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   2010| July-September  | Volume 20 | Issue 3  
    Online since October 1, 2010

 
 
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ORIGINAL ARTICLES
Iron status, inflammation and hepcidin in ESRD patients: The confounding role of intravenous iron therapy
A Jairam, R Das, PK Aggarwal, HS Kohli, KL Gupta, V Sakhuja, V Jha
July-September 2010, 20(3):125-131
DOI:10.4103/0971-4065.70840  PMID:21072151
Uremia is a state of heightened inflammatory activation. This might have an impact on several parameters including anemia management. Inflammation interferes with iron utilization in chronic kidney disease through hepcidin. We studied the body iron stores, degree of inflammatory activation, and pro-hepcidin levels in newly diagnosed patients with end-stage renal disease (ESRD), and compared them with normal population. In addition to clinical examination and anthropometry, the levels of iron, ferritin, C-reactive protein, tumor necrosis factor alfa, interleukin-6, and prohepcidin were estimated. A total of 74 ESRD patients and 52 healthy controls were studied. The ESRD patients had a significantly lower estimated body fat percentage, muscle mass, and albumin; and higher transferrin saturation (TSAT) and raised serum ferritin. Inflammatory activation was evident in the ESRD group as shown by the significantly higher CRP, IL-6, and TNF-α levels. The pro-hepcidin levels were also increased in this group. Half of the ESRD patients had received parenteral iron before referral. Patients who had received intravenous iron showed higher iron, ferritin, and TSAT levels. These patients also showed more marked inflammatory activation, as shown by the significantly higher CRP, TNF-α, and IL-6 levels. We conclude that our ESRD patients showed marked inflammatory activation, which was more pronounced in patients who had received IV iron. High hepcidin levels could explain the functional iron deficiency. The cause of the relatively greater degree of inflammatory activation as well as the relationship with IV iron administration needs further studies.
  13 5,868 471
Tuberculin skin test for the diagnosis of latent tuberculosis during renal replacement therapy in an endemic area: A single center study
SK Agarwal, S Gupta, D Bhowmik, S Mahajan
July-September 2010, 20(3):132-136
DOI:10.4103/0971-4065.70842  PMID:21072152
Patients on renal replacement therapy (RRT) are at-risk for developing tuberculosis (TB). There is limited information on tuberculin skin test (TST) and its predictability for development of TB. In this prospective cohort study, patients taken for RRT were included. Patients with active TB were excluded. TST was done with 5-tuberculin unit. In addition to TST, age, sex, diabetes as basic disease, number of dialysis and blood transfusion (BT), pre-transplant TB, hepatitis B and C infections and type of immunosuppression were correlated with the development of TB. Of the 200 patients included, TST was positive in 21 and negative in 179. In TST negative group, 20 (11.1%) and in TST positive group 5 (23.8%) patients developed TB. TB free survival in two groups was similar (P = 0.08). On multivariate Cox regression analysis, hazard of development of TB by TST was 2.7 [P = 0.11, confidence interval (CI) 0.78-9.7]. There was no difference between TST non-responsive and TST negative patients (P = 0.18). Sensitivity and specificity of TST for predicting TB was only 20 and 9%, respectively. Our study shows that TST in patients on dialysis is an insensitive and nonspecific test to predict development of active TB.
  6 4,472 272
Effect of gene polymorphisms on the levels of calcineurin inhibitors in Indian renal transplant recipients
T Ashavaid, H Raje, K Shalia, B Shah
July-September 2010, 20(3):146-151
DOI:10.4103/0971-4065.70846  PMID:21072155
The outcome of renal transplantation is improved by cyclosporine and tacrolimus. However, its success is limited by drug-induced nephrotoxicity. Therefore, monitoring their levels is important. These levels are influenced mainly by CYP3A4, CYP3A5 and MDR- 1 genes. These levels also affect target molecules of CNIs, mainly IL-2. Inter-individual differences in these levels have been attributed to SNPs in these genes and hence study of these SNPs assumes significance. So far no study has been carried out on Indian renal transplant recipients covering the SNPs of the genes involved in metabolism, efflux and drug target of CNIs, hence the data is lacking for Indian population. The aim is to study A-392G SNP of CYP3A4, A6986G SNP of CYP3A5, C3435T SNP of MDR-1 and T-330G SNP of IL-2 genes and correlate with CNI blood levels. Hundred healthy subjects and 100 consecutive renal transplant recipients; 56 on CsA and 44 on tacrolimus were genotyped by PCR followed by restriction enzyme assay for mentioned SNPs. No significant difference was observed between level/dose (L/D) ratio of CNIs and CYP3A4 and IL-2 SNPs. However, median L/D ratio for tacrolimus was significantly higher in subjects with CYP3A5*3/*3 (n = 24) ( P = 0.011) and MDR- 1 3435TT (n = 18) ( P = 0.0122). The findings from this study show that homozygous mutant patients for CYP3A5 and MDR-1 gene SNPs could be managed with lower tacrolimus dose to avoid nephrotoxicity.
  6 2,458 200
CASE REPORTS
Bilateral renal vein thrombosis and pulmonary embolism secondary to membranous glomerulonephritis treated with percutaneous catheter thrombectomy and localized thrombolytic therapy
SP Janda
July-September 2010, 20(3):152-155
DOI:10.4103/0971-4065.70848  PMID:21072156
Renal vein thrombosis (RVT) is a rare event but is prevalent in patients with nephrotic syndrome. Bilateral RVT is even rarer. The literature is relatively sparse in terms of the management of RVT because of its rarity and consists of a few case reports and case series. We present a case with bilateral RVT complicated by a pulmonary embolism in a patient with membranous glomerulonephritis (MGN). A 19-year-old female presented with acute flank pain and worsening renal function after a couple of weeks in hospital while being treated with diuretics for anasarca secondary to MGN. Venography was used for diagnosis. The patient underwent percutaneous catheter thrombectomy and localized thrombolysis achieving resolution of pain and improvement of renal function. The patient was then anticoagulated for life with warfarin.
  5 2,790 88
ORIGINAL ARTICLES
Sildenafil citrate can improve erectile dysfunction among chronic hemodialysis patients
A Ghafari, B Farshid, AT Afshari, N Sepehrvand, E Rikhtegar, K Ghasemi, S Hatami
July-September 2010, 20(3):142-145
DOI:10.4103/0971-4065.70845  PMID:21072154
Erectile dysfunction (ED) is common among patients with end-stage renal disease (ESRD), who undergo hemodialysis (HD). The aim of this study was to evaluate the safety and effectiveness of sildenafil in male HD patients with ED. Twenty-seven HD patients were recruited for this prospective, randomized, double-blind, placebo-controlled, clinical trial study of sildenafil during a period of 1 week. Efficacy was assessed by using the International Index of Erectile Function (IIEF) before and 1 week after treatment. Baseline demographic and clinical features were similar in both the groups. There was a weak correlation between ED and duration of undergoing dialysis (P = 0.073). There was significant relationship between sildenafil usage and improvement in erectile function (P < 0.0001). Placebo improved significantly the erectile function (P = 0.016), perhaps by psychological way. However, sildenafil had a more significant effect than placebo in increasing IIEF score among HD patients (P = 0.00 compared to 0.016). Sildenafil is effective and safe for treating ED among HD patients.
  5 2,863 158
CASE REPORTS
Cryptococcal sepsis in small vessel vasculitis
S Satish, R Rajesh, S Shashikala, G Kurian, VN Unni
July-September 2010, 20(3):159-161
DOI:10.4103/0971-4065.70850  PMID:21072158
While meningoencephalitis due to cryptococcus is well known in immunocompromised patients, disseminated cryptococcosis and cryptococcemia is rare outside the setting of advanced HIV infection. We report a case of disseminated cryptococcosis occurring in a patient with Wegener's granulomatosis on immunosuppressive medications.
  3 3,775 88
REVIEW ARTICLE
Aminoglycoside use in renal failure
S Nayak-Rao
July-September 2010, 20(3):121-124
DOI:10.4103/0971-4065.70839  PMID:21072150
Aminoglycosides are the mainstay in the treatment of serious gram negative infections including catheter-associated infections. They are not metabolized and are rapidly excreted as such by glomerular filtration resulting in a plasma t˝ of approximately two hours in those with normal renal function. The t˝ , however, can extend to 30-60 hours in patients who are functionally anephric; therefore, dosage reduction or modification is necessary in renal failure patients. In patients on hemodialysis the clearance of aminoglycosides is significant and variable. The concept of conventional postdialysis dosing in patients on hemodialysis needs to be revised in favor of higher predialysis doses to maintain effective bactericidal activity. This article is a brief review of the use of aminoglycosides in renal failure patients.
  3 5,391 581
ORIGINAL ARTICLES
Percutaneous real-time ultrasound-guided renal biopsy performed solely by nephrologists: A case series
SS Yesudas, NK Georgy, S Manickam, A Raheena, RC Monai, BA Noble, A Pillai
July-September 2010, 20(3):137-141
DOI:10.4103/0971-4065.70844  PMID:21072153
Renal biopsy is an integral part of the nephrologists' diagnostic armamentarium. Usually it is performed by radiologists or nephrologists with radiologist's assistance. Our aim was to assess the efficacy and safety of percutaneous ultrasound-guided renal biopsy performed solely by nephrologists. We performed real-time ultrasound-guided renal biopsy on 37 patients (N group). The results were then compared with those of a similar number of biopsies done with radiologist's support (NR group) immediately prior to these. In the N group, 36 biopsies (97.3%) were successful and were histopathologically adequate, whereas in the NR group, all biopsies were successful but only 28 were adequate (75.68%). Eighteen patients required only a single attempt in the N group, whereas majority (34 patients) in the NR group required two or more attempts. The average attempt per bit of renal tissue was 1.22 in both the groups. The average number of passes per patient was 1.77 in the N group and 2.32 in the NR group. The mean size of renal tissue obtained was 1.41 ± 0.47 cm in the N group and 1.19 ± 0.42 cm in the NR group. The average number of glomeruli was 15.62 ± 5.26 and 13.7 ± 7.38 in the N and NR groups, respectively (P<0.05). In the N group, there were no complications except two cases of post procedural hematuria that was managed conservatively. There was no need for blood transfusion and both of them were discharged after 48 hours. No patient had peri-renal collection or hematoma on repeat ultrasonography of the abdomen at 24 hours. However, in the NR group, five patients developed complications and one patient required laparotomy. Our study shows that percutaneous ultrasound-guided renal biopsy can be safely and successfully performed entirely by nephrologists without outside assistance. In our series, nephrologists who performed solely took fewer attempts, had better yield and fewer complications when compared to biopsies performed with radiologist's assistance. More and more nephrologists should take up this simple yet vital procedure.
  2 5,778 175
CASE REPORTS
Child with acute lobar nephronia
M Vijayakumar, N Prahlad, G Nandhini, N Prasad, S Muralinath
July-September 2010, 20(3):162-165
DOI:10.4103/0971-4065.70847  PMID:21072159
A five-year-old girl child presented to us with a history of two weeks high grade fever treated outside with intensive antibiotic therapy for an ultrasound abdomen finding of hypoechoic lesion in the midpole of the left kidney. As fever and sonographic findings persisted, a CT abdomen was done, which showed features of lobar nephronia but reported as Wilm's tumor. Child underwent open biopsy and the diagnosis of lobar nephronia was confirmed. Child was continued on antibiotics and fever and sonographic findings improved.
  1 4,712 122
Constrictive pericarditis in a renal transplant recipient with tuberculosis
P Sreejith, S Kuthe, V Jha, HS Kohli, M Rathi, KL Gupta, V Sakhuja
July-September 2010, 20(3):156-158
DOI:10.4103/0971-4065.70849  PMID:21072157
Tuberculosis is a common cause of pericarditis in the developing countries and constrictive pericarditis is a serious sequel. There are only three cases of constrictive pericarditis in kidney transplant recipients previously reported in literature. Here, we report a case of constrictive pericarditis developing in a renal transplant recipient while on antituberculous therapy for tuberculous pleural effusion.
  1 2,855 103
Delayed diagnosis of pheochromocytoma associated with chronic kidney disease
GH Fernandes, GB Silva, J. H. P. Garcia, C. R. M. Sobrinho, P. L. M. M. Albuquerque, AB Libório, EF Daher
July-September 2010, 20(3):166-167
DOI:10.4103/0971-4065.70843  PMID:21072160
Pheochromocytoma is a rare disease charactrized by excessive production of catecholamines, manifestating mainly with hypertension. We report the case of a 45-year-old woman with history of sudden onset dyspnea, headache, palpitations and sudoresis. An abdominal ultrasound was suggestive of chronic kidney disease (CKD). An abdominal computed tomography and magnetic resonance was performed and showed a mass in the topography of left adrenal. The patient underwent a surgery for the removal of the mass and became stable with normal blood pressure levels, but remained with CKD. The dalayed diagnosis of pheochromocytoma in the present case has contributed to the development of CKD.
  - 2,563 124
IMAGES IN NEPHROLOGY
A young lady with abdominal pain and facial lesions
ME Bhaskar, B Kumar
July-September 2010, 20(3):168-168
DOI:10.4103/0971-4065.70841  PMID:21072161
  - 1,947 151
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