Journal of Nephrology & Therapeutics

Introduction: Membranous nephropathy (MN) is the most common causes of the nephrotic syndrome in nondiabetic, Caucasian adults. Pauci-immune necrotizing and crescentic glomerulonephritis (PNCGN) typically present with rapidly progressive glomerulonephritis. Coexistent MN and PNCGN is a rare occurrence. We report a case of both MPO- and PR3-ANCA associated NCGN with MN that presented as rapidly progressive glomerulonephritis. Case presentation: A 46-year-old female presented with nausea and vomiting. On physical examination, the patient was a febrile and normotensive. Blood tests showed acute kidney injury and anemia. Urinalysis demonstrated numerous dysmorphic red blood cells with granular casts and nephrotic range proteinuria. Further testing showed negative ANA, positive anti-dsDNA, PR3-ANCA and MPO-ANCA. Kidney biopsy revealed the diagnosis of concurrent PNCGN with membranous nephropathy. The diagnosis of concurrent ANCA-associated NCGN with Membranous nephropathy was made. High dose intravenous methyl prednisolone was initiated. Unfortunately, the patient developed diffuse alveolar hemorrhage and underwent 6 cycles of plasmapheresis, intravenous Cyclophosphamide and pulse dose steroids with transitioned to oral prednisone and mycophenolate. On follow up, her disease seemed to be well suppressed without dialysis. Conclusion: Membranous nephropathy with PNCGN is a rare concurrent glomerulopathy, and even more rare with both MPO and PR-3 positivity. The diagnosis of MN with PNCGN should be considered in patients who present with RPGN and nephrotic range proteinuria.

Introduction: Central vein catheters (CVC) are an important means of delivering hemodialysis (HD) to patients who require immediate initiation of dialysis but are without a mature functioning arterio-venous fistula or graft. The frequency of catheter-related bacteremia (CRB) reported in several large series ranged between 2.5 and 5.5 cases/1,000 catheter-days. Aim of the study: The aim of the study was to evaluate the incidence, spectrum of infecting organisms, risk factors, and optimal treatment for catheter-related bacteremia. Methodology: This retrospective study of clinical records was conducted between January 2005 and January 2009 where all episodes of catheter related bacteremia in the preceding 4 years were a subject of our study. Data recorded for each patient included the number of catheter-days, episodes of suspected bacteremia, blood culture results, method of treatment, complications, and outcomes. All patients with CRB were treated with a 21-day course of intravenous antibiotics, with surveillance cultures obtained 1 week after completing the course of antibiotics. The CVC was removed if the patient had uncontrolled sepsis or if other vascular access was ready for use. Once the infection was controlled, catheter salvage was considered successful, leaving the original CVC in place. Results: 93 chronic hemodialysis (HD) patients, 42 male (45.25%) and 51 female (54.8%) were included, with median age 51.67 years. During this study, there were 37087catheter-days, with 52 episodes of CRB, or 1.4 episodes/1,000 catheter-days. Thirty- five infections (67.3%) were caused by gram-positive cocci only, including Staphylococcus aureus, Staphylococcus simulans, and Staphylococcus haemolyticus. Seventeen infections (32.7%) were caused by gram-negative rods only, including a wide variety of enteric organisms. Five CVCs were removed because of severe uncontrolled sepsis, of the remaining 47 cases; attempted CVC salvage was successful in (90.3%). The only important complication of CRB was endocarditis, occurring in 1 of 52 episodes (1.9%). Conclusion: We conclude that in our study, CRB is relatively near the lower limit of normal range with low incidence of complication and frequently involves gram-positive bacteria. CVC salvage is significantly improved when CVC was treated by antibiotic based on blood culture results.

Giving cytomegalovirus (CMV) prophylaxis to CMV positive recipients is expensive in a resource-limited setting like South Africa. We report a retrospective analysis of CMV disease in 47 CMV donor/recipient positive (D+/R+) adult renal transplant patients (> 80% African Blacks) from February 2000 to November 2004 who had received four drug induction immune suppression. We commenced routine valganciclovir prophylaxis for 3 months post renal transplant in January 2007 and reviewed incidence of CMV disease from January 2007, in similar patients, until October 2009. Before prophylaxis, incidence of CMV disease was 32% in D+/R+ and was similar to recipient negative/donor positive (D-/R+) patients, however graft survival analysis adjusted for CMV disease showed that D+/R+ recipients had a hazard ratio of 2.8 (p=0.03) for poor graft outcome. After prophylaxis, among deceased donor recipients the incidence of CMV disease over a mean follow up of 17.3 months was 6% (n=2), and nil in live donor recipients. Our immunosuppressive therapy carries a risk of CMV disease in approximately a third of patients and is associated with poorer graft outcomes. CMV prophylaxis has been highly effective at reducing the incidence of CMV disease, and is important in a setting with ever decreasing availability of organs for transplantation.