Rula Abdurrahman is a graduate from the University of Baghdad, School of Medicine, pursued an expansive medical career and research overseas and is currently a PGY2 Internal Medicine Resident at St. John’s Episcopal Hospital in Far rockaway, New York. She has worked as Case Manager and Clinical Supervisor in the Italian Red Cross to help the war victims in the Middle East in 2003. She is currently following a path of clinical research with multiple abstracts and case presentations while serving as a Resident Physician.
Introduction: For years, so many complications of hemodialysis have been well documented. However, elevated intraocular pressure (IOP) from HD is an extremely rare finding. In fact, this has led to eyeball evisceration in some cases that were refractory to treatment modalities. Case: A 53 years old man with hypertension, DM and ESRD on hemodialysis presented to the ER with shortness of breath and edema. He reported failing to complete four sessions of dialysis due to headache and eye pain. The patient mentioned that during the dialysis he was having headache 9/10, which was relieved few hours after stopping dialysis sessions. Pain was associated with nausea and blurry vision. He denied any previous history of laser eye surgery or glaucoma but has had bilateral cataract surgery within the past year. On examination, patient had generalized edema. Vitals were BP: 170/90, Temp: 96.9F, PR: 70 and RR: 20. Lab findings; WBC: 12000, Hemoglobin: 9.8, Platelets: 219000, K=6.5, BUN=92, Creatinine=12.40, Calcium: 10.4, Pro BNP=5760 and EGFR: 5.18. CT head was unremarkable. Urgent hemodialysis was initiated, during which patient became confused and agitated. He started complaining of bilateral eye pain with occipital headache. This prompted for ophthalmology consult. Measured IOP was 38 (right) and 34 (left) mmHg. Optic cups showed temporal pallor in both eyes. Gonioscopy revealed pigment dispersion in the right eye in the trabecular meshwork (part of the aqueous humor drainage system of the eye). Left eye anterior chamber showed no pigment deposition. IOP dropped down to 24 OD (right eye) and 22 OS (left eye) one hour after commencing Alphagan 0.15%, Xalatan and Timolol 0.5% OU with further drop in IOP to 18 bilaterally in two hours. Diamox 500 mg PO TID was also added. After few days of treatment, he was able to tolerate hemodialysis with no more eye pain or headache. Discussion: Few publications have cited the possibility of hemodialysis leading to elevated IOP especially in susceptible eyes as seen in our patient. However, the pigment deposition (that might be a complication of cataract surgery) was not observed on the left eye. This suggests the possibility of hemodialysis leading to elevated IOP even in a non-susceptible eye. This may happen due to the rapid decrease in serum osmolality leading to shift of fluid from plasma to the aqueous humor as a result of osmotic disequilibrium. Our patient had some occlusions of his trabecular meshwork in the right eye, which could explain the development of his symptoms recently, despite been on hemodialysis for years. Acetazolamide has been used with precautions of metabolic acidosis.
Afroza Begum has completed her graduation and MD under Dhaka University, Fellowship on Pediatric Nephrology from All India Institute of Medical Sciences (AIIMS), India.
Introduction: Glomerular disease pattern changes in different countries, different ethnic groups and in the same group in different times. Our aim of the study was to observe the pattern of glomerular diseases and their histological spectrum in a tertiary level hospital of Bangladesh. Methods: We retrospectively reviewed the clinical record of 303 patients with nephrotic syndrome and nephritis for a one year period from September 2013 to August 2014 in the Department of Pediatric Nephrology of Bangabandhub Sheikh Mujib Medical University (BSMMU). Renal biopsy was done in selected patients with indication and specimen was evaluated by light and immunoflourescence microscopy. Results: Total 303 patients were admitted with different glomerular diseases with mean age 117.3 months (range 15-156 months) of whom 203 were male (68%). Nephrotic syndrome was the most common presentation and was seen in 232 (76.56%) patients of which first attack was predominant (44%), followed by steroid dependent (14%), frequent relapse (12%), infrequent relapse (10%) and congenital nephrotic syndrome (1%) and not defined (7%). Acute glomerulonephritis (AGN) was present in 51(25.1%) patients of which 6 (11.76%) presented with rapidly progressive glomerulonephritis (RPGN). Henoch Schonlein purpura (HSP) was present in 10 (3%), IgA Nephropathy in 2 (0.66%) and Alport syndrome in 2 (0.66%) patients. Patients presented with lupus nephritis were only 6 (1.98%) because there is a separate lupus clinic in this institute. Renal biopsy was done in 65 (21.65%) patients and Mesangial proliferative GN was the predominant finding (32%) followed by minimal change disease (10%), membranoproliferative GN (9%), focal segmental GN (6%), acute proliferative GN (6%), crescentic GN (5%) and IgA deposition (6%). Other pathology present was IgM deposition, chronic GN, diffuse mesengial sclerosis, membranous GN and acute tubular necrosis. Out of 6 lupus nephritis 4 (66.66%) had grade IV nephritis. Biopsy was inadequate in 4(6%) cases. Conclusion: Present study showed that nephrotic syndrome was the most common glomerular disease followed by AGN and HSP. Mesangial proliferative GN was the most common histopathology followed by minimal change disease and membranoproliferative