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   2017| November-December  | Volume 27 | Issue 6  
    Online since November 14, 2017

 
 
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REVIEW
Nocturnal enuresis in india: Are we diagnosing and managing correctly?
NM Reddy, H Malve, R Nerli, P Venkatesh, I Agarwal, V Rege
November-December 2017, 27(6):417-426
DOI:10.4103/ijn.IJN_288_16  PMID:29217876
Nocturnal enuresis is a common problem affecting school-aged children worldwide. Although it has significant impact on child's psychology, it is always under-recognized in India and considered as a condition which will outgrow with advancing age. Nocturnal enuresis classified as primary or secondary and monosymptomatic or nonmonosymptomatic. Factors that cause enuresis include genetic factors, bladder dysfunction, psychological factors, and inappropriate antidiuretic hormone secretion, leading to nocturnal polyuria. Diagnosis consists of detailed medical history, clinical examination, frequency-volume charts, and appropriate investigations. The frequency-volume chart or voiding diary helps in establishing diagnosis and tailoring therapy. The first step in treating nocturnal enuresis is to counsel the parents and the affected child about the condition and reassure them that it can be cured. One of the effective strategies to manage enuresis is alarm therapy, but currently, it is not easily available in India. Desmopressin has been used in the treatment of nocturnal enuresis for close to 50 years. It provides an effective and safe option for the management of nocturnal enuresis. This review covers the diagnosis and management of nocturnal enuresis and introduces the concept of “bedwetting clinics” in India, which should help clinicians in the thorough investigation of bedwetting cases.
  1,512 343 -
ORIGINAL ARTICLES
A randomized controlled trial of intravenous versus oral cyclophosphamide in steroid-resistant nephrotic syndrome in children
KM Shah, AJ Ohri, US Ali
November-December 2017, 27(6):430-434
DOI:10.4103/ijn.IJN_201_16  PMID:29217878
This is a randomized, parallel group, active-controlled trial to compare the efficacy of intravenous cyclophosphamide (IVCP) with oral cyclophosphamide (OCP) in patients with steroid-resistant nephrotic syndrome (SRNS) in children. Fifty consecutive children with idiopathic SRNS were biopsied and then randomized to receive either OCP at a dose of 2 mg/kg/day for 12 weeks or IVCP at a dose of 500 mg/m2/month for 6 months. Both groups received tapering doses of oral steroids. The response was evaluated in terms of induction of complete remission (CR) or partial remission (PR), time to remit, and side effects. The groups were followed up to determine the duration of remission, percentage of patients who remain in sustained remission for more than 1 year after completion of therapy, change in steroid response status, progression to chronic kidney disease stage 3 or more. Of the fifty patients, OCP was given to 25 children and IVCP to 25 children. The demographic data, histopathology, biochemical profile, and duration of follow-up in the two groups were comparable. The rates of induction of CR were 52% versus 44% and of PR were 8% versus 8% in the intravenous (IV) and oral group, respectively. Time to remit was shorter with OCP than IVCP (53 days vs. 84.4 days). Incidence of side effects (both major and minor) was 36% in IVCP versus 20% in OCP group. The actuarial cumulative sustained remission in our study was 12% in IVCP compared with 16% in OCP at 1 year after completion of therapy. Twelve percent children in both the groups exhibited restoration of steroid sensitivity. Thus, in our study, overall, more than half of SRNS patients showed initial response to cyclophosphamide, but only one-fourth patients had sustained remission on follow-up. OCP and IVCP were equally efficacious and safe in idiopathic SRNS in children.
  1,479 236 -
COMMENTARY
Central venous stenosis: What should a nephrologist know?
HJ Mehta
November-December 2017, 27(6):427-429
DOI:10.4103/0971-4065.202825  PMID:29217877
  947 209 -
ORIGINAL ARTICLES
IgA-dominant infection-related glomerulonephritis in India: A single-center experience
J Dhanapriya, T Balasubramaniyan, SP Maharajan, T Dineshkumar, R Sakthirajan, N Gopalakrishnan, M Nagarajan
November-December 2017, 27(6):435-439
DOI:10.4103/ijn.IJN_337_16  PMID:29217879
IgA-dominant infection-related glomerulonephritis (IRGN) is a distinct morphologic variant of IRGN, characterized by dominant or codominant glomerular deposits of IgA, mostly in elderly and patients with diabetes. More cases are being reported in recent times due to increased awareness of the disease entity and increased rate of Staphylococcus infection. It usually presents as rapidly progressive renal failure with proteinuria, and treatment guidelines for this disease entity are not well defined. We report here 12 cases of IgA-dominant IRGN seen over a period of 5 years from a single center. Clinical features, biopsy findings, treatment, and outcomes were analyzed. Out of 12 patients, eight were males. The mean age of presentation was 52.4 ± 21 years. Skin was the most common site of infection seen in six patients. Gross hematuria was seen in 4 patients and 11 had nephrotic proteinuria. Eleven had low serum C3. Only two patients had diabetes. Methicillin-resistant Staphylococcus aureus (MRSA) was the most common organism isolated in six patients. Most common histopathology was crescentic glomerulonephritis seen in seven patients, followed by endocapillary proliferation in three and diffuse proliferative glomerulonephritis in two. Hemodialysis was done in eight patients and six patients received steroid therapy. End-stage renal disease developed in three patients, chronic kidney disease in three, and three patients died due to sepsis. Various infections including MRSA and Escherichia coli were associated with IgA-dominant IRGN both in patients with diabetes and nondiabetics. Suspicion and recognition of the disease is important as it has therapeutic and prognostic implications.
  786 112 -
Renal manifestation in scrub typhus during a major outbreak in central Nepal
A Sedhain, GR Bhattarai
November-December 2017, 27(6):440-445
DOI:10.4103/ijn.IJN_133_17  PMID:29217880
Renal involvement and acute kidney injury (AKI) are common clinical manifestations seen in scrub typhus, a vector-borne tropical disease. There are no data on renal manifestation in scrub typhus in Nepal. We conducted a prospective study to analyze the incidence, urinary abnormalities, course, severity, outcome, and the predictors of AKI in patients with scrub typhus during a major outbreak in Central Nepal. Total 1398 patients admitted with acute febrile illness were subjected for Scrub Typhus Detect Immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) test, of which 502 (35.90%) patients tested positive and were included in the study. Mean age of the patients was 30.37 ± 18.81 years (range, 1–79 years) with 26.29% in the pediatric age group. Female-to-male ratio was 1.26:1. Mean duration of fever was 6.8 ± 3.1 days. Mean IgM ELISA value for scrub typhus was 2.17 ± 1.70 without difference in AKI and non-AKI groups (2.17 ± 1.76 vs. 2.16 ± 1.62; P = 0.94). Urinary abnormalities were seen in 42.3% of patients. Mean serum creatinine was 1.37 ± 0.69 mg/dl with significant difference in two groups (1.85 ± 0.87 vs. 1.03 ± 0.17; P = 0.003). AKI was seen in 35.8% of patients with majority having Stage 1 AKI (68.3%) followed by Stage 2 (34.1%) and Stage 3 (1.2%). Hemodialysis was required for 3.94% of patients. In 54% of patients, AKI occurred in fifth and sixth day of fever. ICU admission was required for 18.73% of patients and 8.57% required ventilator support. Mortality rate was 1.79%, which was higher among patients with AKI (2.96% vs. 1.0%; P = 0.106). Multivariate analysis revealed that the presence of pneumonia, shock, and acute respiratory distress syndrome predicted the development of AKI.
  770 110 -
LETTERS TO EDITOR
Efficacy of thalidomide for recurrent gastrointestinal bleeding due to angiodysplasias in a hemodialysis patient
M Tamzaourte, Y Zajjari
November-December 2017, 27(6):489-490
DOI:10.4103/ijn.IJN_32_17  PMID:29217895
  791 55 -
CASE REPORTS
How harmful can herbal remedies be? a case of severe acute tubulointerstitial nephritis
P Beniwal, N Gaur, SK Singh, N Raveendran, V Malhotra
November-December 2017, 27(6):459-461
DOI:10.4103/ijn.IJN_313_16  PMID:29217884
Acute interstitial nephritis (AIN) is a condition in which acute kidney injury (AKI) is characterized by the histological finding of interstitial inflammation. Hyponidd is an ayurvedic drug containing Momordica charantia, Gymnema sylvestre, Swertia chirata, etc., used for the treatment of Type 2 diabetes mellitus (DM) and polycystic ovarian disease as an insulin sensitizer. There are no case reports of AIN caused by this drug yet. We report a biopsy-proven case of AKI due to severe AIN associated with the use of hyponidd tablet in a 60-year-old male with DM and hypertension. As these types of various indigenous compounds are used as home remedies in our country, awareness about the possible adverse effects of these agents among physicians is very important in the early diagnosis and management.
  724 88 -
Innominate vein stenosis in association with ipsilateral hyperdynamic brachiobasilic fistula causing ipsilateral limb and hemifacial swelling
JB Narendra, J Sreenivas, VS Karthikeyan, NH Nagaraja
November-December 2017, 27(6):452-455
DOI:10.4103/0971-4065.194393  PMID:29217882
A 34-year-old hypertensive woman with a hyperdynamic, left brachiobasilic dialysis fistula presented with a long history of throbbing in her head and swelling of the left side of the face. Tight stenosis of left brachiocephalic vein was found to be causing retrograde flow into the left jugular vein which normalized after dilatation and stenting with resolution of all the symptoms and patient is asymptomatic for 1 year.
  706 84 -
Acute thyroid swelling in renal transplant recipient
DP Engineer, S Prakash, A Yadav, J Kumhar, A Biswas, G Kunal, A Goel
November-December 2017, 27(6):462-464
DOI:10.4103/ijn.IJN_335_16  PMID:29217885
Tuberculosis (TB) of thyroid gland is rare entity even in solid organ transplant recipients who have a high risk of TB. Thyroid TB is easily diagnosed by fine needle aspiration cytology. The majority of cases require only antitubercular drugs for treatment, and surgical intervention is required only in few patients. We here describe a case of thyroid TB presenting as an acute abscess in postrenal transplant recipient with a background of acute rejection treated with steroid and antithymocyte globulin.
  676 68 -
Renal complications of hematopoietic stem cell transplantation: Report of a case and review of the literature
E Liquete, SR Williamson, N Janakiraman, KK Venkat
November-December 2017, 27(6):468-471
DOI:10.4103/ijn.IJN_230_16  PMID:29217887
We report the development of minimal change disease superimposed on preexisting chronic kidney disease secondary to chronic calcineurin inhibitor nephrotoxicity in a hematopoietic stem cell transplantation (HSCT) recipient and review the renal complications of HSCT.
  659 71 -
Nontubercular mycobacterial infection in a renal allograft recipient
U Anandh, K Jayanna
November-December 2017, 27(6):478-481
DOI:10.4103/ijn.IJN_336_16  PMID:29217890
A 71-year-old male, a renal allograft recipient, presented to us with a history of fever and right palm swelling. He had a history of fever 7 years back when he was treated with antitubercular treatment (ATT). Three years back, he was diagnosed to have gout and he was started on allopurinol. He developed severe bone marrow toxicity and allopurinol was changed to febuxostat. On admission, routine investigations did not reveal any focus of infection. The fluid aspirate from the palm revealed acid-fast bacilli (AFB). He was started on ATT; however, he did not show significant improvement. Two months later, he developed multiple subcutaneous lesions, and the pus again came positive for AFB. Due to lack of improvement, the aspirate was sent for molecular diagnostic identification. The mycobacteria was identified as Mycobacterium haemophilum. His treatment was changed to rifampicin, clarithromycin, and ciprofloxacin. As he showed slow improvement, his immunosuppression was tapered slowly. At 7 months of therapy, he is clinically better and his lesions are healing. His renal functions stayed stable despite tapering of cyclosporine in a patient who is on rifampicin. This case, the first report of M. haemophilum infection in a kidney transplant recipient in India, illustrates the difficulty in diagnosing nontubercular mycobacterial infection in transplant recipients. It also emphasizes the dilemma in tapering immunosuppressive drugs in disseminated nontubercular mycobacterial infections where there are considerable interactions between ATT and immunosuppressives.
  657 67 -
Nutcracker syndrome with hypertension as an unusual initial presentation
NA Narkhede, AB Deokar, KP Mehta, NN Kamat
November-December 2017, 27(6):472-474
DOI:10.4103/ijn.IJN_184_16  PMID:29217888
Hypertension has been rarely reported in patients with the nutcracker phenomenon (NCP)/syndrome. We describe a case of a young adolescent female patient where a computed tomography angiography (CTA) provided evidence of left renal vein dilatation, probably due to its compression through the angle between the aorta and the superior mesenteric artery, during the evaluation of secondary hypertension. Blood levels of renin and aldosterone were within normal limits. Ultrasonography of the kidney showed minimal scarring on the left side. As there were no other signs of secondary hypertension, we proceeded with a CTA, which revealed findings compatible with the so-called NCP/syndrome.
  638 69 -
Squamous cell carcinoma of skin after 20 years of renal transplantation
J Poddar, AD Sharma, S Patel, U Suryanarayana
November-December 2017, 27(6):456-458
DOI:10.4103/ijn.IJN_308_16  PMID:29217883
Solid organ transplant recipients are at high risk of developing malignancies due to the prolonged use of immunosuppressant drugs. Squamous cell carcinoma of skin can occur in these patients even after decades of organ transplant. A 45-year-old male underwent renal transplant for end-stage renal disease 23 years ago and was on immunosuppressive drugs since then. The patient was on regular follow-up. Three years back, he developed squamous cell carcinoma of both forearms and hands, which was treated with radiation therapy using 8 MeV electrons, by parallel opposed fields to a dose of 60 Gy/30 fractions. Complete response to treatment was achieved at 3 months posttreatment. The patient is currently on follow-up and asymptomatic for skin lesions. Hence, these patients require longer follow-up, active surveillance, and screening for early diagnosis and prompt treatment of the premalignant and malignant conditions.
  629 65 -
Trimethoprim-sulfamethoxazole-induced hepatotoxicity in a renal transplant patient
R Slim, N Asmar, C Yaghi, K Honein, R Sayegh, D Chelala
November-December 2017, 27(6):482-483
DOI:10.4103/ijn.IJN_339_16  PMID:29217891
Drug-induced liver injury (DILI) represents liver damage from various therapeutic drugs. Antimicrobials are among the most common causes of DILI. We report a case of hepatic toxicity due to Trimethoprim-sulfamethoxazole (TMP-SMX) in a patient who underwent renal transplantation. Diagnosis has been made after a careful history taking, exclusion of competing etiologies and reversal of biochemical abnormalities after withdrawal of the antibiotic. TMP-SMX liver toxicity is well known but remains unpredictable and is rarely reported.
  586 83 -
Spontaneous splenic haematoma in a patient on hemodialysis: A case report
J Pandiaraja
November-December 2017, 27(6):475-477
DOI:DOI: 10.4103/ijn.IJN_285_16  PMID:29217889
Spontaneous splenic hematoma is one of the rare and life-threatening complications of chronic renal failure. The diagnosis of splenic hematoma is mostly made by imaging such as ultrasound or computed tomography. The management of spontaneous splenic hematoma is not standardized till now due to the rarity of this condition. Splenectomy is recommended in hemodynamically unstable patients with features of shock. This is a case report of spontaneous splenic hematoma in a patient with chronic renal failure. This case is reported due to the rarity with renal failure.
  555 53 -
ORIGINAL ARTICLES
Reduced baroreflex sensitivity, decreased heart rate variability with increased arterial stiffness in predialysis
C Lal, M Kaur, AK Jaryal, KK Deepak, D Bhowmik, SK Agarwal
November-December 2017, 27(6):446-451
DOI:10.4103/ijn.IJN_63_17  PMID:29217881
High cardiovascular morbidity and mortality is observed in predialytic chronic kidney disease (CKD) patients. The underlying mechanism of cardiovascular dysfunction often remains unclear. The present study was designed to perform multiparametric assessment of baroreflex sensitivity (BRS), arterial stiffness indices, and cardiovascular variabilities (heart rate variability [HRV] and blood pressure variability [BPV]) together in predialytic CKD patients; compare it with normal healthy controls; and determine their relationships in predialytic nondiabetic CKD patients. Thirty CKD Stage 4 and 5 predialytic non-diabetic patients and 30 healthy controls were enrolled in the study. BRS was determined by spontaneous sequence method. Short-term HRV and BPV were assessed using 5 min beat-to-beat data of RR intervals and blood pressure by time domain and frequency domain analysis. Arterial stiffness indices - carotid-femoral pulse wave velocity (PWV) and augmentation index - were measured using SphygmoCor Vx device (AtCor Medical, Australia). Predialytic CKD patients had significantly low BRS, high PWV, and low HRV as compared to healthy controls. Independent predictors of reduced systolic BRS in predialytic CKD patient group on multiple regression analysis emerged to be increase in calcium-phosphate product, increase in BPV, and decrease in HRV. Predialytic nondiabetic CKD Stage 4 and 5 patients have poor hemodynamic profile (higher PWV, lower HRV, and reduced BRS) than healthy controls. Reduced HRV and altered calcium-phosphate homeostasis emerged to be significant independent predictors of reduced BRS.
  540 61 -
LETTERS TO EDITOR
Strongyloid hyperinfection syndrome in a renal transplant recipient
S Sriperumbuduri, K Kalidindi, S Guditi, G Taduri
November-December 2017, 27(6):487-488
DOI:10.4103/ijn.IJN_246_16  PMID:29217893
  504 72 -
CASE REPORTS
Bowel migration of dormant chronic ambulatory peritoneal dialysis catheter: A vexed problem not avoided by flushing
P Vincent, J Gopinathan, R Narayanan
November-December 2017, 27(6):484-486
DOI:10.4103/ijn.IJN_268_16  PMID:29217892
Delayed bowel erosion by peritoneal dialysis catheter is rare with fewer than thirty cases having been reported in the literature. This complication is usually encountered when the catheter is kept dormant. Two cases have also been reported with catheters in active use. The risk factors for bowel erosion include immunosuppression, diverticulosis, and amyloidosis. An 80-year-old male with chronic kidney disease Stage 5 due to hypertensive nephrosclerosis underwent chronic ambulatory peritoneal dialysis catheter insertion. Due to improvement in the glomerular filtration rate and clinical parameters including extracellular fluid volume status, peritoneal dialysis was not initiated. Weekly catheter flushes were performed. After 5 months, he developed watery diarrhea after a regular flushing episode. Computed tomography scan revealed the catheter displaced into the sigmoid colon with the tip in the rectum. He was managed successfully with catheter removal alone and conservative treatment. He remains asymptomatic at 3-month follow-up. This case is presented to emphasize the fact that delayed bowel erosion can happen with dormant catheter even in the absence of risk factors. Periodic flushing has not prevented this complication in our patient. Perforations can be self-curing when diagnosed early and when patients present without features of peritonitis or sepsis. Such cases can be managed successfully with catheter removal alone.
  529 44 -
LETTERS TO EDITOR
Streptococcus gallolyticus subsp. pasteurianus peritonitis in a patient on continuous ambulatory peritoneal dialysis
M Shanmuganathan, BL Goh, C.T.S. Lim
November-December 2017, 27(6):488-489
DOI:10.4103/ijn.IJN_245_16  PMID:29217894
  417 40 -
Indian Journal of Nephrology
Published by Wolters Kluwer - Medknow
Online since 20th Sept '07