Mild Renal Artery Stenosis Can Induce Renovascular Hypertension and is Associated with Elevated Renal Vein Renin Secretion

Renovascular hypertension is a syndrome which encompasses the physiological response of the kidney to changes in renal blood flow and renal perfusion pressure. Such physiological changes can occur with renal artery occlusion irrespective of the severity of the lesion. We have analyzed hypertensive patients with mild renal artery stenosis and compared them to patients with no stenosis. Renal vein renin sampling from catheterization of the renal vein was performed in all these patients. Patients with mild stenosis had higher renal vein renin ratio (3.01 ± 1.5) than the patients with no stenosis (1.10 ± 0.29; p = 0.002). Patients with mild stenosis were also found to have higher diastolic blood pressure and renal artery resistive indices when compared to patients with no stenosis. We therefore conclude that mild stenosis can precipitate renin‐mediated hypertension in renovascular stenosis and also emphasis that parameters pertinent to renal physiology need to be evaluated before considering treatment options in patients with renal artery stenosis and medical management with RAAS blockade is the preferred modality of therapy for patients with renin‐mediated hypertension.     

Major outcomes of patients with tuberculous meningitis on directly observed thrice a week regime

Background:

Revised National Tuberculosis Control Programme (RNTCP) of Government of India provides intermittent thrice-a-week directly observed treatment short course (RNTCP regimen).

Objective:

Assessments of all-cause mortality and nine-month morbidity outcomes of patients with tuberculous meningitis (TBM) on RNTCP regimen.

Materials and Methods:

We prospectively followed up patients registered with RNTCP center, with a diagnosis of TBM from January 1^st, 2010 to December 31^st, 2011. Morbidity was assessed using modified Rankin Scale (mRS).

Results:

We had 43 patients with median duration for follow-up of 396 days and that of survivors of 425 days. Two patients defaulted. Fourteen patients (32.5%) had mRS score of 4 to 6 and 29 had mRS of 0 to 3 after 9-month treatment. Severe disability was not related to any factor on logistic regression. Severe disability was seen in one patient (6.66%) among the 15 patients with stage 1, nine (37.5%) out of 24 patients with stage 2 and three (75%) out of 4 patients with stage 3 disease. Eight patients died (18.6%) of whom 4 died during the intensive phase and 4 during the continuation phase of RNTCP regimen. Mortality was independently related to treatment failure with adjusted Hazard ratio of 8.29 (CI: 1.38-49.78) (P = 0.02). One patient (6.66%) died out of the 15 patients with stage 1 disease, 5 (20.8%) out of 24 patients with stage 2 disease and 2 (50%) out of the 4 with stage 3 disease.

Discussion and Conclusion:

RNTCP regimen was associated with good compliance, comparable mortality and morbidity.     

Membranous Nephropathy With Crescents in a Patient With Hashimoto’s Thyroiditis: A Case Report

Membranous nephropathy is a common cause of nephrotic syndrome in adults. It usually occurs secondary to underlying disease processes such as autoimmune disorders, malignancy, infection, and drugs. The presentation of nephrotic syndrome with concomitant precipitous decline in renal function warrants investigation of a coexistent disorder.We report the case of a 30-year-old male who presented with symptoms and signs of hypothyroidism.A diagnosis of Hashimoto’s thyroiditis was contemplated based on the presence of high serum levels of antithyroglobulin and antithyroid peroxidase antibodies. Upon initiation of treatment with levothyroxine, patient symptomatology improved; however, the laboratory studies demonstrated continued elevated creatinine, hematuria, and proteinuria, which had not been addressed. Two months following treatment initiation, he had progressive deterioration in renal function and proteinuria. A renal biopsy revealed coexistent necrotizing and crescentic glomerulonephritis and membranous nephropathy.The final diagnosis was necrotizing, crescentic glomerulonephritis with superimposed membranous nephropathy likely secondary to Hashimoto’s thyrodiitis.Induction treatment with oral cyclophosphamide and prednisone was started.At the end of 6 months of treatment, there was improvement in renal function and proteinuria and maintenance treatment with azathioprine and low-dose prednisone was initiated. This case highlights the importance of precise and detailed evaluation of patients with autoimmune diseases such as Hashimoto’s thyroiditis particularly in the presence of active urine sediment. Proper evaluation and diagnosis of such patients has implications on the prognosis and response to treatment.     

Pattern and risk factors of stroke in the young among stroke patients admitted in medical college hospital,Thiruvananthapuram

Background:

Stroke in the young is particularly tragic because of its potential to create a long-term burden on the victims, their families, and the community. There had been relatively few studies on young stroke in Kerala''s socio-economic setup, that too encapsulating the mentioned apparently relevant dimensions of stroke in the young.

Objective:

To study the prevalence, patterns and risk factors of young stroke.

Settings and Design:

A cross-sectional study with case control comparison at Government Medical College Hospital, Thiruvananthapuram, Kerala, India.

Materials and and Methods:

Total 100 stroke patients were identified over a period of 2 months, and data were collected on the basis of questionnaire developed for the purpose.

Results:

Of 100 stroke patients, 15 had stroke in the young, among which 9 (60%) had ishaemic stroke. Hypertension was the most common risk factor. Smoking, alcohol, atrial fibrillation, and hyperlipidemia were found to be more common in cases (young stroke) when compared with controls. Alcohol use and atrial fibrillation were significantly higher among young stroke patients. Physical inactivity was significantly lesser in those with stroke in the young than elderly. Atrial fibrillation emerged as an independent risk factor of stroke in the young with adjusted odds ratio of 6.18 (1.31-29.21).

Conclusion:

In all, 15% of total stroke occurred in young adults <50 years. The proportion of hemorrhagic stroke in young adults is higher than in elderly. Atrial fibrillation is identified as an independent risk factor of stroke in the young. Compared with stroke in elderly alcohol use, smoking, hyperlipidemia, and cardiac diseases, which are known risk factors, are higher in young stroke.     

Clinical response to antibiotics among children with bloody diarrhea

WHO recommends ciprofloxacin as the drug of choice for bloody diarrhea. We retrospectively analyzed antibiotic response in 100 children with bloody diarrhea admitted between 2006–2010. Cotrimoxazole (n=55) had higher chance of attaining improved appetite and normal activity in 48h, hospitalization of <3d, blood disappearance in ≤5d and not requiring a second antibiotic compared to others (n=45). Older antimicrobials should be tried in all possible situations.