Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure

The findings of diffuse tubular injury with abundant tubular calcium phosphate deposits on renal biopsy are referred to as nephrocalcinosis, a condition typically associated with hypercalcemia. During the period from 2000 to 2004, 31 cases of nephrocalcinosis were identified among the 7349 native renal biopsies processed at Columbia University. Among the 31 patients, 21 presented with acute renal failure (ARF), were normocalcemic, and had a history of recent colonoscopy preceded by bowel cleansing with oral sodium phosphate solution (OSPS) or Visicol. Because the precipitant was OSPS rather than hypercalcemia, these cases are best termed acute phosphate nephropathy. The cohort of 21 patients with APhN was predominantly female (81.0%) and white (81.0%), with a mean age of 64.0 yr. Sixteen of the 21 patients had a history of hypertension, 14 (87.5%) of whom were receiving an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. The mean baseline serum creatinine was 1.0 mg/dl, available within 4 mo of colonoscopy in 19 (90.5%) patients. Patients presented with ARF and a mean creatinine of 3.9 mg/dl at a median of 1 mo after colonoscopy. In a few patients, ARF was discovered within 3 d of colonoscopy, at which time hyperphosphatemia was documented. Patients had minimal proteinuria, normocalcemia, and bland urinary sediment. At follow-up (mean 16.7 mo), four patients had gone on to require permanent hemodialysis. The remaining 17 patients all have developed chronic renal insufficiency (mean serum creatinine, 2.4 mg/dl). Acute phosphate nephropathy is an underrecognized cause of acute and chronic renal failure. Potential etiologic factors include inadequate hydration (while receiving OSPS), increased patient age, a history of hypertension, and concurrent use of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker.     

Race/ethnicity, poverty status, and renal transplant outcomes

BACKGROUND: There are known racial disparities in renal graft survival. Data are lacking comparing associations of race/ethnicity and socioeconomic status with graft failure and functional status after transplantation. Our goal was to test if African-American and Hispanic race/ethnicity and poverty are associated with worse outcomes following renal transplantation. METHODS: We performed a retrospective cohort study using a nationwide registry (United Network for Organ Sharing). We studied 4,471 adults who received renal transplants in 1990. Outcomes were graft failure and functional status over 10 years. RESULTS: Cumulative incidence of graft failure was higher among African-Americans and Hispanics than whites (77% vs. 64% vs. 60 %; P<0.001) and among transplant recipients living in the poorest areas (70% vs. 58% in the richest; P<0.001). African-American and Hispanic race/ethnicity were independently predictive of graft failure (RR 1.8, 95% CI 1.6-1.9; RR 1.3, 95% CI 1.2-1.6, respectively) in multivariate analyses but poverty status was not (RR 1.0, 95% CI 0.9-1.1). Days with impaired functional status were higher for African-Americans compared to whites (RR 1.6, 95% CI 1.3-1.9) but not independent of poverty. Poverty was independently associated with impaired functional status (RR 1.3, 95% CI 1.0-1.6). CONCLUSIONS: African-Americans and Hispanics had higher rates of graft failure compared to whites after adjustment for poverty and other covariates whereas poverty, but not race/ethnicity, was related to functional status following renal transplantation. National datasets should include individual-level measures of socioeconomic status in order to improve evaluation of social and environmental causes of disparities in renal transplant outcomes.     

Altered Immunogenicity of Donor Lungs via Removal of Passenger Leukocytes Using Ex Vivo Lung Perfusion

Passenger leukocyte transfer from the donor lung to the recipient is intrinsically involved in acute rejection. Direct presentation of alloantigen expressed on donor leukocytes is recognized by recipient T cells, promoting acute cellular rejection. We utilized ex vivo lung perfusion (EVLP) to study passenger leukocyte migration from donor lungs into the recipient and to evaluate the effects of donor leukocyte depletion prior to transplantation. For this purpose, female pigs received male left lungs either following 3 h of EVLP or retrieved using standard protocols. Recipients were monitored for 24 h and sequential samples were collected. EVLP‐reduced donor leukocyte transfer into the recipient and migration to recipient lymph nodes was markedly reduced. Recipient T cell infiltration of the donor lung was significantly diminished via EVLP. Donor leukocyte removal during EVLP reduces direct allorecognition and T cell priming, diminishing recipient T cell infiltration, the hallmark of acute rejection.     

The invisible trauma patient: emergency department discharges

BACKGROUND: As the malpractice and financial environment has changed, injured patients evaluated by the trauma team and discharged from the emergency department (ED) are now commonplace. The evaluation, care, and disposition of this population has become a significant workload component but is not reported to accrediting organizations and is relatively invisible to hospital administrators. Our objective was to quantify and begin to qualify the evolving picture of the trauma ED discharge population as a work component of trauma service function in an urban, Level I trauma center with an aeromedical program. METHODS: Trauma registry (contacts, mechanism, transport, injuries, and disposition) and hospital databases (ED closure, occupancy rates) were queried for a 5-year period (1999-2003). Trend analysis provided statistical comparisons for questions of interest. RESULTS: During the 5-year study period, the total number of trauma contacts rose by 18.1% (2,220 in 1999 vs. 2,622 in 2003; trend p < 0.05). This increase in total contacts was not a manifestation of an increase in admissions (1,672 in 1999 vs. 1,544 in 2003) but rather a reflection of a marked increase in patients seen primarily by the trauma team and discharged from the ED (473 in 1999 vs. 1,000 in 2003; trend p < 0.05). These ED discharge patients were increasingly transported by helicopter (12.3% in 1999 vs. 29.2% in 2003; trend p < 0.05) and less frequently from urban areas (57.1% in 1999 vs. 48.1% in 2003; trend p < 0.05) over the course of the study period. Average injury severity of this group increased over the study period (Injury Severity Score of 2.7 +/- 0.1 in 1999 vs. 3.3 +/- 0.1 in 2003; trend p < 0.05). ED length of stay for this group increased 19.8% over the study period (trend p < 0.05), averaging nearly 5 hours in 2003. CONCLUSION: The total number, relative percentage, and injury severity of patients evaluated by the trauma team and discharged from the ED has significantly increased over the last 5 years, representing nearly 5,000 patient care hours in 2003. Systems to care for these patients in a cost- and resource-efficient fashion should be put in place. The impact of this growing population of patients on the workload of the trauma center should be recognized by accrediting agencies, hospital administration, and Emergency Medical Services.     

Myotonic dystrophy with pregnancy

Myotonic dystrophy is a rare heredodegenerative muscular disorder in which pregnancy is unusual. Because of the autosomal dominant inheritance of the disease, 50% of children of an affected parent may have the disease; 20% of them are asymptomatic at birth. Foetal involvement may be manifested by polyhydramnios, arthrogryposis multiplex in utero, respiratory difficulties, and floppiness at birth. A case of myotonic dystrophy with pregnancy is presented here.     

Peripheral refraction for distance and near vision in emmetropes and myopes

We investigated the relationship between myopia and peripheral refraction for distance and near vision by measuring peripheral refractive errors in 10 myopic and 10 emmetropic participants at viewing distances of 2.5 and 0.4 m. Measurements were made at the fovea, and at eccentricities of 10 degrees , 20 degrees and 30 degrees in the temporal and nasal hemispheres of the horizontal visual field. Our results showed that peripheral astigmatism increased with increasing eccentricity, but there was no significant difference between refractive error groups except at 30 degrees eccentricity in the temporal retina. Considering the Mean Spherical Equivalent errors, emmetropes became relatively myopic at peripheral eccentricities, but there was little change in myopes. The effect of viewing distance on astigmatism or Mean Spherical Equivalent error was not significant. Our results do not support the view that myopia is associated with changes in peripheral refraction during distance or near vision.     

Multipotent Plant Probiotic Rhizobacteria from Western Ghats and Its Effect on Quantitative Enhancement of Medicinal Natural Product Biosynthesis

Proceedings of the National Academy of Sciences, India Section B: Biological Sciences - Understanding the chemical basis of rhizobacterial-plant interaction provides immense opportunities for the...