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  ~ Table of Contents - Current issue
Coverpage
November-December 2019
Volume 29 | Issue 6
Page Nos. 379-437

Online since Thursday, November 14, 2019

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OBITUARY  

Professor Dr. HL Trivedi pioneering nephrologist and patriot who cared for his country (31-08-1932 TO 2-10-2019) p. 379
Vivek Kute, Himanshu Patel, Pankaj Shah, Pranjal Modi, Vineet Mishra
DOI:10.4103/ijn.IJN_348_19  
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COMMENTARY Top

Isothermic dialysis-a new panacea for intradialytic hypertension? p. 381
Anirban Ganguli
DOI:10.4103/ijn.IJN_262_18  
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Multiorgan involvement with severe gastrointestinal system manifestations in a patient with granulomatosis with polyangiitis p. 383
Ashish Kataria, Sandeep Magoon
DOI:10.4103/ijn.IJN_31_19  
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Takotsubo Syndrome in the Dialysis Patient - Challenging Diagnosis in a Unique Population p. 385
Charlotte Perrett, Debasish Banerjee
DOI:10.4103/ijn.IJN_335_18  
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ORIGINAL ARTICLES Top

Outcomes of primary arteriovenous fistula for hemodialysis in elderly patients (>65 Years) with end stage renal disease: A study on Indian population p. 387
P Gaur, A Srivastava, SK Sureka, R Kapoor, MS Ansari, UP Singh
DOI:10.4103/ijn.IJN_65_18  
Introduction: The outcome of arteriovenous fistula (AVF) for hemodialysis (HD) in elderly population remains an issue. The aim of our study was to evaluate the outcomes of arteriovenous fistulas created at our institute in patients older than 65 years. Methods: All chronic HD patients with age >65 years who had an AVF created between January 1, 2010 and January 1, 2017 were included retrospectively. Baseline demographic information including age, gender, etiology of renal failure and comorbidities were recorded. Access characteristics including access type and anatomic location were recorded. The end point of study was primary and secondary patency. Minimum follow up period of study was 1 year. Results: A total of 422 AVF were created within the study period. The mean age was 69.3 years. The anatomical site of AVF creation was radiocephalic (RCF) in 74.8% (n = 316), brachiocephalic (BCF) in 18.9% (n = 80) and brachiobasilic (BBF) in 6.1% (n = 26). At one year after creation, cumulative survival of the AVF was 64.7%. At 36 months the primary and secondary patency of RCF, BCF and BBF was 43.6%, 58.6%, 42.6% and 47.3%, 62.5%, 56.9% respectively. The overall median survival did not differ between RCF and BBF fistulas. However, when both were compared with BCF (median survival 1034 days), BBF (median survival 741 days) and RCF (median survival 592 days) had significantly poorer survival (P = 0.004). The most common reason for access failure was thrombosis (28.4%) followed by failure to mature (9%) and aneurysm related complications (9%). Conclusions: Age should not be a limiting factor when choosing AVF as the preferred HD access. Brachiocephalic AVF has better primary and secondary patency with higher overall median survival. However RCF also provides reasonably good survival rates with acceptable complications in elderly population. Thrombosis and fistulas that fail to mature present as a primary concern to patients in elderly population, and demand further study.
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Hand grip strength in patients on maintenance hemodialysis: An observational cohort study from India p. 393
Neeraj Birajdar, Urmila Anandh, Sunita Premlatha, G Rajeshwari
DOI:10.4103/ijn.IJN_251_18  
Introduction: Malnutrition is a common manifestation in patients with dialysis and is a major cause of mortality in these patients. Various biochemical parameters are used to detect and monitor malnutrition in these patients. Confounding variables present in hemodialysis have an effect on the sensitivity and specificity of these tests. Methods: We studied hand grip strength (HGS) as a monitoring tool for protein malnutrition in these patients. Results: In a prospective observational study over 18 months, 83 patients (60 males) consented to be part of the study. The biochemical parameters showed the mean (±sd) of haemoglobin and albumin as 10.(±1.9) gm/dl and 3.5 (±0.5) gm/dl respectively. Majority of the patients (54/83) were well nourished according to subjective global assessment (SGA). The hand grip score in the cohort was weak in the majority of patients. It is interesting to note that majority of the males have weak HGS as compared with the general population of the same age group. The female patients had HGS which were in the normal range of values that of the population. A multiple regression analysis showed that there was a significant association with serum creatinine and HGS. Conclusions: No correlation between albumin and HGS was noted. Of the anthropometric variables a significant correlation was noted between mid arm muscle circumference and HGS.
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Direct correlation between age at diagnosis and severity of nephropathy in fabry disease patients p. 398
Sebastián P. A. Jaurretche, Norberto Antongiovanni, Fernando Perretta
DOI:10.4103/ijn.IJN_167_18  
Introduction: Nephropathy is one of the major complications of Fabry disease and mainly includes reduced glomerular filtration rate and proteinuria. Affected patients show different degrees of annual loss of renal function according to the magnitude of proteinuria and decrease in estimated glomerular filtration rate (eGFR) at the baseline. Objetive: To analyze the relationship between age at diagnosis and severity of nephropathy in a Fabry disease population. Methods: Cross-sectional design with retrospective data collection. Results: Seventy-two patients were studied with mean age of 26.26 ± 16.48 years and 30 men (41.6%). Twenty-seven paediatric patients and 45 adults were included. Thirteen genotypes were found: E398X, L415P, c886A>G, L106R, c.680G>A, A292T, c. 448.delG, R363H, C382Y, R301Q, D109G, del 3 and 4 exons, W81X, all pathogenic mutations of GLA gene. The mean eGFR in paediatric population was 115.81 ± 20.87 ml/min/1.73 m2 and in adults was 80.63 ± 42.22 ml/min/1.73 m2. The Pearson's bilateral correlation coefficient test (value = −0.462) between the age at diagnosis and eGFR indicates inverse correlation between both variables with a strong statistical significance (P = < 0.01). Spearman's bilateral correlation coefficient (value = +0.385) between the variables at diagnosis and the degree of proteinuria indicates direct correlation between both variables with a strong statistical significance (P= <0.01). Conclusions: Diagnosis of Fabry disease patients at a younger age could be a key to improve the nephropathy prognosis and allow early and effective interventions.
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Heavy metals and pesticides in chronic kidney disease – Results from a matched case–control study from a rural population in Shivamogga district in South India p. 402
YJ Anupama, SK Kiran, Shrikanth N Hegde
DOI:10.4103/ijn.IJN_325_18  
Introduction: There is a high prevalence of chronic kidney disease (CKD) in the rural agrarian population of South India and it often appears unrelated to major known causes such as diabetes or glomerulonephritis. Methods: In a matched case–control study conducted in a rural population in Shivamogga district in South India, the association of heavy metals – lead (Pb), arsenic (As), cadmium (Cd) – and pesticides in CKD was studied. Blood and spot urine samples were tested quantitatively for heavy metals and qualitatively for pesticides. Results: In all, 69 matched pairs (40 female, 58%) were recruited. The mean estimated glomerular filtration rate (mL/min/1.73 m2) was 60.1 (14.2) in cases and 83.4 (13.4) in controls. Elevated blood lead level >5 μg/dL was seen in 15 cases and 25 controls, respectively [P = 0.035, matched odds ratio (MOR) 0.5, 95% confidence interval (CI) 0.22–1.05]. Urinary Pb was elevated in 16 cases and 13 controls, respectively (P = 0.28, MOR 1.25, 95% CI 0.58–2.73). There was no significant association with As and Cd, while pesticide residues were undetectable in cases as well as controls. These results did not change even after excluding CKD cases with diabetes, stage 2 hypertension, and significant proteinuria. Conclusions: There was no statistical significant association between any of the studied heavy metals and CKD, although there was a significant burden of heavy metals in the studied subjects.
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Low concentration trisodium citrate as a non-inferior locking agent for non-tunneled dialysis catheters in the Asian Setting p. 410
Varadharajan Jayaprakash, Dhakshinamoorthy Jagadeswaran, Krishnamoorthy Ezhilmathi, Arumugam Sathiapriya, Makkena Vamsikrishna, Elayaperumal Indhumathi, Matcha Jayakumar
DOI:10.4103/ijn.IJN_360_18  
Introduction: Unfractionated heparin is the commonly used catheter lock solution in patients with temporary dialysis catheters as hemodialysis access. The effectiveness of trisodium citrate as an alternate catheter lock agent has not been studied in Asian population. Methods: In this prospective quasi-experimental study, which included 180 patients with central venous dialysis catheter, patients were randomly allotted to citrate 4.67% and heparin 5000 units/ml arms in the ratio of 2:1. Baseline demographic and dialysis related data, incidence of catheter-related bloodstream infections, and mean catheter days in both the study cohorts were collected and compared. Formal cost analysis for citrate 4.67% use as catheter lock was done. Results: The mean age of the total study population was 50.49 ± 14.87 years. Sixty-six females (36.7%) and 80 (44.4%) diabetic patients were included in the study. The overall incidence of catheter-related bloodstream infection (CRBSI) was 11.11%. The majority had nontunneled dialysis catheters (95%; n = 114). On analyzing the data of patients with nontunneled catheters, it was found that the total number of catheter days for the citrate and heparin groups were 4,795 and 2,419 days, respectively. The number of CRBSI episodes per 1,000 catheter days for the citrate and heparin groups were 2.711 and 2.89, respectively. Citrate catheter lock cost only 6% of that of heparin lock. Conclusions: The incidence of catheter related bloodstream infections was comparable between the heparin and citrate 4.67% lock cohorts. The use of low concentration citrate as catheter lock was cost-effective when compared with heparin.
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CASE REPORTS Top

Gastrointestinal Involvement in Granulomatosis with Polyangiitis: Case Report and Review p. 415
Sahil Bagai, Aman Sharma, Rajesh Gupta, Vivek Kumar, Manish Rathi, Harbir S Kohli, Krishan L Gupta, Raja Ramachandran
DOI:10.4103/ijn.IJN_141_18  
Granulomatosis with polyangiitis (GPA) commonly affects upper/lower respiratory tract and kidneys. It causes necrotizing vasculitis of small and medium-sized blood vessels. Gastrointestinal (GI) involvement is an uncommon manifestation of GPA, and presentation with predominant GI manifestation is noteworthy. We report a case of 50-year-old male with melena due to GI vasculitis along with other systemic involvement. The patient was treated with pulse methylprednisolone, cyclophosphamide, and plasmapheresis. To manage the refractory GI bleed, the patient underwent surgical resection, and the histology of the surgical specimen confirmed necrotizing vasculitis.
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Takotsubo Syndrome during Haemodialysis p. 419
Nikolaos Tsigaridas, Stavros Mantzoukis, Marina Gerasimou, Konstantinos Bakas, Emilios Andrikos, Elisavet Kokkolou, Aphrodite Tsinta, Dimitrios Patsouras
DOI:10.4103/ijn.IJN_267_18  
Takotsubo syndrome (TS) is typically characterized by transient (reversible) systolic dysfunction of the apical and mid segments of the left ventricle (LV), usually without obstruction of coronary arteries, in postmenopausal women after a stressful event. Usually, patients may experience symptoms such as chest pain, shortness of breath, palpitations, and rarely syncope or cardiogenic shock. There are many theories about pathophysiology of TS. Among these, most acceptable is the catecholamine theory. The prognosis is usually good with recovery of symptoms and imaging findings at most within a few weeks. However, complications may occur. We present the 11th published case of a patient on hemodialysis, who presented with TS and discuss why this situation may occur in patients on hemodialysis. Contrary to our patient, half of previously published cases presented with atypical symptoms. Therefore, it is important to be alert in order to timely diagnose, support the patient, and treat if any complications appear.
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A rare case of acute kidney injury due to levofloxacin-induced crystal nephropathy p. 424
Faizan Ahmed Ansari, Sonu Manuel, Rohan Dwivedi, Shashikiran Kabbare Boraiah, Sree Bhushan Raju, Megha Uppin, Alok Sharma
DOI:10.4103/ijn.IJN_295_18  
Crystal-induced acute kidney injury (AKI) is caused by the intratubular precipitation of crystals, which results in obstruction and kidney injury. Levofloxacin is commonly used fluoroquinolone antibiotic especially for respiratory and urinary tract infections. It rarely causes any serious adverse events. Several cases of crystal nephropathy after ciprofloxacin use have been reported. Pre-existing renal dysfunction, high dose of the drug, and advanced age are considered as risk factors. To best of our knowledge, only two cases of crystal nephropathy due to levofloxacin use have been reported, we add a new one to it. The patient responded to conservative treatment with complete recovery on follow-up.
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Atheroembolic renal disease: A case series p. 427
KS Jansi Prema, Anila A Kurien
DOI:10.4103/ijn.IJN_265_18  
Atheroembolic renal disease (AERD), a part of systemic cholesterol embolization syndrome, is caused by the occlusion of small arteries in the kidneys by cholesterol crystal emboli from ulcerated atherosclerotic plaques. Kidney is commonly involved because of its proximity to the abdominal aorta and its enormous blood supply. AERD is an under diagnosed condition. We report eight cases of AERD, highlighting the variability in its clinical presentation and the importance of a renal biopsy to arrive at a definitive diagnosis.
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LETTERS TO EDITOR Top

His heart broke posttransplant: A rare disease with good outcome p. 431
Bhanu Mishra, Sunil Prakash, Subhash Chandra, Sanjeev Gera, Ashwini Goel, Amit K Yadav, Ganesh Dhanuka, Satendra Yadav
DOI:10.4103/ijn.IJN_354_18  
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De-Novo focal crescentic IgA nephropathy in a renal allograft recipient p. 432
Ashok Ramasamy, Dharshan Rangaswamy, Mahesha Vankalakunti, Ravindra Prabhu Attur, Shankar Prasad Nagaraju, Indu Rao
DOI:10.4103/ijn.IJN_283_18  
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Asymptomatic nontyphoidal Salmonella bacteriuria in a patient with SLE nephritis: An ominous threat or innocent bystander? p. 434
Sutapa Rath, Shennaz Firdaus, Monalisa Mohanty, Rajeev Kumar Seth, Amit Kumar Satapathy, Bijayini Behera
DOI:10.4103/ijn.IJN_21_19  
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A very rare unexpected fatal complication of nephrotic syndrome p. 435
Praveen Kumar Etta, Sujeeth Reddy, Mulpuru Venkateswar Rao, Madhavi Thatipamula
DOI:10.4103/ijn.IJN_45_19  
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