Renal infections

Fig. 11. Cluster analysis used to assist in diagnosis of kidney diseases (adapted from Batchelor 418>). (A) acute nephritis, (B) nephrotic syndrome, (C) normal, (D) acute renal infection, (E) essential hypertension, and (F) chronic renal failure...

Tlie clinical utility of another first-generation, non-nitrogen-containing bisphosphonate, tiludronate, has been limited because of concern over renal adverse effects observed in early trials. In a dose-finding study for the treatment of HCM, 19 patients received i.v. drug followed by oral maintenance therapy [70]. Three patients had elevated serum creatinine levels after i.v. drug administration of 4.5 or 6.0 mg/kg, 1 of whom developed acute renal insufficiency and subsequently died, most probably due to tiludronate, although renal infection and allopurinol therapy could have played a contributory role. 

Polyclonal increases in serum immunoglobulins are the normal response to infections. IgG response predominates in autoimmune responses IgA in skin, gut, respiratory, and renal infections and IgM in primary viral infections and bloodstream parasites, such as malaria. Chronic bacterial infections may cause an increase in serum levels of all immunoglobulins. In such cases, estimations of the individual immunoglobulins seldom provide more information than protein electrophoresis. They are of value, however, in the differential diagnosis of liver disease and of intrauterine infections. In primary biliary cirrhosis, the IgM level is greatly increased in chronic active hepatitis, IgG and sometimes IgM are increased and in portal cirrhosis, IgA and sometimes IgG are increased. In intrauterine infections, production of IgM by the fetus increases, and the IgM level in umbilical cord blood is increased. Estimations of IgE are used in the management of asthma and other allergic conditions, especially in children. 

The remaining 20% of recurrent UTIs are relapses, i.e., persistence of infection with the same organism after therapy for an isolated UTI. The recurrence of symptomatic or asymptomatic bac-teriuria after therapy usually indicates that the patient has renal involvement, a structural abnormality of the urinary tract, or chronic bacterial prostatitis. In the absence of structural abnormalities, relapse often is related to renal infection and requires a long duration of treatment. Women who relapse after short-course therapy should receive a 2-week course of therapy. In patients who relapse after 2 weeks of therapy, therapy should be continued for another 2 to 4 weeks. If relapse occurs after 6 weeks of therapy, urologic evaluation should be performed, and any obstructive lesion should be corrected. If this is not possible, therapy for 6 months or longer may be considered. Asymptomatic adults who have no evidence of urinary obstruction should not receive long-term therapy. 

Nebuloni M, Tosoni A, Boldorini R, et al. BK virus renal infection in a patient with the acquired immunodeficiency syndrome. Arch Pathol Lab Med. 1999 123 807-811. 

Uric acid stones are a product of purine metabolism and a diagnosis of gout should be considered. Chronic renal infections and urinary retention syndromes are other major causes. It is easy to see the importance of obtaining a comprehensive history and the chemical definition of any stone that is passed. Dietary advice and strenuous treatment of infections can prevent reoccurrence of the calculi. 

Dalla Palma L, Pozzi-Mucelli F, Pozzi-Mucelli RS (1995) Delayed CT findings in acute renal infection. Clin Radiol 50 364-370... 

Thoeny HC, De Keyzer F, Oyen RH et al (2005) DW-MRI kidneys in healthy volunteers and patients with parenchymal diseases. Radiology 235 911-917 Thornbury JR (1991) Acute renal infections. Urol Radiol 12 209-213... 

Renal infection, notably xanthogranulomatous pyelonephritis, may mimic WT. 

Inflammatory and immune diseases Autoimmune disease (A,I), asthma (A), osteoarthritis (I), rheumatoid arthritis (I), septic shock (A,I), infections (A,I), familial cold auto-inflammatory syndrome (I), Muckle Wells syndrome (I), chronic infantile neurological cutaneous and articular syndrome/neonatal onset multisystemic inflammatory disease (CINCA/NOMID) (I), Crohn s disease (I), gout (I), acute renal failure (A,l)... 

Under certain circumstances, and very rarely, the inhibition of gluconeogenesis by metformin may suppress lactic acid metabolism and precipitate a potentially fatal lactic acidosis. Impairment of renal function, liver disease, alcoholism, conditions that give rise to increased lactate production (e.g. congestive heart failure, infections) are therefore contraindications for the application of metformin. 

A large and rapidly growing number of clinical trials (phase I and phase II) evaluating the potential of DNA vaccines to treat and prevent a variety of human diseases are currently being performed ( http // clinicaltrials.gov) however, there is yet no licensed DNA vaccine product available for use in humans. The clinical trials include the treatment of various types of cancers (e.g., melanoma, breast, renal, lymphoma, prostate, and pancreas) and also the prevention and therapy of infectious diseases (e.g., HIV/ABDS, malaria, Hepatitis B vims, Influenza vims, and Dengue vims). So far, no principally adverse effects have been reported from these trials. The main challenge for the development of DNA vaccines for use in humans is to improve the rather weak potency. DNA vaccines are already commercially available for veterinary medicine for prevention of West Nile Vims infections in horses and Infectious Hematopoetic Necrosis Vims in Salmon. 

Historically the only melanocortin peptide to be used clinically is the parent hormone from which all these peptides are derived from namely ACTH (see above). It has also been used in the treatment infantile spasms for epilepsy, where it is administered as an intramuscular injection only over a 2-12 weeks period. Obvious side effects include weight gain, puffy face, high blood pressure and an increased risk of infection and should never be administered to patients with diabetics, renal or heart failure. ACTH is also used as a stimulation test to measure adrenal cortex activity, i.e. production of cortisol and is used to ascertain whether someone has Addison s disease. 

Additional culture and sensitivity tests may be performed during therapy because microorganisms causing the infection may become resistant to penicillin, or a superinfection may have occurred. A urinalysis, complete blood count, and renal and hepatic function tests also may be performed at intervals during therapy. 

The antipsychotic dru are used cautiously in patients exposed to extreme heat or phosphorous insecticides and in those with respiratory disorders, glaucoma, prostatic hypertrophy, epilepsy, decreased renal function, lactation, or peptic ulcer. The antipsychotic drags are used cautiously in elderly and debilitated patients because these patients are more sensitive to the antipsychotic dragp. lithium is used cautiously in patients who are in situations in which they may sweat profusely and those who are suicidal, have diarrhea, or who have an infection or fever. 

The oral antidiabetic drugs are contraindicated in patients with known hypersensitivity to tiie drugs, DKA, severe infection, or severe endocrine disease. The first generation sulfonylureas (chlorpropamide, tolazamide, and tolbutamide) are contraindicated in patients with coronary artery disease or liver or renal dysfunction. Other sulfonylureas are used cautiously in patients with impaired liver function because liver dysfunction can prolong the drug s effect. In addition, the sulfonylureas are used cautiously in patients with renal... 

The uses of the various anabolic steroids include management of anemia of renal insufficiency, control of metastatic breast cancer in women, and promotion of weight gain in those with weight loss after surgery, trauma, or infections. Stanozolol is used prophylactically... 

The antineoplastic dm are contraindicated in patients with leukopenia, thrombocytopenia, anemia, serious infections, serious renal disease, or known hypersensitivity to the drug and during pregnancy (see Display 55-1 for pregnancy classifications of selected antineoplastic drag s). 

Antineoplastic drug s are used cautiously in patients with renal or hepatic impairment, active infection, or other debilitating illnesses, or in those who have recently completed treatment with other antineoplastic drug > or radiation tiierapy. 

From a therapeutic point of view, it is essential to confirm the presence of bacteriuria (a condition in which there are bacteria in the urine) since symptoms alone are not a reliable method of documenting infection. This applies particularly to bladder infection where the symptoms of burning micturition (dysuria) and frequency can be associated with a variety of non-bacteriuric conditions. Patients with symptomatic bacteriuria should always be treated. However, the necessity to treat asymptomatic bacteriuric patients varies with age and the presence or absence of underlying urinary tract abnormalities. In the pre-school child it is essential to treat all urinary tract infections and maintain the urine in a sterile state so that normal kidney maturation can proceed. Likewise in pregnancy there is a risk of infection ascending from the bladder to involve the kidney. This is a serious complication and may result in premature labour. Other indications for treating asymptomatic bacteriuria include the presence of underlying renal abnormalities such as stones which may be associated with repeated infections caused by Proteus spp. 

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