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   2013| January-February  | Volume 23 | Issue 1  
    Online since February 16, 2013

 
 
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ORIGINAL ARTICLES
Hospital-acquired acute kidney injury in medical, surgical, and intensive care unit: A comparative study
TB Singh, SS Rathore, TA Choudhury, VK Shukla, DK Singh, J Prakash
January-February 2013, 23(1):24-29
DOI:10.4103/0971-4065.107192  PMID:23580801
Acute kidney injury (AKI) is a common complication in hospitalized patients. There are few comparative studies on hospital-acquired AKI (HAAKI) in medical, surgical, and ICU patients. This study was conducted to compare the epidemiological characteristics, clinical profiles, and outcomes of HAAKI among these three units. All adult patients (>18 years) of either gender who developed AKI based on RIFLE criteria (using serum creatinine), 48 h after hospitalization were included in the study. Patients of acute on chronic renal failure and AKI in pregnancy were excluded. Incidence of HAAKI in medical, surgical, and ICU wards were 0.54%, 0.72%, and 2.2% respectively ( P < 0.0001). There was no difference in age distribution among the groups, but onset of HAAKI was earliest in the medical ward ( P = 0.001). RIFLE-R was the most common AKI in medical (39.2%) and ICU (50%) wards but in the surgical ward, it was RIFLE-F that was most common (52.6%). Acute tubular necrosis was more common in ICU ( P = 0.043). Most common etiology of HAAKI in medical unit was drug induced (39.2%), whereas in surgical and ICU, it was sepsis (34% and 35.2% respectively). Mortality in ICU, surgical and medical units were 73.5%, 43.42%, and 37.2%, respectively ( P = 0.003). Length of hospital stay in surgical, ICU and medical units were different ( P = 0.007). This study highlights that the characters of HAAKI are different in some aspects among different hospital settings.
  3,230 327 3
Clinical features, epidemiology, and short-term outcomes of proliferative lupus nephritis in Eastern India
D Sircar, G Sircar, R Waikhom, A Raychowdhury, R Pandey
January-February 2013, 23(1):5-11
DOI:10.4103/0971-4065.107187  PMID:23580798
Race and ethnicity are important predictors of prognosis in lupus nephritis. This study was conducted to determine the clinical features, epidemiological profile, and short-term outcomes in patients of lupus nephritis from a single center in Eastern India. A total of 86 patients of class III/IV lupus nephritis were studied. Seventy-eight of them received cyclophosphamide for induction and eight of them received mycophenolate. The patients were evaluated for response, estimated glomerular filtration rate (eGFR), and proteinuria at 6 months. About 44% patients had a partial or complete response at 6 months and 64% at 1 year. The factors correlating with response at 6 months were older age at diagnosis, hypertension, activity, and chronicity indices and duration of symptoms prior to therapy. Chronicity index and hypertension were the predictors of response by logistic regression at 6 months. Compared to the Caucasian and African American patients, patients with proliferative lupus in Eastern India presented with a lower eGFR, lower proteinuria, and higher chronicity scores. Older age at diagnosis, hypertension, activity, chronicity indices, and duration of symptoms correlated with response. Short-term outcomes were similar to those described in Caucasian patients.
  3,048 315 -
Microbiological aspects of peritonitis in patients on continuous ambulatory peritoneal dialysis
S Vikrant, RC Guleria, A Kanga, BS Verma, D Singh, SK Dheer
January-February 2013, 23(1):12-17
DOI:10.4103/0971-4065.107188  PMID:23580799
The objective of the study was to identify the microbiological spectrum and drug-sensitivity pattern of peritonitis in patients on continuous ambulatory peritoneal dialysis. This was a prospective study done over a period of a year-and-a-half at a tertiary-care hospital in a hilly state of India. The effluent dialysate bags from 36 consecutive patients with peritonitis were studied. One hunderd ml dialysate fluid was processed under aseptic conditions by lysis centrifugation method. Microscopy and culture was done from the deposits for bacteriological, fungal, and mycobacterial isolates. They were identified by colony morphology and their biochemical reactions. Drug susceptibility testing was done by Kirby-Bauer disc diffusion method. In 36 dialysates, 33 (91.6%) dialysates were culture-positive and in 3 (8.4%), the culture was negative. A total of 36 microorganisms were isolated in 33 cultures. Among the 36 microorganisms, 19 (52.8%) isolates were gram-positive, 10 (27.8%) were gram-negative, 5 (13.9%) were fungi, and 2 (5.6%) were mycobacterial isolates. All gram-positive organisms were sensitive to ampicillin, amoxi-clavulanic acid, cefazolin, clindamycin, and vancomycin. Neither a methicillin-resistant Staphylococci aureus nor a vancomycin-resistant Enterococcus was isolated in gram-positive isolates. Gram-negative organisms were sensitive to ciprofloxacin, ceftriaxone, ceftazidime, cefepime, gentamicin, piperacillin-tazobactam and imipenem. One of the gram-negative isolate was an extended spectrum beta-lactamase producer. Gram-positive peritonitis was more frequent than gram-negative peritonitis in our continuous ambulatory peritoneal dialysis patients. Mycobacterial causes were responsible for peritonitis in patients with culture-negative peritonitis which was not responding to the conventional antimicrobial therapy.
  2,471 256 -
Are oral protein supplements helpful in the management of malnutrition in dialysis patients?
TK Jeloka, G Dharmatti, T Jamdade, M Pandit
January-February 2013, 23(1):1-4
DOI:10.4103/0971-4065.107185  PMID:23580797
A randomized study was planned to compare the effects of whey and egg albumin protein supplements in dialysis patients. Fifty adult patients were randomized to receive either whey protein or egg albumin as per their deficit calculated from K/DOQI recommendations. Actual intake was calculated from three-day dietary diary. Assessment of nutritional status was done by serum albumin and bioelectric impedance analysis (BIA). Repeat evaluation was done after 6 months. The mean initial intake of protein in whey and egg albumin group was 0.74 ± 0.3 vs. 0.69 ± 0.2 g/kg/day, ( P = 0.5) and calorie intake was 20 ± 5.6 vs. 20.5 ± 5.1 kcal/kg/day, ( P = 0.8), respectively. Out of 50 patients, two died within 2 months and were excluded from the study and 14 (28%) dropped out within one month because of side effects. The most common side effect in drop-outs was nausea and vomiting (43%). Out of remaining 34 patients who completed the study, 80% could not consume >50% of the recommended supplement because of side effects. The protein and calorie intake remained similar at baseline and 6 months in both the groups. The main side effects in whey group were bloating and nausea with vomiting, and in egg protein group were nausea with vomiting, bloating and anorexia. Oral protein supplements were not tolerated in dialysis patients and side effects resulted in high degree of non-compliance.
  2,225 282 -
Calcineurin inhibitor induced nephrotoxicity in steroid resistant nephrotic syndrome
A Sinha, A Sharma, A Mehta, R Gupta, A Gulati, P Hari, AK Dinda, A Bagga
January-February 2013, 23(1):41-46
DOI:10.4103/0971-4065.107197  PMID:23580804
Prolonged therapy with calcineurin inhibitors (CNI) is effective in patients with difficult nephrotic syndrome. However, information on prevalence and risk factors for nephrotoxicity in children with steroid-resistant nephrotic syndrome is limited. This retrospective observational study was conducted on 40 patients with steroid-resistant nephrotic syndrome treated with cyclosporine (CyA) (n = 28) or tacrolimus ( n = 12) for more than 2 years. Nephrotoxicity was defined by the presence of striped fibrosis involving ≥10% of the interstitium or nodular hyalinosis in more than one arteriole. Ten additional parameters were graded semi-quantitatively. Continuous data are presented as median and interquartile range (IQR). The median (IQR) age at onset of nephrotic syndrome and CNI therapy were 30 (21-45) and 49.5 (40-102.5) months. A second renal biopsy, following 30 (26-35) months of CNI therapy, showed histological toxicity in 10 (25%) patients. Toxicity was seen in 7 and 3 patients receiving CyA and tacrolimus, respectively, and 5 patients each with minimal change and focal segmental glomerulosclerosis. Therapy with CNI was associated with significant increases in scores for global glomerulosclerosis, tubular atrophy, interstitial fibrosis, nonnodular arteriolar hyalinosis ( P < –0.001 for all), arteriolar smooth-muscle vacuolization ( P = –0.02), juxtaglomerular hyperplasia ( P = –0.002), and tubular microcalcinosis ( P = –0.06). Risk factors for nephrotoxicity were initial resistance (OR 9; 95% CI 1.0-80.1; P = –0.049); dose of CyA (OR 9.2; 95% CI 1.1-74.6; P = –0.037); duration of heavy proteinuria (OR 1.2; 95% CI 1.0-1.4; P = –0.023); and hypertension during therapy (OR 6; 95% CI 1.3-28.3; P = –0.023). Following prolonged CNI therapy, one in four biopsies show features of toxicity. Prolonged duration of heavy proteinuria, hypertension, initial steroid resistance and high CyA dose predict the occurrence of nephrotoxicity.
  2,057 197 2
CASE REPORTS
Bilateral psoas and bilateral perinephric abscesses complicating acute pyelonephritis in pregnancy
I Veerappan, A Shanmugam, S Kumar, P Velayutham
January-February 2013, 23(1):59-62
DOI:10.4103/0971-4065.107213  PMID:23580809
Acute pyelonephritis complicates 1-2% of pregnancies and causes significant maternal and fetal morbidity and mortality. The diagnosis of renal tuberculosis (TB) is often delayed and commonly presents with sterile pyuria or along with other pyogenic organisms. We report a case where the diagnosis of renal TB was missed in a pregnant woman when she presented with acute pyelonephritis, septic shock, and acute renal failure. There was clinical recovery with antibiotics, but bilateral psoas and perinephric abscesses (TB, Enterococcus sp., and E. coli) were diagnosed when she presented with loin pain and palpable left renal angle swelling. Bilateral psoas abscess due to TB in the absence of skeletal TB and human immunodeficiency virus infection is rare. The presentation of renal TB in pregnancy, its complications, and its management are discussed.
  2,073 134 1
ORIGINAL ARTICLES
Neutrophil-to-lymphocyte ratio, insulin resistance, and endothelial dysfunction in patients with autosomal dominant polycystic kidney disease
K Turkmen, F Tufan, E Selçuk, T Akpinar, H Oflaz, T Ecder
January-February 2013, 23(1):34-40
DOI:10.4103/0971-4065.107195  PMID:23580803
Endothelial dysfunction (ED), insulin resistance (IR), and inflammation are risk factors for increased cardiovascular morbidity and mortality in autosomal dominant polycystic kidney disease (ADPKD). ADPKD patients may have increased carotid intima-media thickness (CIMT) and decreased coronary flow velocity reserve (CFVR). The neutrophil-to-lymphocyte ratio (NLR) was introduced as a marker to determine inflammation in various disorders. We aimed to investigate the relationship between NLR and IR, CFVR, CIMT, and the left ventricular mass index (LVMI) in normotensive ADPKD patients. Twentynine ADPKD patients (age 38.8 ± 10.2 years; 8 men and 21 women) and 19 healthy controls (age 33.8 ± 7.4 years; 8 men and 11 women) were included in this cross-sectional study. CFVR was calculated with echocardiography as the ratio of hyperemic to baseline diastolic peak coronary flow velocities. CIMT was measured in the distal common carotid artery by using a 10-MHz linear echocardiography probe. HOMA-IR was calculated NLR was calculated as the ratio of the neutrophil and lymphocyte counts. Age, sex, body mass index, and levels of glucose, creatinine, low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol, triglycerides, C-reactive protein (CRP), microalbuminuria, and creatinine clearance were similar between ADPKD patients and healthy subjects. NLR, CIMT, LVMI, and HOMA-IR were significantly higher and CFVR values were significantly lower in patients with ADPKD compared to that in healthy subjects. NLR showed positive correlation with CIMT, HOMA, insulin, glucose, and HDL cholesterol levels, while it was inversely correlated with CFVR and albumin level in all subjects. In patients with ADPKD, NLR showed positive correlation with HDL cholesterol level and inverse correlation with LVMI and albumin level. NLR that was found to be increased in patients with ADPKD may be a readily available marker of inflammation and ED.
  1,940 159 4
CASE REPORTS
Sternal tuberculosis in a patient with chronic kidney disease
M Yadla, S Reddy, P Sriramnaveen, CK Kishore, A. V. S. S. N Sridhar, AY Lakshmi, B Vijayalakshmi, B Phanindra, V Sivakumar
January-February 2013, 23(1):57-58
DOI:10.4103/0971-4065.107210  PMID:23580808
Sternum is generally regarded as resistant to infections and thus is an infrequent site of osteomyelitis. Involvement of sternum by Mycobacterium tuberculosis is rare. Sternal tuberculosis in chronic kidney disease (CKD) was not reported till date. We report a 40-year-old patient with stage IV CKD, who presented with sternal and cervical lymphnodal tuberculosis.
  1,980 104 -
Sunitinib induced nephrotic syndrome and thrombotic microangiopathy
PK Jha, M Vankalakunti, V Siddini, R Bonu, GK Prakash, K Babu, HS Ballal
January-February 2013, 23(1):67-70
DOI:10.4103/0971-4065.107215  PMID:23580811
Sunitinib is an oral, multitargeted receptor tyrosine kinase inhibitor of targets such as vascular endothelial growth factor and platelet derived growth factor receptor. It is used for the treatment of metastatic renal cell carcinoma (RCC). Use of sunitinib has been associated with renal dysfunction and nephrotic syndrome. However, simultaneous occurrence of nephrotic syndrome and renal dysfunction in a patient treated with sunitinib is rare. We report a case of metastatic RCC treated with sunitinib for 22 months who presented with nephrotic syndrome and renal dysfunction. Renal biopsy was diagnostic of thrombotic microangiopathy with diffuse effacement of podocytic foot process.
  1,773 108 1
ORIGINAL ARTICLES
Outcomes and characteristics of intermittent hemodialysis for acute kidney injury in an intensive care unit
S Sankarasubbaiyan, JD Janardan, P Kaur
January-February 2013, 23(1):30-33
DOI:10.4103/0971-4065.107193  PMID:23580802
Renal replacement therapy in intensive care units (ICUs) varies globally and is dependent on medical and non-medical factors. We performed a retrospective analysis of patients initiated on dialysis in an ICU. Patient and clinical characteristics, cause of kidney injury, laboratory parameters, hemodialysis characteristics, and survival were reviewed. Acute physiological and chronic health (APACHE II) score was use to study the sickness profile. A total of 92 patients underwent 525 hemodialysis sessions. There were 60 male and 32 female patients. The mean age of the patients was 56.5 ± 16 years. The cause of acute kidney injury included sepsis 64, cardiac 7, malaria 7, postoperative 4, trauma 3, poisoning 2, and others 4. Vasopressors were used in 75% and mechanical ventilation was used in 74 (82%) of the cases. APACHE II score was 22.3 + 7.4. The mean creatinine level was 3.6 + 3.7 mg/dl. The duration of dialysis was less than 4 h in 324 (61.2%) sessions and greater than 6 h in 118 (22.5%) sessions. The percentage of 30-day survival was 30%. Intermittent hemodialysis customized to renal support needs of ICU patients is an appropriate option in resource-limited settings.
  1,605 167 -
CASE REPORTS
Combined approach with therapeutic drug monitoring and pharmacogenomics in renal transplant recipients
S Manvizhi, BS Mathew, DH Fleming, G Basu, GT John
January-February 2013, 23(1):71-73
DOI:10.4103/0971-4065.107216  PMID:23580812
In patients undergoing renal transplantation, dose individualization for tacrolimus is routinely achieved with therapeutic drug monitoring (TDM). The patient started on 5.5 mg/day of tacrolimus had a significantly elevated tacrolimus trough concentration. The tacrolimus dose was regularly reduced following TDM at many time periods in the post transplant period but the tacrolimus concentration was consistently elevated. Genomic analysis done after four years revealed mutations in the genes encoding for CYP3A5 and MDR1 (2677G > T). Pharmacogenomics alongside TDM, will soon emerge as the backbone of dose individualization. But for genomics to be beneficial, it should be advocated in the pre-transplant or early post transplant period.
  1,468 223 -
Neonatal Bartter syndrome associated with ileal atresia and cystic fibrosis
AO Akuma, SK Mittal, AA Sambo
January-February 2013, 23(1):47-50
DOI:10.4103/0971-4065.107200  PMID:23580805
A rare case of neonatal Bartter syndrome presenting with severe hyperkalemia is reported in a preterm child born to consanguineous parents. This child also had ileal atresia, and meconium plugs were found at laparotomy. The diagnosis of cystic fibrosis was subsequently made on genetic testing. Despite full intensive care management and surgical interventions, he died of respiratory failure after 70 days. This is the first reported case of such conglomeration of pathologies in a newborn child. Second, in highlighting this case we want clinicians to be aware that a subtype of neonatal Bartter syndrome can present with initial hyperkalemia so that an erroneous diagnosis of pseudohypoaldosteronism is not made when this is seen in combination with hyperkalemia and hyperrenin hyperaldosteronism.
  1,549 94 -
Encephalopathy secondary to isoniazid in patients on hemodialysis
MT Abbas, FY Khan, S Sulimon, A Baidaa
January-February 2013, 23(1):54-56
DOI:10.4103/0971-4065.107206  PMID:23580807
We report isoniazid (INH)-induced encephalopathy in two male patients on hemodialysis. One of them had tuberculous adenitis, and the other had pulmonary tuberculosis. Both were given rifampicin, INH, pyrazinamide, and ethambutol with pyridoxine 40 mg/day. Two patients developed disturbances in consciousness. After excluding other causes, INH-induced encephalopathy was suspected so the drug was stopped and dose of pyridoxine increased. Both patients retained their consciousness within 1 week and were discharged.
  1,450 110 2
ORIGINAL ARTICLES
Association between high molecular weight apolipoprotein isoforms and lipoprotein levels in advanced chronic kidney disease and the effect of hemodialysis
JK Gambhir, OP Kalra, A Khaira, H Kaur
January-February 2013, 23(1):18-23
DOI:10.4103/0971-4065.107189  PMID:23580800
To explore the association between high molecular weight apo(a) isoforms and lipoprotein(a) [Lp(a)] in chronic kidney disease (CKD) and the effect of maintenance hemodialysis (MHD), plasma Lp(a) and apo(a) isoforms were determined in age and sex-matched CKD stage 4 and stage 5 patients (repeated after 4 weeks of MHD) and healthy controls ( n = 18). Median Lp(a) increased with severity of CKD. Upon HMW apo(a) isoform stratification, Lp(a) in S 2 isoform group was 37.6 mg/dl in CKD stage 4 and 64.0 mg/dl in stage 5 ( P < 0.024 and P < 0.001 vs. controls), whereas in S 3 + S 4 group there was no significant increase. Following MHD, Lp(a) also decreased significantly only in the S 2 group. Increase in Lp(a) in CKD patients with HMW apo(a) isoforms is mainly restricted to S 2 isoform group, furthermore, decrease in Lp(a) levels in response to MHD is also seen in this group only.
  1,418 136 -
CASE REPORTS
Cerebral infarction in patient with minimal change nephrotic syndrome
A Babu, P Boddana, S Robson, L Ludeman
January-February 2013, 23(1):51-53
DOI:10.4103/0971-4065.107203  PMID:23580806
We report a case of 68-year-old Caucasian man who presented with cerebral infarcts secondary to arterial thrombosis associated with nephrotic syndrome. His initial presentation included edema of legs, left hemiparesis, and right-sided cerebellar signs. Investigations with computed tomography and magnetic resonance imaging of brain showed multiple cerebral infarcts in middle cerebral and posterior cerebral artery territory. Blood and urine investigations also showed impaired renal function, hypercholesterolemia, hypoalbuminaemia, and nephrotic range proteinuria. Renal biopsy showed minimal change disease. Cerebral infarcts were treated with antiplatelet agents and nephrotic syndrome was treated with high dose steroids. Patient responded well to the treatment and is all well till date.
  1,451 102 -
LETTERS TO EDITOR
Focal xanthogranulomatous pyelonephritis presenting as renal tumor
S Shinde, DK Kandpal, SK Chowdhary
January-February 2013, 23(1):76-77
DOI:10.4103/0971-4065.107219  PMID:23580815
  1,396 79 -
Plasmodium vivax malaria presenting as hemolytic uremic syndrome
MP Patel, VB Kute, MR Gumber, DN Gera, PR Shah, HV Patel, HL Trivedi, AV Vanikar
January-February 2013, 23(1):74-75
DOI:10.4103/0971-4065.107217  PMID:23580813
  1,230 108 2
Post-renal transplant Kaposi's sarcoma of skin
DN Gera, DK Yadav, SB Patil, MP Patel
January-February 2013, 23(1):78-80
DOI:10.4103/0971-4065.107221  PMID:23580817
  1,203 93 -
Benzene hexachloride poisoning with rhabdomyolysis and acute kidney injury
PR Shah, VB Kute, MR Gumber, HV Patel, MP Patel, DK Yadav, AV Vanikar, HL Trivedi
January-February 2013, 23(1):80-81
DOI:10.4103/0971-4065.107222  PMID:23580818
  1,158 92 1
CASE REPORTS
Nephrotic syndrome associated with meningioma
PP Zachariah, A Mathew, R Rajesh, G Kurien, VN Unni
January-February 2013, 23(1):63-66
DOI:10.4103/0971-4065.107214  PMID:23580810
A 58-year-old man presented with recurrent frontal meningioma and nephrotic syndrome. Renal biopsy could not be done in view of the rapid neurological deterioration. The patient underwent surgical resection of the tumor. Within 4 weeks, the edema decreased, serum albumin improved, and proteinuria decreased spontaneously. At three months of followup, the patient had attained complete remission of nephrotic state.
  1,126 91 -
LETTERS TO EDITOR
Nephrotic syndrome after thymectomy for myasthenia gravis
VB Kute, PR Shah, JD Shrimali, MR Gumber, HV Patel, AV Vanikar, HL Trivedi
January-February 2013, 23(1):75-76
DOI:10.4103/0971-4065.107218  PMID:23580814
  1,121 81 -
Close encounter with destiny: Lessons learnt
S Krishnan
January-February 2013, 23(1):77-78
DOI:10.4103/0971-4065.107220  PMID:23580816
  941 77 -
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