Acute Kidney Injury in Acute Febrile Illness.

INTRODUCTION : Acute renal failure has dominated the attention of Nephrologists for decades, with focused research aiming at reducing the morbidity and mortality related to the entity. Despite advances in diagnostics, management and dialysis related interventions the results have been disappointing with no significant mortality differences in last five decades. The importance of this quest to reduce mortality and renal morbidity is amplified by the fact that 60% critically ill patients die during hospitalization and 13% of the survivors become dialysis dependent. In patients who recover from acute renal failure after variable periods of renal replacement therapy, renal insufficiency is observed in 41% and five year survival is about 50%. This puts an additional burden on health infrastructure and economy. AIM : To study the clinical features, prognosis and outcomes of acute kidney injury (AKI) in patients presenting with scrub typhus, malaria, dengue fever, typhoid, leptospirosis and undifferentiated fever particularly to identify patients at high risk of developing AKI and mortality related to AFI, aiming to identify mechanisms for effective management using the RIFLE criteria and testing the utility of Cystatin C as a biomarker for diagnosis of AKI. PATIENTS AND METHODS : Consecutive in-patients with AFI were enrolled prospectively after admission to a tertiary care referral hospital. They were studied based on etiology of AFI. AKI in these patients was investigated and graded using the RIFLE criteria. Their presentation and course during hospital stay was studied to estimate morbidity, severity of AKI, dialysis requirement, mortality and evaluated for prognostic indicators. RESULTS : 163 patients were enrolled in the study and 136 patients were studied based on inclusion criteria. The mean age was 40.9 ± 15.6 (16 to 77 years) and sex ratio 2:1 (male 91: female 45). AKI was observed in 71.3% and was graded using the RIFLE criteria as Risk (R) in 19.9%, Injury (I) in 15.4% and Failure (F) in 36%. 10 (7.4%) patients had hospital associated AKI. Undifferentiated fever had the highest incidence of AKI (94.7%) with dialysis requirement in 26.3% and death in 52.6%, while in the differentiated fevers AKI was commonest in malarial infection by P. falciparum (100%). Maximum dialysis requirement was noted in in mixed malarial infection (27.8%) and highest mortality in dengue fever (42.7%). Overall 26.5% patients died during hospital stay with 33% mortality in AKI as compared to 10.3% in the non AKI group. RIFLE criteria was identified as a sensitive tool for diagnosis of AKI in AFI and patients have worse prognosis and outcomes from R through I and F stages in terms of organ support, dialysis requirement and death. RIFLE staging using Cystatin C appears to be sensitive in diagnosing AKI in AFI earlier and may be a useful adjunct for early management. Fractional excretion of sodium (FENa) was useful in identifying early AKI. The Liano scoring at admission identified high risk patients and may be useful for triage to high dependency care. Renal Failure Index (RFI) was higher in those who underwent dialysis and died. Hemodialysis was initiated in 18.4% of whom 48% required SLED. Mortality in patients initiated on hemodialysis was 64% with 100% mortality in those requiring SLED. CONCLUSION : AKI has a high incidence in AFI. Application of the RIFLE criteria shows incremental risk for morbidity, dialysis requirement and mortality. Patients requiring hemodialysis have high mortality. Cystatin C has promise as a biomarker for early identification and management of AKI in AFI

Isolated Neurogenic Bladder Associated With Human T-Lymphotropic Virus Type 1 Infection in a Renal Transplant Patient From Central Australia: A Case Report

© 2018 Elsevier Inc. This manuscript version is made available under the CC-BY-NC-ND 4.0 license: http://creativecommons.org/licenses/by-nc-nd/4.0/ This author accepted manuscript is made available following 12 month embargo from date of publication (Sept 2018) in accordance with the publisher’s archiving policyHuman T-lymphotropic virus type 1 (HTLV-1) is endemic amongst the Aborigines of the Northern Territory of Australia. HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP) has been associated with this infection. In general population, isolated neurogenic bladder dysfunction in HTLV-1-infected individuals without HAM/TSP has been reported, and the HTLV-1 proviral load has been found to be higher in such patients compared with asymptomatic carriers. In solid organ transplantation, few cases of HAM/TSP have been reported worldwide, but not an isolated neurogenic bladder. Case A 50-year-old indigenous women from Alice Springs with end stage renal disease secondary to diabetic nephropathy with no prior history of bladder dysfunction received a cadaveric renal allograft following which she developed recurrent urinary tract infections. The recipient was seropositive for HTLV-1 infection. HTLV-1 status of donor was not checked. Urodynamic studies revealed stress incontinence and detrusor overactivity without urethral intrinsic sphincter deficiency. She had no features of myelopathy. There was elevation of the serum and cerebrospinal fluid HTLV-1 proviral load. The magnetic resonance imaging myelogram was normal. Pyelonephritis was diagnosed based on clinical features, positive cultures, and renal allograft biopsy. Continuous suprapubic catheter drainage helped preventing further episodes of allograft pyelonephritis in spite of chronic colonization of the urinary tract. Conclusion Isolated bladder dysfunction is a rare manifestation of HTLV-1 infection and is probably associated with high proviral loads. This may adversely affect renal allograft and patient outcomes

Thrombotic thrombocytopenic purpura and systemic lupus erythematosus: Successful management of a rare presentation

Thrombotic thrombocytopenic purpura (TTP) and systemic lupus erythematosus (SLE) very rarely present simultaneously and pose a diagnostic and therapeutic dilemma to the critical care team. Prompt diagnosis and management with plasma exchange and immunosuppression is life-saving. A patient critically ill with TTP and SLE, successfully managed in the acute period of illness with plasma exchange, steroids and mycophenolate mofetil is described

Wasp sting: An unusual fatal outcome

Wasp stings are not uncommon especially in populations living in proximity of forested areas all over the world. Local manifestations following stings are common and un-usually life threatening anaphylaxis may occur, requiring prompt treatment. Multi organ failure and acute renal failure following wasp stings are rare and histological evaluation suggest acute tubular necrosis secondary to hemolysis, rhabdomyolysis and direct venom toxicity. A rare com-plication of a patient following multiple wasp stings with disseminated intravascular coagulation, acute renal failure and thrombotic microangiopathy is presented

Atypical fulminant presentation of amebiasis in chronic kidney disease patient on maintenance hemodialysis

Amebiasis is a common cause of dysentery in India and can have an atypical fulminant course with negative serological tests in immunosuppressed individuals such as chronic kidney disease (CKD). We present a patient of CKD on dialysis who presented with features of dysentery with negative blood and serology workup. The diagnosis of amebic colitis was made after colonoscopy and histopathology which revealed amebic trophozoites and her symptoms abated after appropriate therapy. This case report illustrates the need for colonoscopy and histopathology for definite diagnosis of fulminant presentation of amebic colitis in an immunosuppressed individual such as CKD

Hallucination in kidney transplant recipient: A rare complication of voriconazole

Postkidney transplant recipients are more susceptible to opportunistic infections including fungal infections. Voriconazole is a broad-spectrum antifungal with a good safety profile even in patients with renal dysfunction. Hallucination is a rare and underreported complication of oral voriconazole therapy, especially in kidney transplant recipients. Two patients of postrenal transplant who developed hallucination following oral therapy with voriconazole have been highlighted here. Symptoms improved in both patients following a reduction in dosage or cessation of therapy. This case report highlights the fact that even though voriconazole-induced hallucinations are a rare complication, it is important to be aware of the same so as to be able to diagnose it and institute appropriate corrective measures

Topical anesthetic versus lidocaine infiltration in arteriovenous fistula cannulation

Background: End stage renal disease (ESRD) patients on maintenance hemodialysis undergo arterio-venous fistula (AVF) cannulation prior to each hemodialysis session for blood access. Prior to cannulation lidocaine infiltration is done, which is often perceived as painful. Eutectic mixture of local anesthetic (EMLA) has been found to significantly reduce pain associated with radial artery cannulation compared with lidocaine infiltration. Aims: To evaluate the efficacy of EMLA compared to infiltration of lidocaine in hemodialysis patients for AVF cannulation. Materials and Methods: A single-centre, crossover study of patients with an AVF on regular maintenance hemodialysis was performed in the dialysis unit of a tertiary care teaching hospital. The site of AVF, number of attempts for AVF cannulation and cannula insertion time were recorded. The patients were asked about the acceptability of application of the anesthetic, delay between anesthetic and cannulation and to score the pain on cannulation. Results: Fifty patients were included in the study. With the visual analog scale, pain score on infiltration was 4.8. Pain score on cannulation after topical application was 2.9 and after infiltration, 2.0. The number of attempts for cannulation and the cannula insertion time were similar. Anesthesia was more stressful in the injectable group rather than the topical group (P < 0.001). Delay between anesthetic and cannulation was unacceptable in the topical group (P < 0.001). Patient compliance was better during infiltration compared to topical (P < 0.005). Mean pain score during infiltration of anesthetic was significantly higher than cannulation pain after either anesthetic, although pain on cannulation was higher in the topical group (P < 0.001). Conclusions: EMLA offers a suitable alternative to lidocaine infiltration for patients using AVF for blood access

Spontaneous rupture of tuberculous spleen in a HIV seropositive patient on maintenance hemodialysis

Spontaneous rupture of the spleen usually occurs secondary to infection, hematolo-gical disorders or infiltrative lesions of the spleen. In patients with positive human immuno-deficiency virus (HIV) antibodies and the acquired immunodeficiency syndrome (AIDS) who pre-sent with acute abdomen, splenic rupture should be considered as a possible cause and should addi-tionally be investigated for co-infection with tuberculosis. Spontaneous rupture of spleen in asymp-tomatic patients requires a high index of suspicion for diagnosis. We herein report on a HIV-positive patient on maintenance hemodialysis, who presented with spontaneous rupture of a tuberculous spleen