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   2012| July-August  | Volume 22 | Issue 4  
    Online since September 22, 2012

 
 
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ORIGINAL ARTICLES
Causes of death in renal transplant recipients with functioning allograft
J Prakash, B Ghosh, S Singh, A Soni, SS Rathore
July-August 2012, 22(4):264-268
DOI:10.4103/0971-4065.101245  PMID:23162269
The survival of transplant recipients is significantly lower than age-matched controls in the general population. The aim of this study was to analyze the trends in mortality of renal allograft recipients at our centre. We retrospectively analyzed data from all patients who were transplanted between October 1988 and June 2010 and were followed at our center. Patients were considered to have death with graft function (DWGF) if death was not preceded by return to dialysis or re-transplantation. The study included 98 renal allograft recipients (male : female - 7.99 : 1). The mean recipient and donor ages were 35.06 ± 11.84 (range: 15-69) and 41.17 ± 10.44 (range: 22-60) years, respectively. Basic kidney diseases were CGN (chronic glomerulonephritis) (60.20%), CIN (chronic interstitial nephritis) (15.31%), DN (diabetic nephropathy) (8.16%), ADPKD (autosomal dominant polycystic kidney disease) (2.04%) and others (14.29%). They were followed up for a mean 79.91 ± 60.05 patient-months. Mortality occurred in 25 (25.51%) patients (male : female - 4 : 1). Causes of death were sepsis/infection (36%), coronary artery disease (28%), CVA (8%), failed graft (4%), and rest unknown (24%). DWGF was 88% of total death and contributed to 78.57% of total graft loss. Overall patient survival at 1, 5, 10, and 15 years were 90.8%, 80.2%, 65.6%, and 59.1%, respectively (Kaplan-Meier analysis). Those who died exhibited significant differences in recipient's age (median 40 years vs 31 years, P=0.007), pretransplantation hypertension (HTN) (100% vs 65.75%, P>0.001), post-transplant infection (76% vs 42.47%, P=0.005), coronary artery disease (28% vs 1.37%, P>0.001), and serum creatinine at last follow up (median 2.3mg/dL vs 1.56mg/dL, P=0.003). Cardiovascular disease, in addition to infection, is an important cause of death during the first 15 years following renal transplantation even in nondiabetic recipients. Death with functioning graft is of concern.
  3 1,964 175
Periodontal status in patients undergoing hemodialysis
SM Parkar, CG Ajithkrishnan
July-August 2012, 22(4):246-250
DOI:10.4103/0971-4065.101242  PMID:23162266
The aim of the study was to assess the periodontal status of patients among group of patients receiving hemodialysis in two super specialty renal institutes in the state of Gujarat. A cross-sectional study of 304 subjects, 152 subjects each in dialysis, and control group was conducted. Oral hygiene status was assessed using a Simplified Oral Hygiene Index, and periodontal status was assessed using the Community Periodontal Index (CPI) and Loss of Attachment (LOA) as per WHO methodology 1997. The dialysis group had poor oral hygiene than the control group (P>0.001). There was high severity of periodontitis in the dialysis group as compared with the control group (P>0.001). None of the subjects had healthy periodontium. There was high severity of periodontitis (for both in terms of CPI and LOA) in the dialysis group as compared with control group that was found to be statistically highly significant (P>0.001). However, no statistically significant difference was observed (P>0.05) when the intergroup comparison for CPI and LOA were made among the subgroups according to the duration of dialysis. Periodontal disease is prevalent in chronic renal failure patients who showed the unacceptable level of oral hygiene and hence there is need for oral health promotion and preventive programs among the patients receiving dialysis.
  2 2,211 258
CASE REPORTS
Hereditary ADAMTS 13 deficiency presenting as recurrent acute kidney injury
TE Jamale, NK Hase, M Kulkarni, AM Iqbal, E Rurali, MG Kulkarni, P Shetty, KJ Pradeep
July-August 2012, 22(4):298-300
DOI:10.4103/0971-4065.101257  PMID:23162276
We report here a case of 26-year-old male who presented with history of recurrent acute renal failure associated with microangiopathic hemolytic anemia and thrombocytopenia. ADAMTS 13 deficiency due to mutation in the gene encoding for ADAMTS 13 was identified as the cause. After eight episodes of acute kidney injury (AKI), patient started developing hypertension, proteinuria, and renal insufficiency. Treatment with regular monthly plasma infusions prevented further episodes of AKI and stabilized the renal function. Hypertension and proteinuria are controlled with angiotensin II receptor blockers.
  1 1,321 85
Postrenal transplant laryngeal and visceral leishmaniasis - A case report and review of the literature
PK Jha, M Vankalakunti, V Siddini, K Babu, SH Ballal
July-August 2012, 22(4):301-303
DOI:10.4103/0971-4065.101259  PMID:23162277
Visceral leishmaniasis (kala-azar) is a disease caused by protozoa of genus Leishmania. It is currently regarded as the second most dreaded parasitic disease, next to malaria. There have been very few case reports of visceral leishmaniasis among the renal transplant recipients. We present a renal allograft recipient with symptoms of fever, sore throat, hoarseness of voice, lymphadenopathy, splenomegaly, and pancytopenia after 7 years post-transplant period. On investigating, he was diagnosed to have extensive visceral leishmaniasis with laryngeal involvement. Despite extensive PubMed literature search, we could not find any case report of postrenal transplant visceral and laryngeal leishmaniasis and to the best of our knowledge this is the first case report of this kind.
  1 1,792 88
LETTERS TO EDITOR
Succesfully treated Curvularia lunata peritonitis in a peritoneal dialysis patient
U Kalawat, GS Reddy, Y Sandeep, P Ram Naveen, Y Manjusha, A Chaudhury, V Siva Kumar
July-August 2012, 22(4):318-319
DOI:10.4103/0971-4065.101269  PMID:23162282
  1 1,353 68
How does KDQoL-36 questionnaire predict quality of life in Indian hemodialysis patients?
Z Rostami, B Einollahi
July-August 2012, 22(4):319-320
DOI:10.4103/0971-4065.101271  PMID:23162283
  1 1,023 112
ORIGINAL ARTICLES
A multicenter cross-sectional study of mental and physical health depression in MHD patients
RE Vettath, Y. N. V. Reddy, Y. N. V. Reddy, S Dutta, Z Singh, M Mathew, G Abraham
July-August 2012, 22(4):251-256
DOI:10.4103/0971-4065.101243  PMID:23162267
Depression is ranked fourth among the disabling diseases affecting people worldwide and is the most common psychological problem in patients with End Stage Renal Disease (ESRD). The aim of this study is to assess the physical and emotional health status of renal dialysis patients, based on the SF-36 scale in relation to their economic status. S0 ixty maintenance hemodialysis patients, with a mean age of 40±13 years were included in this cross-sectional study using the SF-36 scale. It comprises 36 questions regarding physical and mental functions, body pain, vitality, etc. An SF-36 score of 50 or less was considered as moderate to severe depression and 51-100 as mild depression to good health. 56.81% of the patients who are below poverty line under dialysis had moderate to severe depression with regard to their health status. A physical health score of up to 50 was seen in 63.63% of patients below poverty line 63.63% (P= 0.16). A mental health score of 0-50 was observed in 61.63% of the cohort studied (P = 0.22). Among the patient with diabetes (28.33%) 55.56% had depression. Dialysis duration was directly associated with deteriorating physical health status and inversely proportional to their mental health status (P>0.05). There are problems in other regular activities due to depressed physical and mental health. T0 he factors that were identified in this study that influence depression such as poverty status, increasing age, vintage and frequency of dialysis and treatment with erythropoietin dosage should be addressed and treated accordingly to improve the quality of life. Improving self-esteem with fruitful employment opportunities, concerted rehabilitation by professionals and easing of economic burden by private-public partnership is an achievable goal.
  1 2,040 181
SYSTEMATIC REVIEW
Deflazacort in comparison to other steroids for nephrotic syndrome
KR Jat, A Khairwa
July-August 2012, 22(4):239-245
DOI:10.4103/0971-4065.101238  PMID:23162265
Patients with nephrotic syndrome require steroids for long time and sometimes repeatedly resulting in various adverse effects. Deflazacort (DFZ) had been described as equally effective and with fewer side effects as compared with other steroids. This review evaluates the literature on efficacy and toxicity of DFZ as compared with other therapies for nephrotic syndrome. A systematic review of Pubmed database and Cochrane Central Register of Controlled Trials with last search date of 20 th April 2011. Search terms included "nephrotic AND deflazacort" without any limitations. Randomized control trials comparing DFZ vs placebo or other therapies in subjects with nephrotic syndrome were included. Two authors extracted data independently. Three studies meet inclusion criteria and data were synthesized qualitatively. The limited evidence suggested that DFZ appeared to be equally effective in inducing remission or decreasing proteinuria in patients with nephrotic syndrome. It caused significantly less decrease in bone mineral content (BMC) in spine as compared with prednisolone. The results related to weight change, blood pressure change, Cushingoid symptoms, and urinary calcium excretion were inconsistent between included studies. By reviewing the available limited evidence, DFZ appears to be of similar efficacy for nephrotic patients, but there were inconsistent results regarding side effect profile of DFZ as compared with other steroids except for decrease in BMC where DFZ was better. There is need for larger randomized controlled trials to evaluate effectiveness and adverse effect profile of DFZ as compared with other steroids in nephrotic syndrome.
  1 4,124 452
CASE REPORTS
Chronic tubulointerstitial nephritis in a solitary kidney of a child with Noonan syndrome
V Golay, R Pandey, A Roychowdhary
July-August 2012, 22(4):304-306
DOI:10.4103/0971-4065.101260  PMID:23162278
Noonan syndrome is a genetic disorder with involvement of many organ systems; facial dysmorphism and cardiovascular defects being the common abnormalities. Renal involvement is uncommon and abnormalities of the genitourinary system are usually limited to structural anomalies and cryptorchidism. We report a case of Noonan syndrome with chronic tubulointerstitial nephritis in a solitary kidney.
  - 1,428 58
Contrasting approaches to end of life and palliative care in end stage kidney disease
AN Koshy, R Mace, L Youl, S Challenor, R Bull, RG Fassett
July-August 2012, 22(4):307-309
DOI:10.4103/0971-4065.101263  PMID:23162279
With increased numbers of the elderly, including nursing home patients, being accepted for end-stage kidney disease (ESKD) management, there is heightened interest and focus on end of life decisions, advanced care planning and directives, withdrawal from dialysis and palliative care in this setting. Despite this, care at the individual patient level can vary greatly. Here, we present two contrasting cases to highlight the importance of early and ongoing involvement of palliative care in patients with ESKD. In the first case, a high quality of life was preserved before the patient died with dignity, with early interdisciplinary palliative care involvement. In the second case there was a long protracted period of poor quality of life prior to death. This was associated with resistance to the involvement of palliative care, mainly from the family. Addressing end of life care issues early in the chronic kidney disease (CKD) trajectory and ensuring patients, their families and health care providers are well informed, may contribute to a better outcome for the patient and their family.
  - 1,469 92
Catastrophic antiphospholipid antibody syndrome in a child with thrombotic microangiopathy
N Prasad, D Bhadauria, N Agarwal, A Gupta, P Gupta, M Jain, H Lal
July-August 2012, 22(4):310-313
DOI:10.4103/0971-4065.101266  PMID:23162280
Thrombotic microangiopathic hemolytic anemia (TMHA) is not uncommon in clinical nephrology practice while antiphospholipid syndrome (APS) is uncommon. Although less than 1% of patients with APS develop catastrophic APS (CAPS), its potential lethal outcome because of thrombosis in multiple organs and subsequent multiorgan failure emphasizes its importance in nephrology practice. Here is a case of catastrophic APS in a 7-year-old girl, who presented to us with TMHA associated with antiphospholipid antibodies and subsequently died because of CAPS.
  - 1,638 95
Reversible dialysis-dependent renal failure due to undiagnosed renovascular disease
R Jha, D Gude, G Narayan, SN Mandal, PC Gupta
July-August 2012, 22(4):314-317
DOI:10.4103/0971-4065.101267  PMID:23162281
Renovascular disease (RVD) can present with resistant hypertension, acute or rapidly progressive renal failure and occasionally nephrotic proteinuria. Revascularization plays an important role in controlling blood pressure and preserving renal function. It is widely believed that delay in revascularization would result in irreversible loss of renal function. However, we report a favorable outcome despite delayed revascularization in two patients of RVD- one presenting with recurrent flash pulmonary edema and other with progressive renal failure. The former's serum creatinine returned to normal despite 3 months of anuria and the latter became dialysis-independent despite 2 months of progressive decline in renal function. Both remain dialysis-free 3 years after surgery.
  - 1,395 78
Acute renal failure due to bilateral ureteric necrosis following percutaneous chemical lumbar sympathectomy
P Ranjan, J Kumar, SS Chipde
July-August 2012, 22(4):292-294
DOI:10.4103/0971-4065.101252  PMID:23162274
We report a case of acute renal failure as a result of obstructive uropathy as a consequence of instillation of phenol used for chemical sympathectomy in Beurger's disease of the lower limbs. Extensive bilateral ureteral necrosis occurred as a result of phenol instillation that. Such practices are still common among the general surgeons and such a complication has not been described before.
  - 1,664 84
Polyarteritis nodosa presenting with spontaneous perirenal hematoma
P Mukhopadhyay, M Rathi, HS Kohli, V Jha, KL Gupta, V Sakhuja
July-August 2012, 22(4):295-297
DOI:10.4103/0971-4065.101254  PMID:23162275
Spontaneous perirenal hematoma following ruptured microaneurysm is an unusual but serious complication of polyarteritis nodosa. We describe a young male who presented with spontaneous perirenal hematoma and was subsequently diagnosed to have polyarteritis nodosa. He was managed with immunosuppressive medications with no recurrence of symptoms.
  - 1,653 81
LETTERS TO EDITOR
Unusual association of a positive pANCA pauci-immune extracapillary glomerulonephritis in a lupus patient
W Fadili, NH Bassit, ZE Ghali, I Laouad
July-August 2012, 22(4):320-321
DOI:10.4103/0971-4065.101274  PMID:23162284
  - 1,109 73
ORIGINAL ARTICLES
Glomerular diseases in the Military Hospital of Morocco: Review of a single centre renal biopsy database on adults
T Aatif, O Maoujoud, DI Montasser, M Benyahia, Z Oualim
July-August 2012, 22(4):257-263
DOI:10.4103/0971-4065.101244  PMID:23162268
Epidemiological studies provide useful information for clinical practice and investigations. This report aimed to determine glomerular diseases frequencies in a region of Morocco. All native renal biopsies (January 2000 to December 2007) on adults were reviewed, but only glomerular diseases were analyzed. The diagnosis of each case was based on histological, immunopathological and clinical features. We have performed 171 renal biopsies in 161 patients (101 males and 60 females), the mean age was (range) 40.4 ±15 years (16-72). Clinical indications that lead to renal biopsy were: nephrotic syndrome (60.3%), renal failure of unknown aetiology (31.6%), asymptomatic urinary abnormalities (6.2%) and nephritic syndrome(1.9%). Primary glomerular diseases were reported in 84 patients (52%). The most common histological lesion was minimal change disease (26%). Idiopathic membranous glomerulopathy was the second most common lesion (23%) followed by membranoproliferative glomerulonephritis (17%), IgA nephropathy (12%), focal and segmental glomerulosclerosis (9.4%) and crescentic glomerulonephritis (6%). Secondary glomerular diseases were reported in 53 patients (33%). Lupus nephritis was the secondary glomerular disease most frequent (45%) followed by amyloÏdosis (19%), diabetic nephropathy (15%), and Good pasture's syndrome (7.6%). The most common complications of the procedure were pain at biopsy site in 4%, gross hematuria in 11.1%, perirenal hematoma in 5% and hematuria requiring nephrectomy in 0.6% patients.Minimal change disease was the most frequent primary glomerulopathy and lupus nephritis was the most frequent secondary glomerulopathy in our group. The reasons for these findings are unclear. This information is an important contribution to the understanding the prevalence of renal diseases in North Africa.
  - 1,762 143
Holistic health assessment tool for patients on maintenance hemodialysis
PR Singhania, S Mandalika
July-August 2012, 22(4):269-274
DOI:10.4103/0971-4065.101246  PMID:23162270
The recent emphasis on assessment of the psychological status, availability of newer and better methods of interpreting the anthropometric measurements of renal patients on dialysis therapy prompted the authors to develop the "Holistic Health Assessment Tool for dialysis patients (HHAT-D)." A total of 30 subjects (25-65 years), enrolled from dialysis centers in Mumbai were administered the HHAT-D tool to assess anthropometric, biochemical, functional, and psychological status (knowledge, needs, that coping strategies) along with dietary intake. The results showed that majority of the patients (73.3%) were mild to moderately malnourished. A highly significant negative correlation of anthropometric measurements (BMI, lean body mass, mid arm circumference, arm muscle area, bicep skin fold thickness, % usual body weight, and % standard body weight) with the HHAT-D scores (P>0.01) confirmed the validity of the tool in assessing the degree of malnutrition. The poor health status of the patients was further confirmed by the average (40%) to poor (36.6%) flexibility status and poor dietary nutrient intake. Moderate (36.6%) to high (60%) coping effectiveness was recorded in the patients as assessed using the "coping effectiveness inventory." A high degree of interitem correlation (Cronbach's coefficient alpha-test value 0.836) also proved the reliability of the HHAT-D tool. Thus, the HHAT-D was found to be a specific and reliable tool for assessment of holistic health status of patients on maintenance hemodialysis to improve quality of life and facilitate faster recovery.
  - 2,189 147
Is early removal of prophylactic ureteric stents beneficial in live donor renal transplantation?
KN Indu, G Lakshminarayana, M Anil, R Rajesh, K George, K Ginil, M Georgy, B Nair, S Sudhindran, T Appu, VN Unni, KV Sanjeevan
July-August 2012, 22(4):275-279
DOI:10.4103/0971-4065.101247  PMID:23162271
Prophylactic ureteric stenting has been shown to reduce ureteric leaks and collecting system obstruction following renal transplantation and is in widespread use. However, the optimal time for removal of ureteric stents after renal transplantation remains unclear. Aim of this study was to compare the result of early versus late removal of ureteric stents after kidney transplantation of the laparoscopically retrieved live related donor grafts. Eligible patients were live donor kidney transplant recipients with normal urinary tracts. All recipients underwent extravesical Lich-Gregoire ureteroneocystostomy over 4F/160 cm polyurethane double J stents by a uniform technique. They were randomized on seventh postoperative day for early removal of stents on postoperative day 7 (Group I), or for late removal on postoperative day 28 (Group II). The incidence of urinary tract infections, asymptomatic bacteriuria, and urological complications were compared. Between 2007 and 2009, 130 kidney transplants were performed at one centre of which 100 were enrolled for the study, and 50 each were randomized into the two groups. Donor and recipient age, sex, native renal disease, immunosupression, number of rejection episodes, and antirejection therapy were similar in the two groups. The occurrence of symptomatic urinary tract infection during the follow-up period of 6 months was significantly less in the early stent removal group [5 out of 50 (10%) in Group I, vs 50 out of 15 (30%) in Group II, P=0.02]. Asymptomatic bacteriuria was documented in 2 out of 50 (4%) in Group I and 4 out of 50 (8%) in Group II (P=0.3). There was no statistically significant difference in the rate of ureteric leak, ureteric obstruction, or hematuria in the two groups (P=1.0). We conclude that, in kidney transplant recipients of laparoscopically retrieved live donor grafts, early stent removal at the end of first week reduces the incidence of urinary tract infection without increasing the rate of urine leak or ureteric obstruction.
  - 1,976 127
Hyperuricemia beyond 1 year after kidney transplantation in pediatric patients: Prevalence and risk factors
B Einollahi, H Einollahi, Z Rostami
July-August 2012, 22(4):280-284
DOI:10.4103/0971-4065.101248  PMID:23162272
Hyperuricemia is frequent among adult renal transplant recipients; however, data among pediatric kidney recipients are scarce. This study is designed to estimate the prevalence and risk factors of late post-transplant hyperuricemia in pediatric recipients. A retrospective observational multicenter study on 179 pediatric renal recipients (5-18 years) was conducted between April 2008 and January 2011 from five kidney transplant centers of Tehran, Iran. All recipients were followed up for more than 1 year (5.9 ±3.3 years) after transplantation. A total of 17686 blood samples were obtained for serum uric acid (SUA). The normal range of SUA was defined as SUA 1.86-5.93 mg/dl for children between 2 and 15 years in both genders; 2.40-5.70 mg/dl for girls aged >15 years; 3.40-7.0 mg/dl for boys aged >15 and more than 6 and 7 mg/dl in boys and girls older than 15 years old. The median age of the children was 13 years. Male recipients were more popular than female (male/female 59/41%). Hyperuricemia was detected in 50.2% of patients. Mean SUA concentration was 5.9±1.7 mg/dl and mean SUA concentration in hyperuricemic patients was 7.7±1.2 mg/dl. While at multivariate logistic regression elevated serum creatinine concentration (P>0.001) and the time span after renal transplantation (P=0.02) had impact on late post-transplant hyperuricemia. High cyclosporine level (C0 and C2) was not risk factor for huperuricemia. Late post-transplant hyperuricemia was found in about half of pediatric renal recipients, and was associated with impaired renal allograft function.
  - 1,239 76
The high prevalence of chronic kidney disease-mineral bone disorders: A hospital-based cross-sectional study
B Ghosh, T Brojen, S Banerjee, N Singh, S Singh, OP Sharma, J Prakash
July-August 2012, 22(4):285-291
DOI:10.4103/0971-4065.101249  PMID:23162273
Mineral bone disorder (MBD) is an important complication of chronic kidney disease (CKD). However, there are limited data on the pattern of MBD in Indian CKD population. The aim of this study was to describe spectrum of MBD in patients with CKD in our center. This was a hospital-based cross-sectional observational study. Patients with stage 4 and 5 CKD were included in this study. Those receiving calcium supplement, vitamin D or its analogues, and calcimimetic were excluded. Serum/plasma levels of creatinine, albumin, calcium, phosphate, total alkaline phosphatase (TAP), intact parathormone (iPTH), and 25-OH vitaminD (25-vitD) were measured. Radiological survey of bones was carried out in all cases, and echocardiography done in selected patients. Statistical analysis was done using Sigmaplot 10.0 software. A total of 150 patients (114 males, 36 females) were included in this study. Mean age was 45.67±16.96 years. CKD stage 4 and 5D were found in 26% (n=39) and 74% (n=111) of study population, respectively. The most common underlying native kidney diseases in patients of CKD 4 and 5D were diabetic nephropathy (41.03%) and CGN (41.44%), respectively. Median (first quartile, third quartile) values for serum levels of corrected calcium (cCa), phosphate, cCaXPO4 product, TAP, plasma iPTH, and 25-vitD in stage 4 CKD were 8.36 (7.79, 8.91) mg/dL, 4.9 (3.92, 6.4) mg/dL, 41.11 (34.01, 53.81) mg 2 /dL 2 , 97 (76.5, 184.25) IU/L, 231 (124.5, 430.75) pg/mL, and 12 (6.98, 23.55) ng/mL, respectively; and in stage 5D CKD were 8.36 (7.66, 8.95) mg/dL, 5.7 (4.23, 6.95) mg/dL, 46.5 (37.16, 54.47) mg 2 /dL 2 , 180 (114.5, 276.25) IU/L, 288 (169.75, 625.0) pg/mL, and 18.4 (10.0, 26.4) ng/mL, respectively. Prevalence of hypocalcemia (56.41% vs. 54.95%), hyperphosphatemia (64.10% vs. 70.27%), and hyperparathyroidism (84.62% vs. 88.29%) was not different between patients with CKD 4 and 5D. However, iPTH level outside the target range and increased TAP level were significantly (P<0.001) more common in CKD stage 5D. Multiple logistic regression analysis for hyperparathyroidism revealed significant inverse correlation with cCa in CKD 5D. There were no significant differences in vitamin D status and prevalence of valvular calcification between CKD stage 4 and 5D. X-ray revealed renal osteodystrophy in 8 (5.33%) patients, while it was normal in 118 (78.67%) patients. Secondary hyperparathyroidism, hyperphosphatemia, hypocalcemia, increased TAP, and 25-OH vitamin D deficiency and insufficiency were quite common in CKD 4 and 5 patients. The commonest type of MBD in CKD 4 and 5D was secondary hyperparathyroidism.
  - 2,711 309
Indian Journal of Nephrology
Published by Wolters Kluwer - Medknow
Online since 20th Sept '07