Background.Chicken pox, although a common infection among children, is rare in immunocompromised patients, particularly renal transplant recipients, and carries a very high incidence of morbidity and mortality There is little data on chickenpox in adult renal transplant recipients, although reports have suggested that it may follow a virulent course requiring frequent hospitalization, and in severe cases can cause death.Aims.To evaluate the incidence, severity and complications of a varicella/chickenpox infection in renal transplant recipients over 10 years follow-up.Results.An incidence of 1.48% of our patients were diagnosed with varicella infection during this 10-year period from June 2000 to June 2010 in our live-related renal transplant program, with a median patient age of 39 years (range 21–54 years). Graft dysfunction was observed among five patients following the infection, two of whom became dialysis-dependent. The other three had mild graft dysfunction from which they subsequently recovered, suggesting that infection was responsible for graft dysfunction. None of them developed rejection following exposure or with modification of immunosuppression. All of our patients required admission with 47.8% presenting with various presentations, with orchitis, pancreatitis, encephalitis and gastritis each affecting 8.6% of the patients. All patients were managed with intravenous acyclovir for 2 weeks followed by oral acyclovir for 3 months. The infection was associated with an increased mortality of 13.4% due to superadded infections and central nervous system involvement in one patient with fatal bilateral pneumonia.Conclusions.This infection, which is a benign disease with a largely stable course among the general population, can have severe outcomes for immunocompromised patients, accounting for almost 90% with significant morbidity and mortality in the 8.6% of infected patients, thus highlighting the importance of pre-transplant vaccination in this subgroup of the population.
Developing a non-invasive method such as diffusion-weighted magnetic resonance imaging (DWMRI) could be used as a feasible and reproducible modality in the differential diagnosis of allograft dysfunction. We assessed the functional status of the renal allograft by DWMRI and its applicability in assessment of graft dysfunction on all end-stage renal transplant patients who attained normal renal function on the 7th day post-transplantation. Follow-up imaging of the recipient allograft was performed at the end of 90 and 180 days and in case of graft dysfunction. Kidney biopsies were performed to correlate with the corresponding MRI. The apparent diffusion coefficient (ADC) maps of the cortex and medulla were obtained by studying the DWMRI. The ADC values were significantly lower in the medulla compared with the cortex in normal donor kidneys and normally functioning transplanted kidneys, while they decreased significantly when rejection occurred. The reduction in ADC values occurred both in the cortex and in the medulla, and correlated with the degree of rejection on the kidney biopsies. The ADC values increased significantly during the recovery from rejection. We conclude that DWMRI can be beneficial in the diagnosis and follow-up of transplant patients during acute rejection.
BACKGROUND AND OBJECTIVEChyluria can be confused with nephrotic syndrome when massive proteinuria is present on urine examination during evaluation of a milky/white urine. Our objective was to attempt to resolve diagnosis in the case of nephrotic range proteinuria when there is no clear evidence of a significant kidney lesion.DESIGN AND SETTINGRetrospective review of the medical records of all patients referred the nephrology department at a single institution.PATIENTS AND METHODSWe identified a subgroup of patients misdiagnosed with nephrotic syndrome and treated aggressively with immunosupression with no benefit and who were later diagnosed as having chyluria.RESULTSTwelve patients were identified (8 men, 4 women) with a median age of 34.5 years. Chyle was positive in the urine in eight while chyle was positive on oral ingestion of butterfat in another 4. Six had undergone kidney biopsy and were treated as having minimal change disease. Eight had massive proteinuria and a history of treatment with prednisone, but none of these patients had shown improvement in their clinical presentation. Two patients showed excellent results with diethylcarbamazine with angiotensin-converting enzyme inhibitors in while eight required betadine instillation in the fistulous connection with success in six. Surgical correction was successfully tried in two of these resistant cases.CONCLUSIONIn individuals with nephrotic range proteinuria with a normal or low lipid profile status along with normal serum albumin levels, urine color and nature, frequency, and checking the urine for chyle can help identify the large subgroup who unnecessarily have to undergo kidney biopsy and at times are treated with immunosuppression, which is not only life threatening but useless in these patients.
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