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  ~ Table of Contents - Current issue
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May-June 2019
Volume 29 | Issue 3
Page Nos. 151-219

Online since Thursday, May 9, 2019

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REVIEW ARTICLE  

Therapeutic plasma exchange in renal disorders Highly accessed article p. 151
D Ranganathan, GT John
DOI:10.4103/ijn.IJN_420_17  
Nephrologists use hemodialysis and hemofiltration to remove low molecular weight toxic constituents, and increasingly deploy therapeutic plasma exchange (TPE)/plasmapheresis to eliminate higher molecular weight substances such as immunoglobulins or immune complexes from plasma. This review discusses different modalities of TPE, their application in renal disorders, its rationale and complications. TPE is recommended based on evidence, in alloantibody-mediated diseases such as humoral antibody mediated renal transplant rejection, autoantibody mediated glomerulonephritis (GN) disorders for example, anti-glomerular basement membrane GN, as well as in antineutrophil cytoplasmic antibody mediated GN and antibody mediated thrombotic thrombocytopenic purpura. In many other renal illnesses, the rational use of TPE is gaining currency. Double membrane filtration, immune adsorption and cryofiltration are important modifications in TPE
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ORIGINAL ARTICLES Top

Gender differences in dose of erythropoietin to maintain hemoglobin target in hemodialysis patients Highly accessed article p. 160
JA Coronado Daza, G Urrútia Cuchi
DOI:10.4103/ijn.IJN_124_18  
Dialysis patients receiving erythropoietin (EPO) for anemia management are a challenge due to the significant interindividual variability in erythropoietic response. Our objective was to determine if there is a gender-dependent difference in the EPO doses required to maintain the hemoglobin (Hb) targets in adult patients undergoing hemodialysis. We conducted a historic cohort study with a 12-month follow-up. We include patients with the Hb target, normal serum albumin, and normal transferrin saturation index. Monthly data were gathered for the following: Hb level, EPO doses, and intravenous iron doses. In the 11 hemodialysis facilities included, 1844 patients were on hemodialysis. We considered 389 patients for follow-up, 190 of which were excluded mainly for failing to keep the Hb level in the established range. The final cohort for analysis included 141 men (70.9%) and 58 women (29.1%). At baseline, men weighed more than women (P < 0.001). At the end of the follow-up period, the EPO required to maintain Hb level between 10 and 13 g/dl was significantly higher in women in the monthly dose, weekly dose, and weekly EPO dose/patient weight, with no difference in the monthly iron dose. There was a significant association between female gender and the use of high EPO doses (odds ratio, 4.1; 95% confidence interval, 1.4–12.2; P = 0.01). Our study demonstrates that women require higher doses of EPO to achieve Hb targets.
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Urinary albumin excretion, estimated glomerular filtration rate, and prevalence of microalbuminuria in obese nondiabetic and nonhypertensive adults: A cross-sectional study p. 166
VR Bhatt, VB Khese, SL Jadhav, AL Kakrani
DOI:10.4103/ijn.IJN_116_18  
Context: Obesity even in absence of diabetes and hypertension increases the risk for microalbuminuria (MAU), glomerular hyperfiltration, and therefore nephropathy. Aims: This study aims to assess the urinary albumin excretion (UAE), prevalence of MAU, and values of estimated glomerular filtration rate (eGFR) in obese nondiabetic and nonhypertensive patients, vis a vis thin healthy subjects, and attempts to correlate anthropometric measurements with UAE and eGFR. Setting and Design: Cross-sectional analytical study on 60 cases who were obese according to Asia Pacific guidelines and 60 nonobese controls. Patients with diabetes, hypertension, ischemic heart disease, and established renal disease were excluded. Methods and Material: Albuminuria was assessed in each patient by quantitative immunoturbidimetry method on a spot urine sample. eGFR was calculated by Cockcroft–Gault formula. Statistical Analysis: Data was analyzed using SPSS (2015 version). Mann–Whitney U-test, Fisher Exact test, and Spearman's correlation coefficient was used for various variables. Results: The mean age of cases was 31.90 ± 6.32 years. About 78.33% were in class 1 and 21.66% in class 2 obese groups. The mean UAE at 21.20 ± 26.82 mg/g creatinine was higher in the case group. The prevalence of MAU was 11.66% and 3.33% in case and control groups, respectively. The cases had a significantly higher mean eGFR of 123.29 ± 20.49 mL/min/kg as compared with controls who had a mean eGFR of 106.59 ± 10.15 mL/min/kg. There was moderate correlation between anthropometric measurements and eGFR. Conclusion: Younger, class 1 obese patients had a higher UAE, eGFR, and three times higher MAU prevalence, even in absence of diabetes and hypertension, with a correlation between anthropometry and eGFR as compared with nonobese individuals.
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Functional status in hemodialysis - A comparative study with FIM, ADLQ and 7D5L instruments p. 172
N Viswanath, KT Harichandra Kumar, Satish Haridasan, Sreejith Parameswaran, PS Priyamvada
DOI:10.4103/ijn.IJN_363_17  
There is only limited information on the functional status (FS) of patients receiving hemodialysis (HD) from developing countries where the etiology of chronic kidney disease (CKD) and demographic profile are different. The study aims to assess the FS in patients with CKD using three validated generic instruments. A total of 116 adult patients on HD with a dialysis vintage >3 months were enrolled. FS was assessed using three generic tools – Functional Independence Measure (FIM) (scores 18–126), Seven domains and five levels (7D5L) (scores 0–28), and Activities of Daily Living Questionnaire (ADLQ) (scores 0–6) scales. A higher FIM and ADLQ scores and lower 7D5L score indicated good FS. The mean age of patients was 41.28 ± 15.44 years. About 77.6% were males and 80.2% were unemployed. About 67.2% were receiving twice-weekly HD, and 28.4% were receiving thrice-weekly dialysis. The mean scores were 119.05 ± 11.42 with FIM, 6.44 ± 4.26 with 7D5L, and 5.51 ± 1.19 with ADL instruments. More than 80% showed full functional independence with ADLQ instrument. With FIM, the overall scores showed a tendency for functional independence, but the subdomains involving locomotion/mobility were impaired to a greater extent. The proportion of patients with full independence was less with 7D5L. We observed an inferior FS in individuals <40 years. Patients on HD were functionally independent as assessed by FIM and ADLQ instruments. However, 7D5L appeared to be better in identifying mild to moderate limitations in daily activities. The domains involving motor tasks seem to be affected to a greater extent. The current scales for assessing FS do not incorporate a time-dependent component.
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Dietary counseling by renal dietician improves the nutritional status of hemodialysis patients p. 179
KL Vijaya, Mesa Aruna, S. V. L Narayana Rao, Pathapati Rama Mohan
DOI:10.4103/ijn.IJN_272_16  
Proper nutrition may reverse the malnutrition and can modulate renal function in hemodialysis patients. In majority of the dialysis units in India, nutritional advice is given by health professionals working in dialysis. We compared the impact of dietary counseling by a renal dietitian, on nutritional status with that by health professionals working in dialysis units in patients undergoing maintenance hemodialysis. Nutritional assessments were made using subjective global assessment (SGA) scale, which combines assessment of intake, physical findings, and functional status. Two hundred and seventy-seven patients undergoing hemodialysis from two renal care units in Nellore, Andhra Pradesh, South India, were enrolled (138 patients in control group, 139 in experimental group). In the experimental group, patients were given repeated dietary counseling by a renal dietician, whereas control group patients were provided with the necessary nutritional information by another health professional. Detailed nutritional, biochemical, and SGA assessment were done on all of them at the beginning and completion of study after 6 months. Patients were categorized as well-nourished (WN) (SGA = 1–14), mild to moderate malnourishment (MMM) (SGA = 15–35), and severe malnutrition (SM) (SGA = 36–49). In the present study, the overall malnutrition rate at baseline was 95.3%, and it dropped down to 91.7% after 6 months after nutritional counseling. In the experimental group, malnutrition status decreased from 97.2% to 89.8%, whereas in the control group, malnutrition situation remained same. Compared to baseline, in the control group, there was no improvement in the WN group. However, a shift has been observed from MMM group to SM group suggesting more number of patients are becoming malnourished. Contrarily, in the experimental group, an improvement of +7.2% in WN group and +14.3% in MMM group and a drop of −21.6% in severe malnourished group suggesting more number of patients gaining nutrition. The present study observed a significant improvement in nutritional status of patients who received counseling by the renal dietician. The reduction in SGA score was independent of reductions in serum creatinine and blood urea levels.
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Plasma free homocysteine levels in children with idiopathic nephrotic syndrome p. 186
Venkatesh Arumugam, Abhijeet Saha, Manpreet Kaur, Bobbity Deepthi, Trayambak Basak, Shantanu Sengupta, Ajay Bhatt, Vineeta V Batra, Ashish D Upadhyay
DOI:10.4103/ijn.IJN_293_17  
Altered metabolism of homocysteine in children with idiopathic nephrotic syndrome leads to raised plasma-free homocysteine levels. Elevated free homocysteine causes endothelial cell dysfunction and promotes early atherosclerosis and glomerulosclerosis. In this analytical study with a longitudinal follow-up, 29 children with first episode of nephrotic syndrome (FENS) aged 1–16 years along with 30 age andgender-matched healthy controls were enrolled. Plasma-free homocysteine was measured using high-performance liquid chromatography (HPLC). Other variables were measured using standard biochemical methods. The primary outcome measure was plasma-free homocysteine level in children with FENS and in controls. The secondary outcome measure was to observe the levels of plasma-free homocysteine in children with FENS at 12 weeks in remission and in steroid resistant states. Plasma-free homocysteine levels were significantly elevated in children with FENS at disease onset [Median (IQR) 2.170 (1.54–2.71); N = 29; P < 0.001], at 12 weeks of steroid-induced remission [Median (IQR) 1.946 (1.53–2.71); N = 22; P < 0.001], and in steroid-resistant states [Median (IQR) 2.262 (1.53–2.74); N = 7; P < 0.001] compared to controls. The levels did not decrease significantly at 12 weeks of steroid-induced remission compared to onset of nephrotic syndrome. Plasma-free homocysteine levels correlated positively with serum total cholesterol (P = 0.005; r = 0.362) and negatively with serum albumin (P = 0.032; r = 0.281). Plasma-free homocysteine levels are raised in children with FENS posing a risk of endothelial dysfunction which persists at least in short term. Long-term effects of raised plasma-free homocysteine needs to be studied.
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CASE REPORTS Top

Ischemic colitis in association with sevelamer crystals p. 191
KC Keri, V Veitla, NS Samji
DOI:10.4103/ijn.IJN_80_18  
Sevelamer is an important drug used to lower serum phosphate levels in advanced kidney disease and in patients on dialysis. This drug is generally well tolerated but some patients report mild gastrointestinal distress as a side effect. Although regulatory agencies, such as Food and Drug Administration, list bowel ischemia and necrosis as potential and rare side effects, there are few case reports describing these adverse effects. We present a 35-year-old HIV patient with end-stage renal disease on hemodialysis who developed colonic hemorrhage and perforation. Imaging showed ischemic gangrene of bowel wall. Histopathology was consistent with transmural ischemic necrosis with deposition of fibrin thrombi and sevelamer crystals.
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Metformin-associated encephalopathy in hemodialysis p. 194
SP Simon, J Thomas
DOI:10.4103/ijn.IJN_257_17  
Metformin-associated encephalopathy in maintenance hemodialysis is very rare in literature, till now only three to four cases are published. We report a patient on maintenance hemodialysis from standalone unit presented to us with abnormal neurological signs and symptoms. His medication chart included metformin, which he was taking for quite a long time. Computed tomography brain showed hypointensity in bilateral basal ganglia. Magnetic resonance imaging (MRI) brain showed hyperintensity in T2/fluid-attenuated inversion recovery sequences suggestive of Lentiform fork sign. We stopped metformin, and he was continued on regular hemodialysis. He showed dramatic improvement in neurological manifestations. Two months later, we repeated MRI brain, which showed resolution of basal ganglia changes. We should suspect the possibility of this when a diabetic end-stage renal disease presents with unknown etiology of encephalopathy.
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Left inferior vena cava from the perspective of laparoscopic donor surgeon: Anatomic considerations and surgical implications p. 197
K Madhavan, S Jain, P Shridhar, D Bhirud, Y Patidar, V Jain
DOI:10.4103/ijn.IJN_235_16  
Renal vascular aberrations are not uncommon cause for rejection of living kidney donors. While screening a donor for laparoscopic nephrectomy, we encountered a rare, yet important aberration in the form of left-sided inferior vena cava (IVC). There was an initial dilemma regarding the acceptability of the donor and which side kidney to select for donation. Scant literature is available on this particular clinical scenario, and only after a detailed study of the embryology and anatomy of IVC, were we able to make an informed choice. This article highlights the surgical anatomy and clinical implications of this rare condition from the perspective of laparoscopic donor surgeon.
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Renal intra-arterial heparin flushing for blood pressure control in refractory hypertension: A new method to salvage the unsalvageable renal artery stenosis p. 200
Bayushi Eka Putra, Jonny , Alfonsus Hilarius Soewandi
DOI:10.4103/ijn.IJN_194_18  
Refractory hypertension is a type of hypertension that requires special attention. Secondary causes of hypertension should be considered when uncontrolled blood pressure is present, especially in younger patients (<30 years). In this case, the presence of bilateral renal artery stenosis resulted in refractory hypertension and end-stage renal disease requiring renal replacement therapy in the form of hemodialysis. The main challenges will be discussed in this case is to deliver the most beneficial therapy considering the very limited option for revascularization therapy because of the late presentation of patient's condition. Intra-arterial heparin flushing was chosen for this patient to consider the advantages over the risks arising from the actions taken.
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Coexistent amyloid fibrils in a patient with combined light chain deposition disease and light chain cast nephropathy p. 204
Urmila Anandh, Anusha Patrick, Alok Sharma
DOI:10.4103/ijn.IJN_36_18  
Monoclonal secretion of light chains can affect the kidney with varied morphologic manifestations. Myeloma cast nephropathy, proximal tubulopathies, monoclonal immunoglobulin deposition disease, amyloidosis, and tubulointerstitial nephritis are often noted in the renal biopsy of these patients. Most often the histopathological manifestations affect only one compartment of the nephron (tubules, capillaries, glomerulus). Case reports of a combination of cast nephropathy and monoclonal light chain deposition disease are also reported in literature. Here we report an unusual case of coexisting cast nephropathy, light chain deposition disease, and deposition of amyloid fibrils in the biopsy of a lady with monoclonal kappa light chain excretion.
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Collapsing glomerulopathy superimposed on diabetic nephropathy p. 207
Praveen Kumar Etta, MV Rao, S Gowrishankar
DOI:10.4103/ijn.IJN_334_17  
Diabetic nephropathy (DN) is characterized by gradually progressive renal failure and proteinuria. Various types of nondiabetic kidney diseases may superimpose on DN, and affect the natural course, prognosis, and management. Collapsing glomerulopathy (CG) is a form of glomerular proliferative injury, characterized by rapid progression and associated with poor prognosis. CG may be idiopathic or secondary to other causes, and it has also been described with other forms of glomerular diseases. The association of CG with DN has not been reported widely. We report on a patient with DN who has undergone renal biopsy due to massive proteinuria and rapid loss of renal function. Renal biopsy was suggestive of CG superimposed on DN. He was treated conservatively, however, progressed to end-stage renal disease rapidly.
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Stent graft placement for treatment of prosthetic graft outflow stenosis, a viable long-term solution: A case report p. 211
Pranay Pawar, Achintya Sharma, MK Ayyappan, Kapil Mathur, Jithin Jagan, Radhakrishnan Raju
DOI:10.4103/ijn.IJN_135_18  
Failing prosthetic grafts in patients undergoing hemodialysis is a common problem. Balloon angioplasty is the first line in treating these stenoses, but it is associated with poor patency rates due to recoil and subsequent restenosis. The use of stent graft implantation has shown very promising early and long-term results as per recent literature. We describe a case of arteriovenous graft outflow stenosis, which led to complete thrombosis of the graft, which was rescued by surgical thrombectomy and stent graft placement across the venous end of the anastomosis with good results.
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LETTERS TO EDITOR Top

Pancytopenia as a complication of primary hyperoxaluria p. 214
M Khosravi, S Kord, M Mokhtari
DOI:10.4103/ijn.IJN_204_18  
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Use of commercially available multiplex polymerase chain reaction in detection of organism in culture negative peritonitis in peritoneal dialysis p. 215
I Veerappan, R Balasubramaniam, R Sethuraman, S Ranjan
DOI:10.4103/ijn.IJN_383_17  
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Severe hypertriglyceridemia-induced acute pancreatitis: Successful management by plasmapheresis p. 217
B. N. R Ramesh, S Raju, M Surendra, K Prasad, V Krishna
DOI:10.4103/ijn.IJN_241_17  
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Indian Journal of Nephrology
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Online since 20th Sept '07