We prospectively followed-up new patients of tuberculosis while on maintenance hemodialysis at a State Government-run tertiary care institute. Between 2000 and 2010, 1237 new patients were initiated on maintainence hemodialysis. The number of patients diagnosed with tuberculosis after initiation of hemodialysis was 131 (10.5% of 1237). The age was 46.4 ± 10.4 (range 8-85) years and there were 90 (68.7%) males. The number of patients diagnosed with tuberculosis on the basis of organ involvement were: Pulmonary-60, pleural effusion-31, lymph node-21, meningitis-8, pericardial effusion-7, peritoneum-2, latent tuberculosis-2. The incidence of tuberculosis in hemodialysis was found to be 105.9 per 1000 patient years. Male gender, diabetes mellitus, past history of tuberculosis, mining as an occupation, low serum albumin, and duration of hemodialysis more than 24 months, and unemployment were found to be significant risk-factors on univariate analysis.

Rhabdomyolysis is a syndrome characterized by muscle necrosis and the release of intracellular muscle contents into the systemic circulation. We report a patient with chronic kidney disease who had deterioration of renal function due to combination of risk factors like hypothyroidism and interaction of amlodipine and clopidogrel with statins.

Renal infarction due to oral contraceptive pillsA previously healthy, 35-year-old woman, mother of two children, presented with a 3-day history of abdominal discomfort, vomiting and anuria for 2 days. She had no history of diabetes or hypertension. She had been using a combination of ethinylestradiol and drospirenone as a contraceptive for the previous 3 years. Her investigations at presentation were: serum creatinine: 7.9 mg/dL (698 lmol/L), blood urea nitrogen: 185 mg/dL (66 mmol/L), serum proteins: 8.2 g/dL, serum albumin: 4.5 g/dL, serum homocysteine: 4.2 lmol/L (0.56 mg/L), haemoglobin: 11.2 g/dL, total leucocyte count: 4800/mm D-dimer: 1.7 lg/mL (range: 0.5 lg/mL). Kidney sizes on ultrasound were right: 12.4 3 4.6 cm and left: 11.5 3 4.4 cm. Doppler of the renal arteries revealed severe decrease and pruning of the segmental, inter-lobar and arcuate vessels and absence of the cortical blush in both of the kidneys. Urine dipstick examination for proteins was negative. A renal biopsy was done after a session of haemodialysis. It revealed coagulative necrosis (infarct) of the cortex of the kidney, and the artery included in the biopsy was obstructed by fibrin thrombus (Figure 1). She was not pregnant and had no congenital heart disease. There was no history of acute gastroenteritis, trauma or snakebite. There was no history or clinical features suggestive of haemolytic uraemic syndrome. There were no schistocytes on peripheral smear. Electrocardiogram showed normal sinus rhythm with no ischaemic or chamber enlargement changes. Echocardiography revealed normal cardiac chambers and normal valves. The reports of anti-thrombin III: 0.25 g/L (range: 0.19-0.31 g/L), protein C: 90% (range: 70-160%) and protein S: 80% (range: 60-150%). Prothrombin time and partial thromboplastin times were not prolonged in order to investigate for factor V Leiden mutation. Flow cytometry did not find a reduction in CD 55 and CD 59 on red blood cells, thus excluding paroxysmal nocturnal haemoglobinuria. Anti-phospholipid antibodies, lupus antibody, anti-nuclear antibodies and anti-double-stranded DNA were negative.The patient did not regain renal function. She was initiated on continuous ambulatory peritoneal dialysis. One of the adverse effects of oral contraceptive pills is arterial thrombosis. There are experimental reports of acute cortical necrosis in rats induced by oestrone and vasopressin administration [1]. There are a few reports of acute cortical necrosis in patients who used oral contraceptives, but these patients had other features like factor V Leiden mutation [2] and smoking [3].Conflict of interest statement. None declared.

An 18-year-old boy underwent living-donor renal transplantation. His mother was the donor. The patient was started on tacrolimus (0.1 mg/kg/d), prednisolone (20 mg/d) and azathioprine (2 mg/kg/d), after initial 3 days of I.V. methyl prednisolone (15 mg/kg/d), as immunosuppressive regimen. Six months after transplantation, he presented with fever that had occurred for two days. There was no history of dysuria, altered urine colour, pyuria or edema. Serum creatinine increased from 1.0 mg/dl to 1.9?2.8?3.7 mg/dl over the next 3 days. On the day of admission, serum tacrolimus levels, blood and urine cultures, and search for polyoma virus were ordered. A Doppler ultrasound of the renal allograft artery revealed a resistive index of 0.9 and hydronephrosis, which had not been present on any of the previous ultrasound exams. A CT scan of the abdomen, with an empty urinary bladder, confirmed hydronephrosis of the allograft, with possible pelvic ureteric junction obstruction (Fig. 1). Blood clots, a technically poor ureteral implantation and ureteral are common causes of obstruction in the early post operative phase, whereas periureteral fibrosis, lymphocele and calculi are possible causes in the late post-operative phase. On the same day, the renal transplant surgeon reviewed the operation protocol notes and confirmed that an antireflux procedure, the Lich reimplantation, had indeed been performed. The radionuclide micturition cystography did not reveal vesicoureteral reflux. Ureteric stenosis due to polyoma virus-associated nephropathy (PVAN) was provisionally diagnosed. However, it is known that PVAN typically induces stenosis in the distal rather than the proximal part of the ureter [1, 2].On day two, the polyoma virus DNA was found to be negative in both urine and blood. Blood and urine cultures were also sterile. Serum tacrolimus levels were found to be 1.8 ng/l. Circulating donor-specific antibodies determination was unfortunately not available in our hospital. The allograft biopsy was done, under ultrasound guidance, and it revealed neutrophils in the capillaries and in the interstitium, diffuse acute tubular injury and C4d positivity in peritubular capillaries. PVAN may be differentiated from acute antibody-mediated rejection (AMR), but not from acute cellular rejection, by the presence of mononuclear and plasma cell infiltration.After renal transplantation, the ureter receives its entire blood supply from the ureteral branch of the renal artery [3]. Acute rejection involves both the kidney and the ureter, and the resulting edema and possible secondary ischaemia may also lead to ureteral obstruction [3]. In an animal model, Hricak et al. [4], found significant alterations in the ureteral dynamics during rejection, as shown by the progressive decrease in electrical activity of the ureteral muscle on electromyography and the reduced

No abstract