Diagnostic Workup for Diffuse Parenchymal Lung Disease: Schematic Flowchart, Literature Review, and Pitfalls

Purpose

The term diffuse parenchymal lung disease (DPLD) refers to a group of disorders affecting the lung parenchyma that can be categorized into those of known and those of unknown etiology. Early diagnosis is important since some forms of DPLD are characterized by a rapid progression to respiratory failure. Notwithstanding the fact that recently guidelines have been published, some issues concerning the practical evaluation of a patient with suspected DPLD remain unclear.

Methods

In this article we propose a practical approach to the diagnosis and differentiation of DPLD. Moreover, a critical appraisal is provided based on the current literature and frequent pitfalls are highlighted.

Conclusion

we propose a practical workup, but in spite of increasing evidence concerning the diagnosis of DPLD, further studies will be needed to clarify several issues for efficient investigation of newly diagnosed patients with DPLD.     

Is There an Added Value of Cardiopulmonary Exercise Testing in Sarcoidosis Patients?

Background

Cardiopulmonary exercise testing (CPET) with blood gas analysis may be helpful when there is a discrepancy between clinical findings and physiologic tests at rest. The aim of this study was to examine the added value of CPET compared to the measurement of the diffusing capacity of the lung for carbon monoxide (DLCO) in detecting impaired pulmonary gas exchange in sarcoidosis patients.

Methods

The clinical records of 160 (age = 41.3 ± 10.0 years; number of females = 63) sarcoidosis patients referred to the former MUMC ild care center were retrospectively reviewed. Patients performed a symptom-limited incremental exercise test with blood gas analysis on a bicycle ergometer. DLCO was measured by the single-breath method.

Results

DLCO (mean = 83.2 ± 18.0 %) below 80 % of predicted was demonstrated by 38 % of the sarcoidosis patients in our sample. Of the patients with normal DLCO (n = 99, 61.9 %), the P(A-a)O₂ at maximal exercise [P(A-a)O₂max] was moderately increased (>2.5 kPa) in 69.7 % and excessively increased (>4.7 kPa) in 18.2 %. Pulmonary gas exchange impairment (PGEI) was more obvious in patients with lower DLCO values. A DLCO value below 60 % of predicted indicated substantial gas exchange impairment. PaO₂ at rest, DLCO, and FVC as a percentage of predicted and radiographic staging predicted 40 % of the PGEI at maximal exercise.

Conclusion

A substantial number of the symptomatic sarcoidosis patients with normal DLCO appeared to have PGEI at maximal exercise, suggesting that normal DLCO at rest is an inappropriate predictor of abnormal pulmonary gas exchange during exercise. CPET appeared to offer added value in detecting impaired gas exchange during exercise in sarcoidosis patients with unexplained disabling symptoms.     

De novo Crohn's disease in a renal transplant recipient

The prevalence of inflammatory bowel disease (IBD) after renal transplantation is affected by the immune tolerance and the modality of immunosuppression. Mycophenolate mofetil (MMF) may have a promoting effect on the development of posttransplantation erosive enterocolitis and a Crohn's disease-like pattern of colitis. We have presented a 40-year-old man with end-stage renal disease due to chronic glomerulonephritis who commenced hemodialysis for 2 months before receipt of a live unrelated renal transplant. He developed early posttransplantation diabetes mellitus and an anti graft rejection episode, which responded to a methylprednisolone pulse and OKT3 treatment. His immunosuppressive regimen included prednisolone, MMF, and tacrolimus. Three years after transplantation, he developed mild constitutional symptoms, mouth ulcerations, and chronic intermittent bloody diarrhea. Colonoscopy showed active segmental colitis with aphthous ulcers, involving the proximal descending colon and the splenic flexure. Colonic biopsies showed distended and branched crypts in the ascending colon, moderate active chronic colitis with regenerative atypia, skipping appearance, and ulceration in the splenic flexure and descending colon. The edematous crypts were associated with ulcerations in the sigmoid colon and rectum. The features were highly suggestive of Crohn's disease. He was successfully treated with high-dose steroids and 5-aminosalicylic acid. Subsequently, he developed chronic transplant glomerulopathy and restarted hemodialysis. We concluded that de novo Crohn's disease may develop in renal transplant recipients despite immunosuppressive therapy especially with MMF immunosuppression.     

Early Sirolimus Therapy in Renal Transplant Recipients at High Risk: Is It Justified?

Background

We studied early sirolimus (SRL) therapy in renal transplant recipients at high risk after administration of antithymocyte globulin or interleukin-2 receptor blockade induction.

Patients and Methods

In 45 patients, SRL therapy was started within 1 month after transplantation. The primary indications for conversion of treatment from calcineurin inhibitors (CNIs)-mycophenolate mofetil (MMF)-steroid to SRL-MMF-steroid were biopsy-proved rejection (after treatment), CNI toxicity, CNI elimination, and acute tubular necrosis. Pediatric, geriatric, and other patients with medical comorbidities were not excluded.

Results

Post-SRL rejection episodes were reported in 22.2% of recipients including 15.6% who were resistant to steroid therapy. Mean (SD) follow-up after SRL therapy was 59.9 (8.1) months. Proteinuria greater than 2 g/d (P = .001), leukopenia (P < .001), hyperlipidemia (P < .001), and transaminases values (P = .02) increased significantly after SRL therapy. Graft survival was 88.8%, and patient survival was 93.3%. There was significant improvement in serum creatinine concentration and estimated creatinine clearance by the end of the study (P < .001). A high incidence of adverse effects and infections was noted post-SRL therapy, and the drug was discontinued in 31% of patients because of multiple adverse effects. At multivariate analysis, age, hypertension, nutritional status, bone marrow suppression, hyperlipidemia, and graft dysfunction were identified as risk factors for worse graft and patient outcome.

Conclusion

Early treatment with combined SRL-MMF-steroid may be effective as a CNI-free immunosuppression regimen in patients at high risk; however, there is a high rate of adverse effects during long-term follow-up.     

Long-Term Follow-up of 100 High-Risk Renal Transplant Recipients Converted From Calcineurin Inhibitors to Sirolimus: A Single Center Experience

While conversion of stable renal transplant recipients (RTR) from calcineurin inhibitors (CNI) to sirolimus (SRL) is safe and effective, it is still under investigation for recent, high-risk cases. We studied the long-term effects of conversion of high-risk subjects maintained on a CNI, mycophenolate mofetil, plus steroid regimen to SRL, mycophenolate mofetil, plus steroid on graft and patient outcomes. We retrospectively reviewed the first 100 RTR converted to SRL treatment over approximately 5 years. The main indications for conversion were biopsy-proven acute rejection (BPAR), CNI toxicity, CNI elimination, and acute-tubular necrosis (ATN). Exclusion criteria were limited to bone marrow suppression. The overall mean ± SD age was 38.5 ± 15.6 years, including pediatric and geriatric age groups. Mean ± SD body mass index (BMI) was 28.99 ± 8.0 and 40% had a BMI > 30. There were 40% RTR from deceased donors and 60% showed 4 to 6 HLA mismatches. Preconversion total BPAR and steroid-resistant rejection incidences were 35% and 14%, respectively. Mean ± SD time to start of SRL was 11.9 ± 22.8 months posttransplantation. Proteinuria > 2 g/d, leukopenia, and hyperlipidemia increased significantly after conversion (P = .001, P = .0003, and P = .0001, respectively). Patient and graft survivals were 95% and 90%, respectively. There was significant improvement in graft function postconversion (P < .0001). There was a high incidence of side effects and cases of SRL discontinuation. Multivariate analysis demonstrated the influence of bone marrow suppression, obesity, hyperlipidemia, nutritional status, proteinuria, and graft function on graft and patient outcomes. We concluded that conversion from CNI to SRL was effective among high-risk RTR, but with a high incidence of adverse events during long-term follow-up.     

Safe implementation of laparoscopic gastrectomy in a community-based general surgery practice

Background  This study reviewed a 3-year experience with the implementation of laparoscopic gastrectomy at a community hospital. Methods  A retrospective chart review identified all patients that underwent laparoscopic gastrectomy between January 2004 and March 2007. Patient demographics, tumor characteristics, length of stay, operative time, and short-term outcomes (postoperative complications and death) were examined. Results  A total of 49 patients were identified; 25 (51%) were male. Median age was 68 years (range 31–90 years). Thirty-five (71%) and seven (14%) patients presented with adenocarcinoma and gastrointestinal stromal tumor (GIST), respectively. Median operative time was 169 min (range 23–387 min). Conversion to open laparotomy was necessary in six cases (12%). Median length of stay was 5 days (range 0–48 days). There were four (8.2%) postoperative deaths, and eight major complications, which included: myocardial infarction, pulmonary embolism, duodenal stump leak, bleeding, dehiscence, anastomotic leak, and obstruction. Of patients undergoing laparoscopic gastrectomy with curative intent, 36/38 (95%) underwent R0 resection. Median number of lymph nodes that were pathologically evaluated was 11 (range 1–27). Conclusion  To our knowledge, this is the first study to report on the implementation of laparoscopic gastrectomy in a community hospital setting. Laparoscopic gastrectomy can be performed safely in a community hospital setting with operative times and length of stay that are comparable to open cases. Our short-term outcomes are comparable with existing studies from academic/university centers.     

Outcome and survival in different peritoneal dialysis modalities

Peritoneal dialysis (PD) has been accepted as a treatment option for patients with end-stage renal disease, yet experience with PD in Arab countries is limited. This study was undertaken to evaluate the outcome and survival of different PD modalities. All patients managed at the Mubarak Al-Kabeer Hospital Kuwait between August 1982 and December 2003 using PD for three months or more were included in the study. Demographic features, outcome and survival of the patients were analyzed. Four hundred and fifteen patients with end-stage renal failure were admitted into the PD program. Their mean age was 52.06 +/- 16.43 years. Hospital-based intermittent peritoneal dialysis (IPD), continuous ambulatory peritoneal dialysis (CAPD), nightly intermittent peritoneal dialysis (NIPD) and continuous cycling peritoneal dialysis (CCPD) were preferred by 203 (48.9%), 176 (42.4%), 30 (7.2%) and 6 (1.4%) patients respectively. The mean duration of follow up was 12.7 +/- 11.7 months. Fifty-five (13.3%) patients were continuing on PD, 55 (13.3%) had shifted to hemodialysis, 73 (17.6%) underwent renal transplantation, 114 (27.5%) died, 34 (8.2%) returned to their native countries, 79 (19%) transferred to other centers and follow up was lost for 5 (1.45%) patients. Patient survival at two years was 56%, 72% and 87% in IPD, CAPD and NIPD respectively. Technique survival at two years was 60.6%, 75.4% and 100% in IPD, CAPD and NIPD respectively. Peritoneal dialysis modalities provide a feasible modality of renal replacement therapy. The overall outcome and patient and technique survival in home PD modalities were better than hospital-based PD.     

Baseline cardiac troponin I in patients on maintenance dialysis

INTRODUCTION AND OBJECTIVES: There have been conflicting reports in the medical literature regarding baseline levels of cardiac troponins and their usefulness as specific markers of acute myocardial injury in patients on maintenance dialysis. Hence we undertook a study of the normal range of baseline cardiac troponin I (cTnI) in patients on maintenance dialysis in our center. METHODOLOGY: Seventy-five patients aged 45 years or more on maintenance dialysis for at least 1 month were included in the study. None had had an acute cardiac event requiring admission to the hospital during the preceding month. Samples of blood were collected and cTnI levels were estimated using an immunoenzymatic assay (Access Immunoassay system, Beckmann).Correlation of cTnI with gender, age, body mass index (BMI), and adequacy of dialysis (Kt/v) were also done. RESULTS: Forty-six (61.3%) patients were on maintenance hemodialysis and 29 (38.6%) were on peritoneal dialysis. Twenty-four (32%) were over the age of 65 years and 37 (49.3%) were men. Levels of cTnI ranged from 0.000 to 0.568 ng/mL, with mean of 0.040 +/- 0.080. Only six (8%) had levels above 0.1 ng/mL, which was the cut off level for significance in our laboratory. There was no statistically significant correlation of cTnI levels with gender, age, BMI, or Kt/v. CONCLUSIONS: Baseline cTnI levels were below significant levels in the majority of maintenance dialysis patients aged at least 45 years or more. Hence cTnI can be used as a valid marker of acute myocardial injury in this group of patients.