A 47-year-old man with a recent history of wading in floodwaters presented with a 1-week history of cough, myalgia, conjunctival suffusion and decreasing urine output. The patient had uraemia, hypotension, leukocytosis, thrombocytopenia, elevated liver enzymes and oliguria. His condition quickly worsened with haemoptysis, and respiratory distress which subsequently required intubation and mechanical ventilation. Continuous renal replacement therapy was started together with haemoperfusion (HP). The patient initially required norepinephrine and this was discontinued after the first session of HP. He was referred for veno-venous extracorporeal membrane oxygenation (ECMO) due to severe hypoxia and pulmonary haemorrhage. Oxygenation and lung compliance improved, and serum creatinine levels continued to normalise with improved urine output. He was placed off ECMO, extubated and eventually discharged. Patient was diagnosed with severe leptospirosis, acute respiratory failure and acute kidney injury successfully treated with simultaneous ECMO and HP. Blood samples were positive for Leptospira spp. DNA via PCR assay.

Rapid identification of patients likely to develop pulmonary complications in severe leptospirosis is crucial to prompt aggressive management and improve survival. The following article is a cohort study of leptospirosis patients admitted at the National Kidney and Transplant Institute (NKTI). Logistic regression was used to predict pulmonary complications and obtain a scoring tool. The Kaplan–Meir method was used to describe survival rates. Among 380 patients with severe leptospirosis and kidney failure, the overall mortality was 14%, with pulmonary hemorrhage as the most common cause. In total, there were 85 (22.4%) individuals who developed pulmonary complications, the majority (95.3%) were observed within three days of admission. Among the patients with pulmonary complications, 56.5% died. Patients placed on mechanical ventilation had an 82.1% mortality rate. Multivariate analyses showed that dyspnea (OR = 28.76, p < 0.0001), hemoptysis (OR = 20.73, p < 0.0001), diabetes (OR = 10.21, p < 0.0001), renal replacement therapy (RRT) requirement (OR = 6.25, p < 0.0001), thrombocytopenia (OR = 3.54, p < 0.0029), and oliguria/anuria (OR = 3.15, p < 0.0108) were significantly associated with pulmonary complications. A scoring index was developed termed THe-RADS score (Thrombocytopenia, Hemoptysis, RRT, Anuria, Diabetes, Shortness of breath). The odds of developing pulmonary complications were 13.90 times higher among patients with a score >2 (63% sensitivity, 88% specificity). Pulmonary complications in severe leptospirosis with kidney failure have high mortality and warrant timely and aggressive management.

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Introduction:Background: Approximately 50% of children with steroid sensitive nephrotic syndrome (SSNS) will suffer from frequent relapses or steroid dependent course which could be troublesome. In this pilot study, we compare the effectiveness and safety of oral cyclophosphamide and two doses of rituximab as first sparing medication in those children, Methods: This was a prospective open label randomized study of children with SSNS who relapsed frequently or showed a dependent course and received only prednisolone and levamisole. Children who received other immunosuppressive agents or those with a resistant course, evidence of impaired kidney function or leucopenia were excluded. The recruited children were allocated either to the cyclophosphamide or rituximab group. They were monitored for relapses and side effects for at least 12 months. Results: Forty-six subjects were included from two centers; 19 received rituximab and 27 received cyclophosphamide. The one-year relapse-free survival was better among patients treated with rituximab compared to those treated with cyclophosphamide (adjusted HR: 0.36; 95% CI: 0.09 -1.45); however, the difference was not statistically significant.Both rituximab and cyclophosphamide significantly reduced the lowest-dose of steroid required during the year before treatment, compared to the lowest-dose required during a year of follow-up after the start of treatmentsThe adverse-drug reactions (including leukopenia, acute hepatitis and cataract) were lower among patients treated with rituximab (5%) than among those treated with cyclophosphamide (22%); however, the difference was not statistically significant. Conclusions: Rituximab is effective and safe as first line sparing agent in children with steroid dependent or frequently relapsing nephrotic syndrome. A larger multicenter study is required to confirm its superiority over cyclophosphamide

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