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   2018| September-October  | Volume 28 | Issue 5  
    Online since September 10, 2018

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Spectrum of hypokalemic paralysis from a tertiary care center in India
G Chandramohan, T Dineshkumar, R Arul, M Seenivasan, J Dhanapriya, R Sakthirajan, T Balasubramaniyan, N Gopalakrishnan1
September-October 2018, 28(5):365-369
DOI:10.4103/ijn.IJN_225_17  PMID:30270997
Hypokalemic paralysis is an important and reversible cause of acute flaccid paralysis. The treating physician faces unique diagnostic and therapeutic challenges. We did a prospective study and included all patients with acute flaccid weakness and documented serum potassium of <3.5 mEq/L during the period between January 2009 and August 2015. We studied the incidence, etiology, clinical profile, and acid–base disturbances in patients presenting with hypokalemic paralysis and analyzed the significance of periodic and non-periodic forms of hypokalemic paralysis on patient's outcome. Two hundred and six patients were studied with a mean follow-up of 3.6 ± 1.2 years. Mean age was 37.61 ± 2.2 years (range 18–50 years). Males were predominant (M:F ratio 2.1:1). The nonperiodic form of hypokalemic paralysis was the most common (61%). Eighty-one (39%) patients had metabolic acidosis, 78 (38%) had normal acid–base status, and 47 (23%) patients had metabolic alkalosis. The most common secondary cause was distal renal tubular acidosis (RTA) (n = 75, 36%), followed by Gitelman syndrome (n = 39, 18%), thyrotoxic paralysis (n = 8, 4%), hyperaldosteronism (n = 7, 3%), and proximal RTA (n = 6, 4%). Patients with non-periodic paralysis had more urinary loss (40.1 vs. 12.2 mmol, P = 0.04), more requirement of potassium replacement (120 vs. 48 mmol, P = 0.05), and longer recovery time of weakness (48.1 vs. 16.5 h, P = 0.05) than patients with periodic paralysis. Non-periodic form of hypokalemic paralysis was the most common variant in our study. Patients with periodic paralysis had significant incidence of rebound hyperkalemia.
  3,473 183 -
Effect of hemodialysis on corrected QT interval and QTc dispersion
PM Sohal, A Goel, D Gupta, N Aslam, J Sandhu, JS Sandhu, EE John, D Sharma
September-October 2018, 28(5):335-338
DOI:10.4103/ijn.IJN_15_18  PMID:30270992
Hemodialysis patients are at higher risk of cardiovascular disease due to traditional and dialysis-related risk factors. Our aim was to study the effects of hemodialysis on the corrected QT interval (QTc) and QTc dispersion in chronic kidney disease (CKD) without clinically manifest heart disease. Two hundred cases of CKD on chronic intermittent hemodialysis of >3 months' duration were included in the study. Twelve-lead electrocardiography and samples for serum creatinine, potassium, calcium, and magnesium were taken before and after dialysis. The mean age of patients was 52.4 ± 17 years with male-to-female ratio of 3:1. QTc interval and QTc dispersion were prolonged in 47% and 59% before and 50% and 89% of patients after hemodialysis, respectively. The mean values of QTc were 433.4 ± 36.9 ms before and 451.4 ± 39.6 ms after hemodialysis (p = 0.001) and the mean values of QTc dispersion were 60.5 ± 19.3 ms before and 81.5 ± 24.4 ms after hemodialysis (p = 0.001). Similar pattern was observed in all etiological groups of CKD, except for QTc dispersion in malignancy-related CKD (p = 0.216). After hemodialysis, there was a significant fall in the mean values of serum potassium (p = 0.001), rise in serum calcium (p = 0.001), and no change in magnesium (p = 0.424). Patients with post hemodialysis QTc dispersion >74 ms had significantly low mean values of serum potassium and calcium as compared to <74 ms group. Large numbers of hemodialysis patients have a prolonged QTc interval and QTc dispersion with a significant increase in the mean values after hemodialysis. There is a significant fall in serum potassium and rise in serum calcium after dialysis.
  3,185 261 -
Efficacy and cost comparison of ertapenem as outpatient parenteral antimicrobial therapy in acute pyelonephritis due to extended-spectrum beta-lactamase-producing Enterobacteriaceae
V Ramasubramanian, P Murlidharan, S Nambi, S Pavithra, S Puthran, T Petigara
September-October 2018, 28(5):351-357
DOI:10.4103/ijn.IJN_207_17  PMID:30270995
Outpatient parenteral antimicrobial therapy (OPAT) programs are becoming an increasingly popular trend in clinical practice as they offer several benefits to both patients and health-care setups. While OPAT is an established clinical practice in the Western world, the concept itself is alien to patients in India as they prefer the security of hospitals to receive antibiotics over OPAT. We evaluated the clinical response and cost comparison of ertapenem under OPAT versus inpatient settings in patients with extended-spectrum beta-lactamase (ESBL)-positive acute pyelonephritis (APN) given the increasing importance of optimizing both hospital beds and overall cost of patient care in India. APN was chosen as the indication to be studied as it is one of the common complicated urinary tract infections treated in our OPAT unit requiring 10–14 days of parenteral therapy with an agent active against various Gram-negative bacilli and multidrug-resistant organisms. One hundred patients were retrospectively studied based on whether antibiotics were administered during hospital stay alone (hospital only), during both hospital stay, and also as OPAT post discharge (hospital/OPAT) or as OPAT alone (OPAT only). Response to ertapenem and cost of treatment in inpatient versus OPAT settings were compared using Pearson's Chi-square or Fisher's exact test for categorical variables. ANOVA (or Kruskal–Wallis) was used for continuous variables. Baseline urine cultures were ESBL positive with 98% prevalence of Gram-negative bacilli (GNB). Colony counts were ≥100,000 in 74% patients. Only ertapenem, imipenem, and meropenem showed 100% sensitivity to ESBL-positive GNB in baseline urine culture and sensitivity reports. Ertapenem showed 100% sensitivity and complete clinical resolution for 96% patients with APN due to ESBL Enterobacteriaceae. It was administered as OPAT in 90% patients and significantly reduced overall treatment costs.
  3,020 125 -
Relationship of creatinine and cystatin C-based estimated glomerular filtration rates with measured glomerular filtration rate in healthy kidney donors from South Asia
S Kakde, S Alexander, VG David, S Jacob, A Mohapatra, AT Valson, B Gopal, CK Jacob, J Hephzibah, V Tamilarasi, S Varughese
September-October 2018, 28(5):345-350
DOI:10.4103/ijn.IJN_249_17  PMID:30270994
Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation is currently recommended for the estimation of glomerular filtration rate (GFR). This retrospective study aimed to evaluate the correlation between creatinine and cysC-based estimated GFRs and measured GFR in healthy adults. Consecutive healthy adults who were accepted as voluntary kidney donors at our center between January 2008 and December 2012 were included in the study. The 336 individuals who comprised the study population had a mean age of 41.6 ± 11.8 years, male:female ratio 1:1.7, mean creatinine 0.9 ± 0.1 mg/dl, and mean cysC 0.8 ± 0.1 mg/dl. Mean measured GFR by Tc-99m diethylenetriaminepentaacetic acid using Gates method was 98.4 ± 21.2 ml/min/1.73 m2. The mean ± standard deviation of eGFRs by various formulae were as follows: Cockcroft–Gault (CG) = 88.1 ± 15.9 ml/min/1.73 m2, Modification of Diet in Renal Disease (MDRD) = 78 ± 14.7 ml/min/1.73 m2, CKD-EPI creatinine = 88.1 ± 15.5 ml/min/1.73 m2, CKD-EPI cysC = 97 ± 19.9 ml/min/1.73 m2, CKD-EPI creatinine-cysC (CKD-EPI cr-cysC) = 92.5 ± 14.1 ml/min/1.73 m2. The CKD-EPI cr-cysC equation had the highest accuracy, with 43% and 72% of values lying within ±10% and ±20% of the measured GFR, respectively. Bland–Altman analyses for levels of agreement showed least bias with CKD-EPI cysC overall and among females, while among males, CKD-EPI creatinine equation had the least bias. The CKD-EPI equation showed a higher performance than the MDRD and CG equation in GFR estimation of a healthy population. Among CKD-EPI equations, CKD-EPI cr-cysC had the highest accuracy and CKD-EPI cysC the least bias.
  2,955 159 -
Development of an experimental model of a decellularized kidney scaffold by perfusion mode and analyzing the three-dimensional extracellular matrix architecture by edge detection method
SI Almelkar, S Bethapudi, SN Rath
September-October 2018, 28(5):339-344
DOI:10.4103/ijn.IJN_14_17  PMID:30270993
Renal transplant is treatment of choice for the patients with end stage renal disease. The kidney transplants are expensive and there are risks of immunological and infectious complications. We planned to develop an in vitro decellularized kidney scaffold model using sheep kidney. Kidney decellularization was carried out by perfusing chemical detergents such as sodium dodecyl sulfate (SDS), SDS and trypsin, and SDS and ethylenediaminetetraacetic acid solvent solution. Complete kidney was decellularized in 5 days by perfusing various chemical detergents in time-dependent intervals. Histological finding revealed the complete removal of cellular material in various regions of renal corpuscle, distal convoluted tubules, other cortex and medulla region. Details of interlobular veins and arteries were seen through naked eyes after trypan blue dye injection. We used edge detection technique for developing a three-dimensional (3-D) image (Image J software) for nephrological vasculature constructed of decellularized kidney scaffold specimen. This technique opens a gateway for the whole organ decellularization by perfusion technology and further imaging of its 3-D extracellular matrix texture by edge detection technique software.
  2,729 113 -
Warfarin-related nephropathy
Anvesh Golla, R Goli, VK Nagalla, BV Kiran, D. S. B Raju, MS Uppin
September-October 2018, 28(5):378-381
DOI:10.4103/ijn.IJN_3_17  PMID:30271000
Warfarin-related nephropathy also referred to as anticoagulant-related nephropathy (ACRN) is a type of acute kidney injury (AKI) that may be caused by excessive anticoagulation with warfarin and other anticoagulants. Despite the well-described histological entity, the clinical course and approach to ACRN in patients requiring life-long anticoagulation are however not well described in the literature. We report a 50-year-old Indian woman who was on prolonged anticoagulant therapy post-mitral valve replacement. She presented with AKI, and renal biopsy was suggestive of ACRN. Steroids were given and her creatinine levels reached within the normal range in 2 weeks. A presumptive diagnosis of ACRN should be made if a severe warfarin coagulopathy is present and if other causes of AKI have been excluded, in patients with chronic anticoagulant therapy. Renal function should be monitored regularly in patients who are on anticoagulant therapy.
  2,555 132 -
Osteopontin, cardiovascular risk factors and carotid intima-media thickness in chronic kidney disease
V Chaitanya, N Harini Devi, MM Suchitra, P. V. L. N Srinivasa Rao, B Vijaya Lakshmi, V Siva Kumar
September-October 2018, 28(5):358-364
DOI:10.4103/ijn.IJN_321_17  PMID:30270996
The pleiotropic cytokine osteopontin (OPN) is found to be involved in the pathogenesis of both kidney and cardiovascular disease (CVD). We evaluated the relationship between OPN, other cardiovascular risk factors and carotid intima-media thickness (CIMT) in chronic kidney disease (CKD) (predialysis) patients. This is a 2-year cross-sectional prospective study involving 75 patients with CKD from stage 1 to stage 5 attending the nephrology outpatient department and 25 healthy controls. Routine biochemical parameters were analyzed on clinical chemistry Autoanalyzer Beckman Coulter DXC 600 Synchron, USA. OPN was estimated by ELISA method. Carotid intima-media wall thickness was estimated by Doppler of carotid vessels. Serum OPN and other nontraditional cardiovascular risk factors such as CIMT, lipoprotein (a) Lp(a), fibrinogen, and homocysteine were significantly increased in patients of CKD compared to controls. OPN, Lp(a), fibrinogen, CIMT, parathyroid hormone, and homocysteine progressively increased from early stages of CKD and increased further with progression of the disease, but nitric oxide (NO) level progressively decreased with progression of CKD. OPN showed a positive correlation with CIMT, Lp(a), fibrinogen, and homocysteine and negative correlation with estimated glomerular filtration rate and NO. There was a close direct association between circulating levels of OPN and the presence of atherosclerotic plaques in carotid arteries of patients with CKD. Osteopontin and nontraditional CVD risk factors are altered in early stages of CKD and might predict adverse outcomes in these patients.
  2,385 115 -
Posttransplant lymphoproliferative disorder: Experience from a pediatric nephrology unit in North India
RW Thergaonkar, S Bhardwaj, A Sinha, AK Dinda, R Kumar, A Bagga, RN Srivastava, P Hari
September-October 2018, 28(5):374-377
DOI:10.4103/ijn.IJN_143_17  PMID:30270999
Posttransplant lymphoproliferative disorder (PTLD) is reported in 1%–3% among pediatric renal allograft recipients. We report the experience of PTLD among pediatric renal allograft recipients at a pediatric nephrology center in North India. Four cases of PTLD were identified from among records of 95 pediatric renal allograft recipients over a period of 21 years. Constitutional and localizing symptoms were present in three patients each. The diagnosis was suggested on positron emission tomography in three patients and confirmed by histopathology in all. Sites affected included tonsils, cervical lymph nodes, duodenum, and para-aortic lymph nodes in one patient each. The lymphocytic infiltrate was polymorphic in three patients and monomorphic in one. Immunostaining suggested B-cell origin in all patients. There was evidence of Epstein–Barr virus infection in only one patient. The patients were successfully managed with reduction of immunosuppression (in all), rituximab (in 3), and excision of affected tissue (in 1). Over a follow-up period of 30–88 months, there were no episodes of disease recurrence or allograft rejection, and renal function was preserved.
  2,240 105 -
Adenovirus interstitial nephritis: An unusual cause for early graft dysfunction
G Seralathan, AA Kurien
September-October 2018, 28(5):385-388
DOI:10.4103/ijn.IJN_218_16  PMID:30271002
We describe a rare case of adenovirus interstitial nephritis in a 37-year-old man, 4 weeks following deceased donor renal transplantation. He presented with gross hematuria and acute graft dysfunction. A renal biopsy revealed necrotizing tubulointerstitial nephritis with intranuclear viral inclusions in the tubular epithelial cells. Immunohistochemistry and polymerase chain reaction confirmed adenovirus infection. Reduction in immunosuppression alone resulted in rapid improvement of graft function. Awareness of the clinical and characteristic biopsy findings may help establish the correct diagnosis, which is crucial as disseminated infection, if left untreated, is associated with a high mortality rate in renal allograft recipients.
  2,117 142 -
Head drop and flaccid weakness in infantile nephrotic syndrome
GS Dhooria
September-October 2018, 28(5):382-384
DOI:10.4103/ijn.IJN_198_16  PMID:30271001
Dropped head syndrome (DHS) is a relatively rare condition, with a broad differential diagnosis. We report here a case of infantile nephrotic syndrome with DHS caused by severe hypokalemia. Electrocardiogram showed flat T- and U-waves. Multiple factors including recurrent diarrhea, prolonged diuretic and corticosteroid use, hypomagnesemia, poor intake, and malnutrition caused hypokalemia in the case. Head drop and flaccid weakness resolved completely after potassium and magnesium supplementation. Potassium levels should be monitored and corrected promptly in these settings.
  2,167 82 -
Coronary angiography profile at the time of hemodialysis initiation in end-stage renal disease population: A retrospective analysis
M Surendra, S Raju, KK Mukku, CH Ved Prakash, N Raju
September-October 2018, 28(5):370-373
DOI:10.4103/ijn.IJN_271_17  PMID:30270998
Cardiovascular disease is associated with increased mortality in dialysis population. However, there are very few studies that assessed the prevalence of coronary artery disease (CAD) at the time of initiation of hemodialysis (HD). The present study was aimed to assess the prevalence of CAD in end-stage renal disease (ESRD) patients at the time of initiation of HD and the risk factors for CAD in this population. This was a single-center retrospective study and included ESRD patients who underwent coronary angiography (CAG) at the time of initiation of HD. Inclusion criteria were age >18 years and those who were subjected to CAG within 2 weeks of initiation of HD. According to the findings on CAG, patients were divided into no CAD and CAD groups. CAD was diagnosed if there was >50% stenosis of vessel. Clinical and laboratory parameters between these two groups were analyzed. Ninety-seven patients were included in the study based on the inclusion criteria. Forty-four (45%) patients were diagnosed with CAD. Patients who had CAD were younger compared to no CAD group (50.7 + 10 vs. 55.8 + 9.3 years; P = 0.01). Majority of them were males. Diabetic nephropathy (DN) was associated with increased risk of CAD (60% vs. 40%, P = 0.007). History of smoking, high high-sensitivity C-reactive protein (hs-CRP), low total cholesterol, and low high-density lipoprotein (HDL) were associated with significantly increased risk of CAD. Gender, symptoms of CAD, serum low-density lipoprotein (LDL), very LDL, and triglycerides were not associated with increased risk of CAD. Neither calcium (Ca), phosphorus (PO4), nor Ca × PO4products were associated with an increased risk of CAD. Resting electrocardiogram abnormalities had no significance in predicting CAD (32% in CAD and 19% in no CAD group). Echocardiography showed regional wall motion abnormalities/global hypokinesia in 18% patients of CAD group and 3.8% patients of no CAD group (P = 0.03). Single-, double-, and triple-vessel disease was documented in 17 (38%), 13 (29.5%), and 14 (32.5%) patients, respectively, and the most common vessel involved was the left anterior descending artery. At the initiation of HD in ESRD patients, CAD was seen in almost half of the patients. DN was a significant risk factor for CAD. Other risk factors for CAD include smoking, low cholesterol, low HDL, and high hs-CRP levels.
  2,058 100 -
Membranous nephropathy in a patient with charcot-marie-tooth disease: Association of myelin mutations
U Anandh, R Nikalji, A Parick
September-October 2018, 28(5):397-400
DOI:10.4103/ijn.IJN_113_17  PMID:30271005
A 40-year-old female presented to the neurologist with gradually progressive weakness of distal and proximal muscles of both lower limbs and cramps for 2 years. She gave a history of similar illness in her paternal grandmother and her father. Her examination revealed bilateral foot drop and mild proximal muscle weakness. She was diagnosed to have peripheral neuropathy and subsequently treated conservatively. Over the next year, she noticed progressive swelling of both lower limb and frothy urine. A nephrology consultation was obtained, and a renal biopsy was done, which showed membranous nephropathy. She was started on steroids and subsequently on tacrolimus as the proteinuria progressively worsened. Her anti-phospholipase A2 receptor antibody was negative both in blood and in the kidney biopsy tissue. A search for a genetic basis of this rare clinical condition was made, and heterozygous mutation was detected in the myelin gene. This mutation was confirmed with genetic sequencing. The mutation is associated with MPZ gene and is associated with multiple hereditary sensorimotor neuropathy. MPZ knockout mice have been shown to have increased glomerular permeability and proteinuria.
  2,021 76 -
Early eosinophilic antibody-mediated rejection in a renal allograft recipient
H Satish, Sreejith Parameswaran, BH Srinivas, NG Rajesh, R Jayasurya, Rajesh Padhi, PS Priyamvada
September-October 2018, 28(5):389-392
DOI:10.4103/ijn.IJN_102_17  PMID:30271003
Although the predominant component of acute allograft rejection is the T-cells, the milieu is not devoid of other inflammatory cells including plasma cells, eosinophils, and histiocytes. Apart from the CD8 T cell and CD4 T cell-FasL cytotoxicity, experimental models had proven a pivotal role of Th-2 cells in acute rejection, and these have been associated with marked tissue eosinophilia. Herein, we present a unique case of severe eosinophilic acute antibody-mediated rejection in a 22 years old deceased donor renal allograft recipient, within 4 days of transplantation without peripheral eosinophilia. The pathology was successfully dealt with the prevailing modalities of therapy, including steroids, plasmapheresis, intravenous immunoglobulin, and bortezomib. Concurrently, we have briefly reviewed the literature about the role of eosinophils in graft rejection and its prognostication.
  1,945 121 -
Time to revisit the use of nontunneled dialysis vascular catheters even in cost-limited setting
J Sethi, S Bagai, R Ramachandran, V Kumar, M Rathi, HS Kohli, KL Gupta
September-October 2018, 28(5):406-407
DOI:10.4103/ijn.IJN_443_17  PMID:30271008
  1,646 103 -
IgA nephropathy in a patient with IgG myeloma
B Sangeeta Lakshmi, SV Padmavathi Devi, N Sai Sameera, A Sunnesh Reddy, R Ram, Vishnubotla Siva Kumar
September-October 2018, 28(5):404-406
DOI:10.4103/ijn.IJN_377_17  PMID:30271007
  1,659 69 -
Successful treatment of renal infiltration complicated by atypical hemolytic uremic syndrome in a leukemic child
Ö E Ozmen, N Alici, B Topuz, M Akgül, E Akkuzu, Ö Akdemir, N Buyan, S Göral, Z Kaya
September-October 2018, 28(5):401-403
DOI:10.4103/ijn.IJN_211_17  PMID:30271006
Renal infiltration in children with acute leukemia has been reported previously; however, it has rarely been described in association with atypical hemolytic uremic syndrome (aHUS). We present a case of 9-year-old boy who developed life-threatening aHUS in the 1st week of Burkitt leukemia/lymphoma diagnosis with renal infiltration. Complete resolution of aHUS was achieved after therapeutic plasma exchange. This is an uncommon complication of Burkitt leukemia/lymphoma in a pediatric case.
  1,626 70 -
Anti A/B antibody titer rebound: Are we making it worse? Be aware of your intravenous immunoglobulin
A Kher, A Agarwal, P Jha, D Bansal, M Madken, AS Narula, R Khurana, V Kher
September-October 2018, 28(5):407-409
DOI:10.4103/ijn.IJN_230_17  PMID:30271009
  1,606 83 -
Late posttransplant lymphoproliferative disease: Report of a rare case and role of positron emission tomography-computed tomography
P Yadav, N Kumar, N Prasad, H Lal
September-October 2018, 28(5):393-396
DOI:10.4103/ijn.IJN_262_17  PMID:30271004
Posttransplant lymphoproliferative disease (PTLD) is an uncommon complication of immunosuppression after solid organ transplantation. Early PTLD (<1 year after transplantation) is frequently found around the allograft, whereas late PTLD (>1 year after transplantation) does not have such a preference. 18-Fluorodeoxyglucose positron emission tomography-computed tomography (18FDG PET-CT) has clinical significance in the evaluation of PTLD. 18FDG PET-CT scan allows precise anatomic localization of FDG-avid lesions, hence helpful in staging of disease and evaluation of response to therapy. It can better characterize persistent lesions and differentiate residual tumor from fibrosis or necrosis. We present a rare case report of a perigraft PTLD developing 12 years after renal transplantation sparing the graft, in an Epstein–Barr virus-negative patient.
  1,556 70 -
Indian Journal of Nephrology
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