Quiz page. Rupture of the left kidney.
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Aged↗
Biomedical subjects
Sydney Tang
Publications and source records attributed to Sydney Tang.
Pathogenesis of lupus nephritis: an update.
Lupus nephritis (LN) is a prototypic autoimmune disease. Its immunopathogenesis is characterized by the loss of self-tolerance. In this article, we review our current understanding of the disease mediators of LN. There is ample evidence to suggest a pathogenic role of nephritogenic autoantibodies. These antibodies cross react with nucleosomal epitopes, and the in vivo generation of nucleosomes requires apoptosis. Furthermore, there is an intriguing and paradoxical relationship between complement and systemic lupus erythematosus (SLE). Immune complex-mediated activation of complement through the classic pathway is traditionally believed to be a major mechanism by which tissue injury occurs. In contrast, hereditary deficiencies of complement components increase the risk of SLE. Finally, the roles of reactive nitrogen and oxygen species are emphasized.
Animals↗
Chronic viral hepatitis in hemodialysis patients.
Ever since the first outbreaks of hepatitis in hemodialysis units in the late 1960s, a number of hepatotropic viruses transmitted by blood and other body fluids have been identified. This review summarizes the current state of knowledge regarding these blood-borne agents from an epidemiologic and preventive perspective. Data source and study selection were obtained from research and review articles related to the epidemiology of viral hepatitis in hemodialysis and indexed on Medline and Embase from 1965 to 2004. Hepatitis B virus (HBV) was the first significant hepatotropic virus to be identified in hemodialysis centers. HBV infection has been effectively controlled by active vaccination, screening of blood donors, the use of erythropoietin, and segregation of HBV carriers. To date, HBV remains an important cause of morbidity in endemic areas. Hepatitis delta virus is a defective virus that can only infect HBV-positive individuals. Hepatitis C virus is the most significant cause of non-A, non-B hepatitis and is mainly transmitted by blood transfusion. The introduction in 1990 of routine screening of blood donors for HCV contributed significantly to the control of HCV transmission. An effective HCV vaccine remains an unsolved challenge, however. Pegylation of interferon-alpha has made it possible to treat HCV-positive dialysis patients. Unexplained sporadic outbreaks of hepatitis by the mid-1990s prompted the discovery of hepatitis G virus and hepatitis GB virus C in 1995 and the TT virus in 1997. Although epidemiologic analyses revealed high prevalence rates of both viruses in the hemodialysis population, their exact role in liver disease has yet to be determined. The vigilant observation of guidelines on universal precaution and regular virologic testing are the cornerstones of the effective control of chronic hepatitis in the setting of hemodialysis.
Antiviral Agents↗
Mycophenolate mofetil alleviates persistent proteinuria in IgA nephropathy.
BACKGROUND: Mycophenolate mofetil (MMF) is increasingly used to treat primary glomerulopathies. Its effectiveness in IgA nephropathy (IgAN) remains unclear. METHODS: Forty IgAN patients with persistent proteinuria (>1 g/24 hours) despite conventional treatment with blockers of the renin-angiotensin system were randomized to receive MMF for 24 weeks (group 1) or continue conventional therapy (group 2), and followed for 72 weeks. The primary end point was reduction of proteinuria by 50% or more over entry level. RESULTS: Sixteen patients (80%) in group 1 versus six patients (30%) in group 2 reached the primary end point (P= 0.0019). Time-averaged change in proteinuria showed a significant decline in group 1, while control subjects displayed a modest rise (P= 0.003). By 72 weeks, the mean proteinuria was 62.0 +/- 7.7% (P= 0.003) and 120.5 +/- 14.1% (P= 0.351) that of the corresponding baseline value in group 1 and group 2, respectively. There was concomitant increase in serum albumin and decrease in serum IgA levels in group 1 but not group 2 patients. Baseline histologic grades, blood pressure control, and the rates of change in serum creatinine and creatinine clearance were not different between the two groups. Normalization in binding of polymeric IgA to cultured mesangial cells and serum interleukin-6 (IL-6) levels, which sustained to study end, was observed in group 1 but not group 2 subjects. CONCLUSION: In selected patients with IgAN, MMF is effective in lowering proteinuria and ameliorating some of the putative pathogenetic abnormalities.
Adult↗
Lamivudine in hepatitis B-associated membranous nephropathy.
BACKGROUND: Although lamivudine is effective for treatment of chronic hepatitis B (HBV) infection, its potential therapeutic impact on HBV-related membranous nephropathy (MN) in adults has not been characterized. METHODS: We treated 10 HBsAg-positive patients with biopsy-proven MN, elevated serum alanine aminotransferase (ALT), and HBV-DNAemia (group 1), and compared their clinical course with 12 patients diagnosed to have HBV infection, elevated serum ALT, and MN in the pre-lamivudine era (group 2). RESULTS: Baseline demographic and clinical parameters were not different between the 2 groups. In group 1, lamivudine treatment was associated with significant reduction in proteinuria, increase in serum albumin, normalization of ALT levels, and disappearance of circulating HBV-DNA during the first year. Four (40%) and 6 (60%) patients went into complete remission (proteinuria <0.3 g/d) at 6 and 12 months, respectively. In group 2, significant proteinuria persisted during the first year. One (8.3%) and 3 (25%) patients went into remission. Cumulative 3-year renal survival [using end-stage renal disease (ESRD) as primary end point] was 100% in group 1 and 58% in group 2 (P= 0.024, log rank test). Blood pressure control reached the target of below 130/85 mm Hg in both groups. Lamivudine was well tolerated and not associated with any adverse events. Hepatic decompensation or malignancy was not observed during follow-up in both groups. CONCLUSION: HBV-related MN leads to ESRD in a significant proportion of patients before the advent of antiviral therapy. Lamivudine treatment improves renal outcome in HBV carriers with MN and evidence of liver disease.
Adult↗
A report with consensus statements of the International Society of Nephrology 2004 Consensus Workshop on Prevention of Progression of Renal Disease, Hong Kong, June 29, 2004.
This report summarizes the discussions of the International Society of Nephrology (ISN) 2004 Consensus Workshop on Prevention of Progression of Renal Disease, which was held in Hong Kong on June 29, 2004. Three key areas were discussed during the workshop: (1) screening for chronic kidney disease; (2) evaluation and estimating progression of chronic kidney disease; and (3) measures to prevent the progression of chronic kidney disease. Fifteen consensus statements were made in these three areas, as endorsed by the participants of the workshop. The ISN can make use of and take reference to these statements in formulating its policy for tackling chronic kidney disease, a disease with significant global impact.
Hong Kong↗
Prevalence of silent kidney disease in Hong Kong: the screening for Hong Kong Asymptomatic Renal Population and Evaluation (SHARE) program.
BACKGROUND: End-stage renal disease (ESRD) is epidemic worldwide. In Hong Kong, the annual incidence of ESRD has risen from 100 pmp (per million population) in 1996 to 140 pmp in 2003. SHARE (Screening for Hong Kong Asymptomatic Renal Population and Evaluation program) is a population-based screening program aimed at identifying the prevalence of unrecognized renal disease in asymptomatic individuals, allowing further evaluation and disease-modifying interventions. METHODS: From November to December 2003, SHARE was conducted in several large residential communities in Hong Kong. The screening tool included a questionnaire documenting demographics and history or family history of diabetes mellitus (DM), hypertension (HT), and chronic kidney disease (CKD), together with on-site measurements of blood pressure (BP) and urine dipstick for protein, blood, and glucose. RESULTS: There were a total of 1811 participants. One thousand two hundred and one subjects were entered into the final analysis. Among the 1201 who were apparently "healthy" (asymptomatic and without history of DM, HT, or CKD), the prevalence of positive (> or =1+) urine dipstick for protein, glucose, blood, protein or blood, any urine abnormality, and HT (BP> or =140/90) was 3.2%, 1.7%, 13.8%, 16%, 17.4%, and 8.7%, respectively. Thirty three percent of the age over 60 years old group had either hypertension or urine abnormalities, compared with 24.0% in the 41- to 60-year-old group and 9.7% in the 20- to 40-year-old group. Having a family history of diabetes or hypertension increases the risk of having urine abnormalities, while a family history of hypertension also increases the risk of high blood pressure. CONCLUSION: It is concluded that subclinical abnormalities in urinalysis or BP readings are prevalent across all age groups in the adult population. An effective screening program at the primary care level that identifies these subjects for further evaluation is warranted, and the public in Hong Kong should be educated toward the significance of such findings in order to have regular health check for asymptomatic renal diseases.
Adult↗
Quiz page. Posttransplantation lymphoproliferative disorder (PTLD) involving the brain and the allograft.
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Antilymphocyte Serum↗
Predictors and outcome of renal flares after successful cyclophosphamide treatment for diffuse proliferative lupus glomerulonephritis.
OBJECTIVE: To study the incidence, predictors, and outcome of renal flares after successful cyclophosphamide (CYC) treatment for diffuse proliferative glomerulonephritis (DPGN) in patients with systemic lupus erythematosus (SLE). METHODS: Between 1988 and 2001, patients with biopsy-proven SLE DPGN who were treated initially with prednisone and CYC were studied. Those who responded to CYC were followed up for the occurrence of renal flares. The cumulative risk, predictors, and outcome of renal flares were evaluated. RESULTS: We studied 189 patients (167 women; and 22 men) with SLE DPGN. All were initially treated with prednisone and CYC (49% orally; 51% by intravenous pulse). At the last dose of CYC, 103 patients (55%) and 52 patients (28%) had achieved complete and partial renal responses, respectively. Azathioprine (AZA) was given as maintenance therapy in 117 patients (75%). After a mean followup of 96.5 months, 59 patients (38%) experienced renal flares (42% nephritic; 58% proteinuric). The median time to relapse was 32 months. The cumulative risk of renal flare was 28% at 36 months and 44% at 60 months. Independent predictors of nephritic flares were persistently low C3 levels after CYC treatment and absence of AZA maintenance therapy. At the last clinic visit, 16 patients (10.3%) had developed doubling of the serum creatinine level (cumulative risk of creatinine doubling 7.4% at 5 years after renal biopsy and 14.3% at 10 years). Ten patients (6.5%) developed end-stage renal disease (ESRD). Renal survival rates at 5 and 10 years were 94.9% and 87.5%, respectively. Increasing histologic chronicity scores, failure to achieve complete response, persistent hypertension after CYC treatment, and nephritic renal flares were unfavorable factors for doubling of the serum creatinine level and for ESRD by univariate analysis. The occurrence of nephritic flares was the only predictor of creatinine doubling by Cox regression analysis. CONCLUSION: In patients with SLE DPGN, renal flares are common despite initial responses to CYC. Nephritic renal flares are associated with a decline in renal function. Maintenance therapy with AZA reduces, but does not completely prevent, renal flares. More effective maintenance treatment for SLE DPGN after an initial response to CYC should be evaluated.
Adult↗
Spousal renal donor transplantation in Chinese subjects: a 10 year experience from a single centre.
BACKGROUND: The shortage of cadaveric kidneys for renal transplantation is a particularly problematic situation in the locality of Hong Kong. Kidneys from spousal donors are therefore increasingly being used for transplantation. This study was undertaken to evaluate the outcome of spousal donor transplant recipients in comparison with that of genetically related living donor (LRD) allograft recipients. METHODS: From 1988, we have transplanted 22 spousal kidney recipients (group 1). All donors must demonstrate a genuine spousal relationship. Their outcome was compared with that of 24 LRD allograft recipients (group 2) transplanted in the same period with similar demographics, pre-transplant dialysis duration, immunosuppressive protocol and length of post-transplant follow-up. RESULTS: The mean (+/-SD) age was 36.5 +/- 8 and 32.5 +/- 6 years for groups 1 and 2, who were followed for 56.6 +/- 35 and 59.1 +/- 38 months, respectively. There was no difference in the incidence of delayed graft function, acute rejection and serum creatinine level at 5 years. Graft survival rates were 86.4 and 79.2% (P = 0.56), while patient survival rates were 100 and 91.7% (P = 0.171) at 5 years for groups 1 and 2, respectively. CONCLUSIONS: Spousal kidney transplantation shares comparable results with LRD transplantation and should be encouraged in places where cadaveric organs remain scarce. Stringent measures must be implemented to prevent the possible emergence of kidney bartering and to protect the interests of living donors. The ethical and social issues regarding the spousal donor in Hong Kong and other countries are discussed.
Adult↗
Tuberculous infection in southern Chinese renal transplant recipients.
A retrospective study of the prevalence and pattern of tuberculosis among renal transplant patients in a single centre in southern China was performed. Twenty-three cases of tuberculosis were diagnosed among 440 patients between January 1991 and December 2002. There were 18 men and five women. The mean age of the patients was 39.3 +/- 13.4 yr. There were 13 living-related and 10 cadaveric renal transplants. The interval between renal transplantation and the development of tuberculosis ranged from 3 to 127 months with a median of 46 months. There were 18 cases of pulmonary tuberculosis, two cases of pulmonary plus laryngeal tuberculosis, two cases of disseminated tuberculosis, and one case of tuberculosis involving the urinary tract. Diagnosis was established by positive culture for Mycobacterium tuberculosis in 21 patients and response to empirical anti-tuberculosis treatment in two patients. The duration of symptoms before the diagnosis of tuberculosis was 27 +/- 12 d. The patients were treated with standard anti-tuberculosis drugs for 11 +/- 3 months. The anti-tuberculosis treatment was in general well-tolerated. Five patients developed transient hepatitis, three patients developed thrombocytopenia and five patients developed gouty arthritis. One patient died 2 months after initiation of anti-tuberculosis therapy. All other patients completed anti-tuberculosis treatment. No recurrence of tuberculosis was observed after a median follow-up of 90 months. We concluded that (i) tuberculosis is prevalent among southern Chinese renal transplant recipients; (ii) high index of suspicion for tuberculosis among renal transplant recipients is warranted to ensure early diagnosis and prompt initiation of treatment; and (iii) treatment with standard anti-tuberculosis drugs for an extended period of time is well-tolerated and is associated with favourable outcome.
Adult↗
The many facets of presentation of hepatocellular carcinoma.
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Brain Stem Infarctions↗
Septic metastatic endophthalmitis.
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Endophthalmitis↗
Use of tacrolimus in steroid- and cyclophosphamide-resistant minimal change nephrotic syndrome.
The authors report a case of adult-onset minimal change nephrotic syndrome (MCNS) that was resistant to steroid and cyclophosphamide therapy. Introduction of cyclosporin induced an usual cutaneous reaction of severe flushing attacks. Tacrolimus successfully alleviated both the nephrotic syndrome and the cutaneous side effect associated with cyclosporin use. The antiproteinuric mechanisms of tacrolimus and its potential in treating refractory MCNS and other forms of primary glomerulonephritides are discussed.
Anti-Inflammatory Agents↗
Successful treatment of hepatitis C after kidney transplantation with combined interferon alpha-2b and ribavirin.
The management of acute hepatitis C virus (HCV) infection after renal transplantation (RT) remains controversial, due to the potential risk of interferon-induced graft dysfunction. There is little experience with combined interferon and ribavirin therapy in this group of patients. We treated four consenting RT recipients who developed acute de novo HCV infection with a combination of interferon-alpha 2b and ribavirin. After 48 weeks' treatment, sustained virologic and biochemical remission were achieved in three patients infected with HCV genotypes 1a, 2, and 6a, respectively. The median time from treatment onset to ALT normalization was 8 weeks. The fourth patient was a non-responder infected with genotype 1b. Dose-dependent hemolysis was the most frequent side-effect. No patient developed allograft dysfunction. Our experience indicates that the judicious use of combined interferon and ribavirin can be considered in selected RT recipients with severe acute hepatitis C infection.
Adult↗
Clinical features and genetic analysis of a Chinese kindred with Fabry's disease.
BACKGROUND: Fabry's disease is an X-linked recessive inborn error of glycosphingolipid catabolism resulting from deficient activity of lysosomal enzyme alpha-galactosidase A causing occlusive microvascular diseases affecting the kidney, heart, peripheral nerves and brain. It is an uncommon disease in the Oriental population. METHODS AND RESULTS: We report a Chinese kindred of Fabry's disease and the relevant clinical features are discussed. The diagnosis of Fabry's disease was based on serum alpha-galactosidase A activity and typical histological features from renal biopsy in the index patient. Genetic analysis of two hemizygous male patients revealed a missense mutation predicting a leucine to proline substitution (L14P) in the alpha-galactosidase gene causing classical Fabry's disease in this family. This is a novel point mutation not described previously in the literature and the second report describing novel genetic mutations for Fabry's disease in Chinese patients. CONCLUSIONS: Fabry's disease is rare in Chinese patients but this diagnosis should be considered in patients with positive family history of kidney disease and relevant clinical features.
Adult↗
Video-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis.
BACKGROUND: Acute, massive, unilateral hydrothorax is an uncommon but well-recognized complication of peritoneal dialysis. Its clinical course and treatment outcome after a recently advocated technique of video-assisted thoracoscopic (VATS) talc pleurodesis remains unclear. METHODS AND RESULTS: Between July 1998 and March 2002, among 475 CAPD patients in two regional hospitals in Hong Kong, nine patients (three men, six women, mean age 53+/-12 years) developed acute hydrothorax due to pleuroperitoneal communication (R=8, L=1) within 5.8+/-4.2 months (median, 5.2 m; range, 2 days to 11.6 months) of commencing peritoneal dialysis. Analysis of simultaneously obtained peritoneal and pleural fluid in all subjects only showed concordance in protein content (consistently<4 g/l), while fluid glucose and lactate dehydrogenase levels were not comparable. The methylene blue test was negative (n=4). Radionuclide scan (n=6) and contrast CT peritoneography (CTP, n=3) detected pleuroperitoneal communication in half and one-third of the patients, respectively. All patients underwent pleurodesis achieved by talc insufflation into the pleural cavity under VATS guidance. All patients were successfully returned to peritoneal dialysis. After a mean follow-up of 18.8+/-12.5 months, hydrothorax recurred in one patient (at 7 months after pleurodesis), who was successfully treated by repeating the procedure. CONCLUSIONS: Hydrothorax complicating CAPD is more commonly right-sided, and tends to occur within the first year of starting peritoneal dialysis. Isotope scan and CTP are insensitive in diagnosing pleuroperitoneal communication. A low pleural fluid protein content is the most consistent biochemical finding. VATS talc pleurodesis is a safe and reliable treatment of choice that allows sustained continuation of CAPD with low recurrence rate.
Acute Disease↗