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Pulmonary-renal syndromes: Experience from an Indian Intensive Care Unit.

Rajagopala S, Sagar BK, Thabah MM, Srinivas BH, Venkateswaran R, Parameswaran S - Indian J Crit Care Med (2015)

Bottom Line: Clinical characteristics of patients with "definite PRS" were compared with those with "PRS mimics".Patients with PRS had more alveolar hemorrhage, hypoxemia and higher mortality (69%) when compared to "PRS mimics".Multicentric studies are needed to further characterize the burden, etiology, treatment protocols, and outcomes of PRS in India.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, India.

ABSTRACT

Background: The etiology of patients presenting with pulmonary-renal syndrome (PRS) to Intensive Care Units (ICUs) in India is not previously reported.

Aims: The aim was to describe the prevalence, etiology, clinical manifestations, and outcomes of PRS in an Indian ICU and identify variables that differentiate immunologic causes of PRS from tropical syndromes presenting with PRS.

Materials and methods: We conducted a prospective observational study of all patients presenting with PRS over 1-year. Clinical characteristics of patients with "definite PRS" were compared with those with "PRS mimics".

Results: We saw 27 patients with "provisional PRS" over the said duration; this included 13 patients with "definite PRS" and 14 with "PRS mimics". The clinical symptoms were similar, but patients with PRS were younger and presented with longer symptom duration. Ninety-two percent of the PRS cohort required mechanical ventilation, 77% required vasopressors and 61.5% required dialysis within 48 h of ICU admission. The etiologic diagnosis of PRS was made after ICU admission in 61.5%. Systemic lupus erythrematosus (54%) was the most common diagnosis. A combination of biopsy and serology was needed in the majority (69%, 9/13). Pulse methylprednisolone (92%) and cyclophosphamide (61.5%) was the most common protocol employed. Patients with PRS had more alveolar hemorrhage, hypoxemia and higher mortality (69%) when compared to "PRS mimics".

Conclusion: The spectrum of PRS is different in the tropics and tropical syndromes presenting with PRS are not uncommon. Multicentric studies are needed to further characterize the burden, etiology, treatment protocols, and outcomes of PRS in India.

No MeSH data available.


Related in: MedlinePlus

Composite image of the chest-computed tomography (left) of patient 10 with granulomatosis with polyangiitis showing bilateral lower lobe air-space nodules with ground glass opacities. A thick-walled cavity in the right upper lobe was also present (not shown). Broncho-alveolar lavage showed increasingly hemorrhagic returns diagnostic of alveolar hemorrhage. Surgical biopsy confirmed granulomatosis and polyangiitis
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Figure 3: Composite image of the chest-computed tomography (left) of patient 10 with granulomatosis with polyangiitis showing bilateral lower lobe air-space nodules with ground glass opacities. A thick-walled cavity in the right upper lobe was also present (not shown). Broncho-alveolar lavage showed increasingly hemorrhagic returns diagnostic of alveolar hemorrhage. Surgical biopsy confirmed granulomatosis and polyangiitis

Mentions: The clinical characteristics of the individual patients are described in Table 1. Two of these patients (case 9 and 12, both with IgA vasculitis) have been previously described. Patients presenting with PRS were 20–30 years and SLE was the most common etiology of PRS (Table 2, 54% of all patients). Breathlessness and leg swelling were the most common complaints; hemoptysis at presentation was seen in 46% (6/13) only. Patients were symptomatic for a median of 2 (8) weeks before seeking healthcare at any center and were admitted to our ICU after a median of another 4 (5.5) weeks evaluation at several other centers. Patients were admitted with advanced organ dysfunction to the ICU, with a mean APACHE II score of 19.8 ± 7.6 at admission. Mechanical ventilation was required in 92% (12/13) for hypoxemic respiratory failure due to DAH, 77% (10/13) required vasopressors, and 61.5% (8/13) required dialysis within 48 h of ICU admission. The etiologic diagnosis of the PRS was made after ICU admission in 8/13 (61.5%) of patients, with a median delay of 4 (5.5) days. In those with a diagnosis prior to ICU admission, a diagnosis of SLE (4/5, 100%) and IgA nephropathy (1/5) had been made at a median of 9 (12) months prior to the current symptoms. Fifteen percent (2/13) had evidence of nephrotic syndrome at presentation. Recognition of alveolar hemorrhage was mostly clinical, with 77% (10/13) having a drop in hemoglobin and 9/13 (69%) having infiltrates consistent with alveolar hemorrhage [Figures 1 and 3]. Only 3/13 (23%) of our cohort needed broncho-alveolar lavage for the diagnosis of alveolar hemorrhage and BALF showed increasing hemorrhagic returns [Figure 3] in all. The etiologic diagnosis of PRS was made using a combination of biopsy (mostly renal, Figures 4-6) and serology in most of the patients (69%, 9/13). Percutaneous or surgical lung biopsy was performed in 15% (2/13) of the “definite PRS” cohort only [Figure 5, right]. Pulse methylprednisolone followed by enteral steroids (12/13, 92%) and pulse cyclophosphamide (8/13, 61.5%) was the most common protocol employed. In those who did not receive cyclophosphamide, a fulminant fatal course (4/5, 80%) or an active infection (1/5, 20%) prevented initiation of this protocol. Plasmapheresis was administered in 46% (6/13), for a median of 4 (4.5) sessions per patient. PRS was associated with very high mortality (9/13, 69%). Mortality was biphasic with an early peak at 48 h due to fulminant DAH and later (median day 8) due to infection aggravated by immunosuppression. Morbidity in survivors was also high; chronic kidney disease in survivors was seen in 75% (3/4) and brain abscess in another patient (1/4). Two of the survivors are dialysis-dependent at 3 months after discharge (50%, 2/4).


Pulmonary-renal syndromes: Experience from an Indian Intensive Care Unit.

Rajagopala S, Sagar BK, Thabah MM, Srinivas BH, Venkateswaran R, Parameswaran S - Indian J Crit Care Med (2015)

Composite image of the chest-computed tomography (left) of patient 10 with granulomatosis with polyangiitis showing bilateral lower lobe air-space nodules with ground glass opacities. A thick-walled cavity in the right upper lobe was also present (not shown). Broncho-alveolar lavage showed increasingly hemorrhagic returns diagnostic of alveolar hemorrhage. Surgical biopsy confirmed granulomatosis and polyangiitis
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4478672&req=5

Figure 3: Composite image of the chest-computed tomography (left) of patient 10 with granulomatosis with polyangiitis showing bilateral lower lobe air-space nodules with ground glass opacities. A thick-walled cavity in the right upper lobe was also present (not shown). Broncho-alveolar lavage showed increasingly hemorrhagic returns diagnostic of alveolar hemorrhage. Surgical biopsy confirmed granulomatosis and polyangiitis
Mentions: The clinical characteristics of the individual patients are described in Table 1. Two of these patients (case 9 and 12, both with IgA vasculitis) have been previously described. Patients presenting with PRS were 20–30 years and SLE was the most common etiology of PRS (Table 2, 54% of all patients). Breathlessness and leg swelling were the most common complaints; hemoptysis at presentation was seen in 46% (6/13) only. Patients were symptomatic for a median of 2 (8) weeks before seeking healthcare at any center and were admitted to our ICU after a median of another 4 (5.5) weeks evaluation at several other centers. Patients were admitted with advanced organ dysfunction to the ICU, with a mean APACHE II score of 19.8 ± 7.6 at admission. Mechanical ventilation was required in 92% (12/13) for hypoxemic respiratory failure due to DAH, 77% (10/13) required vasopressors, and 61.5% (8/13) required dialysis within 48 h of ICU admission. The etiologic diagnosis of the PRS was made after ICU admission in 8/13 (61.5%) of patients, with a median delay of 4 (5.5) days. In those with a diagnosis prior to ICU admission, a diagnosis of SLE (4/5, 100%) and IgA nephropathy (1/5) had been made at a median of 9 (12) months prior to the current symptoms. Fifteen percent (2/13) had evidence of nephrotic syndrome at presentation. Recognition of alveolar hemorrhage was mostly clinical, with 77% (10/13) having a drop in hemoglobin and 9/13 (69%) having infiltrates consistent with alveolar hemorrhage [Figures 1 and 3]. Only 3/13 (23%) of our cohort needed broncho-alveolar lavage for the diagnosis of alveolar hemorrhage and BALF showed increasing hemorrhagic returns [Figure 3] in all. The etiologic diagnosis of PRS was made using a combination of biopsy (mostly renal, Figures 4-6) and serology in most of the patients (69%, 9/13). Percutaneous or surgical lung biopsy was performed in 15% (2/13) of the “definite PRS” cohort only [Figure 5, right]. Pulse methylprednisolone followed by enteral steroids (12/13, 92%) and pulse cyclophosphamide (8/13, 61.5%) was the most common protocol employed. In those who did not receive cyclophosphamide, a fulminant fatal course (4/5, 80%) or an active infection (1/5, 20%) prevented initiation of this protocol. Plasmapheresis was administered in 46% (6/13), for a median of 4 (4.5) sessions per patient. PRS was associated with very high mortality (9/13, 69%). Mortality was biphasic with an early peak at 48 h due to fulminant DAH and later (median day 8) due to infection aggravated by immunosuppression. Morbidity in survivors was also high; chronic kidney disease in survivors was seen in 75% (3/4) and brain abscess in another patient (1/4). Two of the survivors are dialysis-dependent at 3 months after discharge (50%, 2/4).

Bottom Line: Clinical characteristics of patients with "definite PRS" were compared with those with "PRS mimics".Patients with PRS had more alveolar hemorrhage, hypoxemia and higher mortality (69%) when compared to "PRS mimics".Multicentric studies are needed to further characterize the burden, etiology, treatment protocols, and outcomes of PRS in India.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Puducherry, India.

ABSTRACT

Background: The etiology of patients presenting with pulmonary-renal syndrome (PRS) to Intensive Care Units (ICUs) in India is not previously reported.

Aims: The aim was to describe the prevalence, etiology, clinical manifestations, and outcomes of PRS in an Indian ICU and identify variables that differentiate immunologic causes of PRS from tropical syndromes presenting with PRS.

Materials and methods: We conducted a prospective observational study of all patients presenting with PRS over 1-year. Clinical characteristics of patients with "definite PRS" were compared with those with "PRS mimics".

Results: We saw 27 patients with "provisional PRS" over the said duration; this included 13 patients with "definite PRS" and 14 with "PRS mimics". The clinical symptoms were similar, but patients with PRS were younger and presented with longer symptom duration. Ninety-two percent of the PRS cohort required mechanical ventilation, 77% required vasopressors and 61.5% required dialysis within 48 h of ICU admission. The etiologic diagnosis of PRS was made after ICU admission in 61.5%. Systemic lupus erythrematosus (54%) was the most common diagnosis. A combination of biopsy and serology was needed in the majority (69%, 9/13). Pulse methylprednisolone (92%) and cyclophosphamide (61.5%) was the most common protocol employed. Patients with PRS had more alveolar hemorrhage, hypoxemia and higher mortality (69%) when compared to "PRS mimics".

Conclusion: The spectrum of PRS is different in the tropics and tropical syndromes presenting with PRS are not uncommon. Multicentric studies are needed to further characterize the burden, etiology, treatment protocols, and outcomes of PRS in India.

No MeSH data available.


Related in: MedlinePlus