Anand Yuvaraj

Rare occurrence of fatal Candida haemulonii peritonitis in a diabetic CAPD patient.

Abstract A 68-year-old diabetic chronic kidney disease patient on continuous ambulatory peritoneal dialysis for two years developed Candida haemulonii peritonitis without any predisposing factors. There is no effective treatment for this fungus. A peritoneal biopsy showed morphological changes of acute inflammation and chronicity.

Nutritional status in stage V dialyzed patient versus CKD patient on conservative therapy across different economic status

Abstract Background: This aim of this multi-centric cross-sectional study was to assess the nutritional status in Indian chronic kidney disease (CKD) patients and to compare the nutritional indicators between stage 5 dialyzed (CKD-D) patients below the poverty line (BPL), and stage 3–4 non-dialyzed (CKD-ND) patients above (APL) and below the poverty line. Methods: Patients were selected from a government medical college hospital, a charity-based outpatient dialysis unit, and a non-profit tertiary care center. The study groups included BPL CKD-ND (n = 100), BPL CKD-D (n = 98), and APL CKD-ND (n = 92) patients, based on a cut-off of per capita income US

State of deceased donor transplantation in India: A model for developing countries around the world

1.25 a day. Patients were enquired by a qualified renal dietitian about their pattern of diet, and daily energy and protein intake by 24 h recall method. Anthropometric measurements and biochemical investigations were made and compared. Results: Nutritional indicators were low in all three groups compared to those prescribed by European Best Practice Guidelines (EBPG). BPL CKD-D patients had low serum albumin levels (32.44444 ± 6.279961 g/L; p = 0.017) and 41.83% of them were underweight. The APL CKD-ND group registered the lowest mean daily energy (22.576 ± 6.289 kcal/kg/day) and protein intake (0.71 ± 0.06 g/kg/day), due to dietary restrictions imposed on them by themselves and unqualified renal dietitians. The APL group had better indicators of nutritional status in terms of mid-upper arm circumference (p = 0.001), triceps skin fold thickness (p < 0.001), and serum hemoglobin (p < 0.001). Conclusion: Several nutritional parameters were below the recommended international guidelines for all the three groups, though the high income group had better parameters from several indicators. There is an urgent need for nutritional counseling for CKD-D and CKD-ND patients.

Effect of high-protein supplemental therapy on subjective global assessment of CKD-5D patients.

Renal replacement therapy (RRT) resources are scarce in India, with wide urban-rural and interstate disparities. The burden of end-stage renal disease is expected to increase further due to increasing prevalence of risk factors like diabetes mellitus. Renal transplantation, the best RRT modality, is increasing in popularity, due to improvements made in public education, the deceased donor transplantation (DDT) programme and the availability of free and affordable transplant services in government hospitals and certain non-governmental philanthropic organizations. There are about 120000 haemodialysis patients and 10000 chronic peritoneal dialysis patients in India, the majority of them waiting for a donor kidney. Shortage of organs, lack of transplant facilities and high cost of transplant in private facilities are major barriers for renal transplantation in India. The DDT rate in India is now 0.34 per million population, among the lowest in the world. Infrastructural development in its infancy and road traffic rules not being strictly implemented by the authorities, have led to road traffic accidents being very common in urban and rural India. Many patients are declared brain dead on arrival and can serve as potential organ donors. The DDT programme in the state of Tamil Nadu has met with considerable success and has brought down the incidence of organ trade. Government hospitals in Tamil Nadu, with a population of 72 million, provide free transplantation facilities for the underprivileged. Public private partnership has played an important role in improving organ procurement rates, with the help of trained transplant coordinators in government hospitals. The DDT programmes in the southern states of India (Tamil Nadu, Kerala, Pondicherry) are advancing rapidly with mutual sharing due to public private partnership providing vital organs to needy patients. Various health insurance programmes rolled out by the governments in the southern states are effective in alleviating financial burden for the transplantation. Post-transplant immunological and pathological surveillance of recipients remains a challenge due to the scarcity of infrastructure and other facilities.

Diagnostic dilemma of ultrafiltration failure in a continuous ambulatory peritoneal dialysis patient.

Adequate nutrition in patients on hemodialysis is an important step for improving the quality of life. This prospective study was undertaken to monitor the nutritional status of patients who were given high‐protein supplements on malnutrition inflammation score (MIS) and to correlate with biochemical parameters in maintenance hemodialysis (MHD) patients. This prospective study was conducted on 55 chronic kidney disease patients on MHD (37 women, 18 men), aged between 21 and 67 years. Of the 55 patients, 26 patients received high‐protein commercial nutritional supplements, whereas 29 patients received high‐protein kitchen feeding. Every patient had their MIS, 24‐hour dietary recall, hand grip, mid arm circumference, triceps skin‐fold thickness at 0, 3, and 6 months. Each of the above parameters was compared between the high‐protein commercial nutritional supplement cohort and high‐protein kitchen feeding cohort, and the data were analyzed. Of the 55 patients, 82.61% of patients on high‐protein kitchen feeding group and 66.67% in high‐protein commercial nutritional supplement group were nonvegetarian (P = 0.021). According to the MIS, improvement was observed in malnutrition status from 3‐ to 6‐month period in 38.1% of patients in high‐protein commercial supplement group, whereas only in 8.7% in high‐protein kitchen feeding group (P = 0.04). Assessment showed improvement in malnutrition status with high‐protein commercial nutritional supplement, which was marked in patients with age group >65 years (P = 0.03) and in those in whom serum albumin is <35 g/L (P = 0.02). Both high‐protein kitchen feeding and high‐protein commercial nutritional supplement cohorts were observed to have improvement in overall nutritional status. Older patients >65 years with lower serum albumin levels (<3.5 g/dL) were observed to have significant improvement in nutritional status with high‐protein commercial nutritional supplements.

Renal allograft eosinophilia: An unusual presentation of sudden graft dysfunction

A 42-year-old male with chronic kidney disease (CKD), stage 5 on continuous ambulatory peritoneal dialysis (CAPD) using a swan-neck double-cuff Tenckhoff catheter presented with abdominal pain, vomiting, nausea and reduced appetite for 1 month, along with a poor dialysate outflow and ultrafiltration failure (< 400mL/day) for 20 days. As stated by the patient, dialysate effluent was clear. Abdominal examination was unremarkable. After a 6-hour dwell, the dialysate showed a leucocyte count of 0.17 x 109/L (170 cells) with 0.75 (75%) neutrophils and 0.24 (24%) lymphocytes, Gram stain negative, acid-fast bacilli (AFB) smear negative and no growth on Lowenstein and Jensen culture medium. The Mantoux test done was unremarkable. Blood urea nitrogen was 12 mmol/L (33 mg/dL), serum creatinine 954 μmol/L (10.8 mg/dL), hemoglobin (Hb) 88 g/L (8.8 g/dL), erythrocyte sedimentation rate (ESR) 140 mm/hr, serum albumin 24 g/L(2.4 g/dL), electrolytes were normal. As the outflow was slow, an erect X-ray of the abdomen showed migration of the catheter (Figure 1), and a laproscopic examination showed intraperitoneal catheter with fibrinous exudates and adhesions (Figure 2), which were released. A peritoneal biopsy was done that showed granuloma with Langhans’ type giant cell suggestive of tuberculosis (Figure 3), and the biopsy specimen stained with Ziehl Neelsen stain showed acid-fast tubercle bacillus (Figure 4). A computed tomography (CT) of the chest showed left basal pulmonary scarring, small calcified right apical nodule, and calcified mediastinal nodules suggestive of pulmonary tuberculosis sequelae. The patient was initiated on rifampicin 450 mg OD, pyrazinamide 750 mg BID, ciprofloxacin 500 mg BID, isoniazid 150 mg OD, along with vitamin B6. Dialysate flow and ultrafiltration improved 7 days after starting the medication and the dialysate cell count returned to normal.

Sjogren’s with distal renal tubular acidosis complicating pregnancy

We present a case of sudden allograft dysfunction 11 months after renal transplantation which presented as severe peripheral and allograft eosinophilia and was managed as a case of an acute cellular rejection with significant interstitial graft eosinophilic infiltration. Patient had partial response to antirejection therapy and eventually ended up in a chronic allograft dysfunction.

Occurrence of double primary malignancies in an African renal transplant recipient.

A 33-year-old multiparous lady (G5P2L2A2) presented at 21weeks of gestation with complaints of profound lower limb muscle weakness and dryness of mouth. She had no illness diagnosed prior to the first pregnancy. Both previous pregnancies were caesarean deliveries at 36 and 37weeks gestation with birth weight of 2.4 and 2.6 kg, girls who are alive and well. After her first delivery, the immediate post-operative period was complicated by weakness of the both lower limbs with low serum potassium (Kþ) which had been treated with oral potassium chloride (KCl) syrup. Since then, she had recurrent episodes of similar weakness that improved with KCl supplementation. USG abdomen showed bilateral renal calculi, with no history of passage of stones in the urine. She had nocturia without polyuria. Her evaluation at 21weeks gestation revealed haemoglobin (Hb) 103 g/L (10.3 g/dl), serum creatinine 48.62 micromol/L (0.55mg/dl), Kþ 2.4mmol/ L (2.4mEq/L), sodium 134mmol/L (134 mEq/L), chloride 115mmol/L (115mEq/L), bicarbonate (HCO3) 14mmol/L (14mEq/L), plasma anion gap 5, urine pH 8, urine Kþ 35mmol/L (35mEq/L), albumin 29 g/L (2.9 g/dl), corrected serum calcium 1.95mmol/L (7.8mg/dl), phosphorous 0.71mmol/L (2.2mg/dl), 25(OH) vitamin D 36.94 nmol/L (14.8 ng/ml), TSH 4.17mIU/L, ESR 91mm/h and CRP 47.62 nmol/L (5mg/dl). At 21st week first hospital antenatal visit, her BMI was 15.6 kg/m. The patient was vague in her description of symptoms. She had difficulty in walking and required assistance for minor chores. Her sitting BP was 90/70mmHg. Foetal scan revealed a single foetus with biometry at 5% for gestation and no gross anomalies. Long spells of foetal bradyarrhythmia at 68–72 beats/min due to atrial premature beats were noted as shown in Figure 1(a). There was a normal amount of amniotic fluid and uterine artery Doppler flow pattern. Abdominal scan showed bilateral nephrocalcinosis, as shown in Figure 1(b). SSA antibody was positive by ELISA, ANA and ds DNA, SSB were negative. Hence, renal tubular acidosis secondary to Sjogren’s syndrome was the most possible cause. Her medication was replaced with oral potassium citrate 15ml tid and sodium bicarbonate (NaHCO3) 1 gm tid. Symptomatic improvement in physical activity was observed, with serum HCO3 of 13-14mmol/L(mEq/L) and serum Kþ 4.1mmol/L(mEq/L). Serial scans showed normal interval growth velocity at 5% of gestation, after 27weeks normal foetal heart rates was seen on scan. As she experienced spontaneous labour pains, emergency caesarean was performed at 36weeks. The cardiotocograph for 60minutes prior to delivery was non-reassuring with reduced variability and sporadic decelerations. Preoperative serum HCO3 and Kþ levels were 16mmol/L(mEq/L) and 3.5mmol/L(mEq/L), respectively. Infusions of NaHCO3 and KCl were administered during the caesarean and maintained for the first 24 hours postoperatively. At delivery, the cord blood venous and arterial analysis were normal with no evidence of acute or chronic hypoxia and all intra-operative findings were unremarkable. The placenta separated spontaneously with oxytocin 10 units bolus dose at delivery and blood loss was minimal. Bilateral Tubal ligation was performed with prior informed consent. A live baby girl of 1.98 kg was delivered with normal heart rate and rhythm and the blood tests showed Hb 203 g/L (20.3 g/dl), blood pH of 7.3, serum HCO3 23mmol/L (mEq/L), serum Kþ 4.4mmol/L (mEq/L). On the 2nd postoperative day, the patient was recommenced oral NaHCO3 500mg thrice daily and potassium citrate 15ml thrice daily. She was discharged with serum Kþ of 4.1mmol/L(mEq/L), HCO3 23mmol/L(mEq/L), creatinine 48.62 micromol/L (0.55mg/dl) and Hb 103 g/L (10.3 g/dl). At the 8th week postnatal follow-up, mother was stable with a BMI of 16.3 kg/m, serum Kþ 4.1mmol/L (mEq/L), serum HCO3 16mmol/L (mEq/L). She continued on oral potassium citrate and supplements. The newborn was on breastfeed and had gained weight to 3.7 kg. Care provided by a joint multidisciplinary team of the renal, obstetric, rheumatology, neonatology, paediatric cardiologist, anaesthetic

A maintenance hemodialysis diabetic patient with unexplained pulmonary and gastrointestinal involvement

A 63-year-old African male with end stage renal disease who received a renal transplantation from his daughter after successful treatment of hepatitis C virus, type 1 genotype developed metastatic Kaposis sarcoma and subsequently adenocarcinoma of the prostate. He was successfully treated with chemotherapy and reduction of immunosuppression and switch over to rapamycin.

Case Report: Rare occurrence of Pseudomonas aeruginosa osteomyelitis of the right clavicle in a patient with IgA nephropathy.

A 50‐year‐old man with diabetes mellitus with diabetic retinopathy, peripheral neuropathy, hypertension, and end‐stage renal disease on maintenance hemodialysis, presented with persistent cough and hiccups, continued to be unwell with weight loss, poor appetite, and recurrent respiratory symptoms such as wheezing and cough. Whole body positron emission tomography‐computed tomography scan showed metabolically active lesions in liver, stomach/lesser sac, pancreas, and left sixth rib. As he had repeated bilateral transudative pleural effusion, left mini thoracotomy with pleural biopsy showed no evidence of granuloma or malignancy. Upper gastroscopy showed tiny gastric polyp; biopsy revealed benign lesion. Left posterior rib biopsy from the lesion and iliac crest biopsy showed no evidence of malignancy or granuloma. Further evaluation showed plasma chromogranin A −5737 μg/L (<100 μg/L) with a repeat value of 6950 μg/L (<100 μg/L). He was initiated on oral sunitinib 25 mg once a day and injection octreotide 20 mg subcutaneously once a month. The plasma chromogranin A level and his symptoms, however, showed an initial improvement, but gradually worsened after 4 months despite being on treatment. After 6 months, the patient developed a gangrenous lesion of his glans penis with necrosis. Due to severe pain on conservative measures, penectomy with perineal urethrostomy was performed. Biopsy of the lesion showed blood vessels with intimal calcifications and thrombosis suggesting penile necrosis.