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2007| October-December | Volume 17 | Issue 4
February 22, 2008
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Pathogenesis and management of renal osteodystrophy
AS Narula, A Jairam, KV Baliga, KJ Singh
October-December 2007, 17(4):150-159
Renal osteodystrophy is a common complication of chronic kidney
disease (CKD). It is the part of a broad spectrum of disorders of
mineral and bone metabolism that develop in this clinical setting and result
in both skeletal and extraskeletal consequences. Insights into the mechanisms of bone remodeling, mineral metabolism and vascular calcification have shed light on the systemic nature of the disorder. Central to the assessment
of disturbances in the bone and mineral metabolism is the ability
to assess the bone disease accurately by noninvasive
means. Recent emphasis is on the requirement to begin the therapy early in the course of CKD. Guidelines on a 'step care' approach to the detection and management of alterations in calcium, phosphorus and parathyroid hormone metabolism in various stages of CKD are now available. Although constant improvements in the technicalities of the parathyroid hormone assays have improved the diagnostic capability, controversies regarding this aspect still exist. Noncalcium, nonaluminum-based phosphate binders hold promise for the future developments in the management of calcium-phosphate metabolism. Further research and progress in this area continue to
evaluate the appropriate interventions to address both the skeletal and extraskeletal consequences targeted toward improving patient outcomes.
Continuous ambulatory peritoneal dialysis: A viable modality of renal replacement therapy in a hilly state of India
October-December 2007, 17(4):165-169
Chronic ambulatory peritoneal dialysis (CAPD) has been an established form of therapy in adult patients with end-stage renal failure in India for more than a decade and has emerged as accepted form of renal replacement therapy in urban areas. The objective of this paper is to report the experience with CAPD as a modality of renal replacement therapy from a tertiary care hospital in a hilly state of India with predominant rural population.
A government-owned tertiary care hospital in Himachal Pradesh, a state with a population of 6 million.
Materials and Methods:
This study involved the patients who were initiated on CAPD between October 2002 and December 2006 and who survived and/or had more than 6 months follow up on this treatment with last follow up till June 30, 2007.
A total of 25 patients were included in the analysis. The mean age of the patients was 61 ± 10.2 years. 13 (52%) patients were female. 18 (72%) patients out of these lived in rural areas. The total follow up was 553.1 patient-months with a mean follow up of 22.1 ± 12.4 months. The total duration on peritoneal dialysis treatment was 541.1 patient-months with a mean duration of 21.6 ± 12.2 months and median duration of 19 patient-months (range: 6-56.3 patient-months). No patient had exit-site infection. There were 26 episodes of peritonitis. The rate of peritonitis was 1 episode per 21 patient-months or 0.6 per patient-year during the treatment period. The main cause of death was cardiovascular complications. Patient and technique survival at 1, 2 and 3 years was 80, 36 and 12%, respectively.
Chronic ambulatory peritoneal dialysis (CAPD) is a safe and viable mode of renal replacement in remote and rural places. It can emerge as a revolutionized procedure for ESRD patients dwelling in remote and geographically difficult regions in developing countries such as India.
LETTER TO EDITOR
Vitamin D replacement in tertiary hyperparathyroidism with vitamin D deficiency: Is there any reason for being overcautious?
J Muthukrishnan, R Jha, KD Modi, JP Kumar
October-December 2007, 17(4):187-187
IMAGES IN NEPHROLOGY
Reversible cause of blindness in end stage renal disease on dialysis
M Singh Jhawar, P Pawar, U George, P George, B Pawar, Y Singh
October-December 2007, 17(4):185-186
Role of non-transferrin-bound iron in chronic renal failure and other disease conditions
October-December 2007, 17(4):188-193
Iron is an essential transitional metal required by the body for various biological functions. Iron is securely stored in ferritin and other biomolecules, either in ferrous or ferric state, and there are safe mechanisms for its storage or release from proteins to catalyze biological reactions. Under stress or some pathological conditions, there occurs the release of free iron or non-transferrin bound iron, which is free from its protein bound form, and it undergoes Fenton and Heiber-Weiss reactions to generate powerful reactive oxygen species. The reactive oxygen species generated will damage the biological macromolecules. It has been proved that in uremia or chronic renal failure patients, on conservative management or on hemodialysis program or under many other disease conditions, free iron or non-transferrin bound iron does exist; it induces damage to the biomolecules, thereby enhancing the disease process. In this review I have discussed the role of free iron or non-transferrin iron in general in biology and medicine, particulary in chronic renal failure.
Epidermolysis bullosa dystrophica with renal failure due to secondary amyloidosis
F Mutlubas, S Mir, C Kabasakal, O Yavascan, B Sarsik
October-December 2007, 17(4):178-181
Epidermolysis bullosa dystrophica is a rare hereditary disorder with multiple bullous lesions, erosions and repeated infections. Although skin lesions can be treated with dermatologic care, the patient can also be complicated by life-threatening clinics such as nephropathy, systemic amyloidosis and skin cancers by years. A 16-year-old male who had been followed-up since birth with epidermolysis bullosa dystrophica referred to the nephrology department for nephrotic proteinuria and deep anemia. He went on renal biopsy that demonstrated AA amyloidosis. Although effective colchicine treatment was given, end stage renal disease developed after 6 months that resulted in the death of the patient. Epidermolysis bullosa causes a chronic inflammatory process that progresses with time and can be fatal. Colchicine treatment must be given before the onset of amyloidosis.
Immunoglobulin M nephropathy in familial
O Yavascan, N Aksu, K Demir, S Sarioglu, OD Kara, A Bal
October-December 2007, 17(4):170-173
Familial Mediterranean fever (FMF) is the most common periodic syndrome characterized by various clinical manifestations associated with self-limited auto-inflammatory process. Amyloidosis is its most common renal complication that can be prevented with colchicine treatment. In the last years, further clinical and histological features of FMF nephropathy have been established, such as the associations with vasculitic diseases and various types of glomerulonephritis. IgM nephropathy (IgMN) is an uncommon histological entity that is characterized by prominent diffuse mesangial deposition of IgM. Herein, we present a 10-year-old Turkish female child suffering from FMF in which non-nephrotic proteinuria is due to IgMN other than amyloidosis.
A sinister presentation of typhoid fever
P George, B Pawar
October-December 2007, 17(4):176-177
Hemolytic uremic syndrome (HUS) is a recognized complication of
O157:H7 and Shigella infection. It has been rarely associated with
infection and has a high mortality, if the recognition and treatment of this disease is delayed. A fatal outcome of HUS following
infection is described.
Hereditary spherocytosis with nephrotic syndrome
A Mathew, J Varghese, G Kurian, VN Unni
October-December 2007, 17(4):174-175
Hereditary spherocytosis is an autosomal dominant familial hemolytic disorder due to the abnormality of the erythrocyte membrane. We report a case of nephrotic syndrome due to membranoproliferative glomerulonephritis in a patient with hereditary spherocytosis.
Growth hormone therapy in chronic kidney disease
J Muthukrishnan, R Jha, J Kumar, KD Modi
October-December 2007, 17(4):182-184
Chronic kidney disease (CKD) in growing children leads to a state of impaired growth due to altered metabolic status and defective growth hormone action. This requires direct intervention over and above the management of the renal disease. The physical deficit of short stature has significant impact on the psychological well-being and quality of life. With increasing availability of recombinant human growth hormone (GH) and its approval in CKD patients with significant short stature, it has been increasingly used in short children with CKD. GH therapy in these patients has significantly improved the final adult height achieved. Two prepubertal children with CKD and severe short stature who were treated with GH for approximately 2 years achieved significant growth benefits and one of them attained satisfactory adult height.
Subtle renal dysfunction after radiocontrast administration in prospective renal donors: Does N-acetylcysteine have a role in its prevention?
K Gohel, M Khanpete, B Mukhopadhyaya, U Hegde, S Gang, M Rajapurkar
October-December 2007, 17(4):160-164
Radiographic contrast media (RCM) can cause a reduction in the renal function by multiple mechanisms; reactive oxygen species is one of them.
Whether the reduction can be prevented by the administration
of antioxidants is still debatable.
-acetylcysteine (NAC) has shown some benefit in patients with renal dysfunction in the prevention of radiocontrast-induced nephropathy (RCIN).
: We prospectively studied 95 healthy kidney donors, who were undergoing intravenous urography (IVU) followed by digital subtraction renal angiography (DSRA) with ionic, high-osmolar contrast agent for pretransplant evaluation. Patients were randomly
assigned either to receive the
mg orally twice daily (acetylcysteine group) or placebo (control group) on the day before and that of RCM administration in addition to the intravenous 0.45% saline (1 ml/kg body weight per hour) on the day and following day of the procedure. Serum creatinine, urinary enzymes
-acetyl β glucosaminidase (NAG), γ glutamyl-1-transferase (GGT), alanine amino peptidase (AAP), fractional excretion of sodium (FeNa) and 24-h urinary creatinine clearance were performed before and 48 h after the procedure. The levels of urinary enzymes measured after 96 h of DSRA were available in only 57 donors. Radiocontrast-induced nephropathy was defined as an increase in the baseline serum creatinine of at least 0.5 mg/dl within 48 h after injection of radiocontrast media (RCM).
Increase in the urinary enzymes (NAG, GGT and AAP) and reduction in creatinine clearance was observed in both groups after receiving the contrast media. However, the number of patients with significant increase in enzymuria (at least >50% increase above the baseline value) and mean drop in creatinine clearance was statistically not different between the acetylcysteine and control groups.
Renal damage in the form of reduction in creatinine clearance and increase in urinary enzymes has been observed after administration of radiocontrast. However, clinically significant RCM-induced acute kidney injury is uncommon in patients with normal renal function. Prophylactic oral administration of the antioxidant
-acetylcysteine at a dose of 600 mg twice daily before and on the day of contrast administration is probably not required in patients with normal renal function.
The third World Kidney Day: Looking back and thinking forward
SV Shah, J Feehally
October-December 2007, 17(4):147-149
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