanka, an endemic of chronic kidney disease of unknown origin (CKDu) is affecting rural communities. The endemic has similarities with Mesoamerican Nephropathy (MeN) in Central America, however it has not yet been clarified if the endemics are related diagnostic entities. We designed this study of kidney biopsies from patients with CKDu in Sri Lanka to compare with MeN morphology. Eleven patients with CKDu were recruited at the General Hospital, Polonnaruwa, using similar inclusion and exclusion criteria as our previous MeN studies. Inclusion criteria were 20–65 years of age and plasma creatinine 100–220 μmol/L. Exclusion criteria were diabetes mellitus, uncontrolled hypertension and albuminuria >1g/24h. Kidney biopsies, blood and urine samples were collected, and participants answered a questionnaire. Included participants were between 27–61 years of age and had a mean eGFR of 38±14 ml/min/1.73m². Main findings in the biopsies were chronic glomerular and tubulointerstitial damage with glomerulosclerosis (8–75%), glomerular hypertrophy and mild to moderate tubulointerstitial changes. The morphology was more heterogeneous and interstitial inflammation and vascular changes were more common compared to our previous studies of MeN. In two patients the biopsies showed morphological signs of acute pyelonephritis but urine cultures were negative. Electrolyte disturbances with low levels of serum sodium, potassium, and/or magnesium were common. In the urine, only four patients displayed albuminuria, but many patients exhibited elevated α-1-microglobulin and magnesium levels. This is the first study reporting detailed biochemical and clinical data together with renal morphology, including electron microscopy, from Sri Lankan patients with CKDu. Our data show that there are many similarities in the biochemical and morphological profile of the CKDu endemics in Central America and Sri Lanka, supporting a common etiology. However, there are differences, such as a more mixed morphology, more interstitial inflammation and vascular changes in Sri Lankan patients.</p></div

Light microscopy images of tubulointerstitial pathology in patients with CKDu in Sri Lanka.

<p>Mild to moderate interstitial fibrosis was found in most patients (black arrow heads in A). Tubular atrophy was mostly mild (black arrows in B). Interstitial inflammation was of varying degree ranging from none to severe (B, A, D and C). Signs of pyelonephritis with interstitial inflammation and neutrophil granulocytes in tubules were found in two patients (white arrow heads in D). [Fig A: Ladewig from Patient 7, bar = 200μm. Fig B: periodic acid Schiff from Patient 4, bar = 100μm. Fig C: hematoxylin-eosin from Patient 3, bar = 100μm. Fig D: hematoxylin-eosin from Patient 11, bar = 100μm.].</p

Serum test results, n = 11.

<p>Serum test results, n = 11.</p

Urine test results including urine heavy metals, n = 11.

<p>Urine test results including urine heavy metals, n = 11.</p

Questionnaire results of chronic diseases and medicine use.

<p>Questionnaire results of chronic diseases and medicine use.</p

Light microscopy images of vascular pathology in Sri Lankan patients with CKDu.

<p>Most of the biopsies showed no or mild intimal fibrosis in arteries (arrow head in A). Three patients showed moderate intimal fibrosis (B). [Fig A: hematoxylin-eosin from Patient 6, bar = 100μm. Fig B: hematoxylin-eosin from Patient 3, bar = 100μm.].</p

Summary of renal morphology findings by light and electron microscopy.

<p>Summary of renal morphology findings by light and electron microscopy.</p