Anita Saxena

Nutritional aspect of nephrolithiasis.

Nephrolithiasis is associated with a variety of abnormalities in urinary composition. These abnormal urinary risk factors are due to dietary indiscretions, physiological-metabolic disturbances or both. Stone disease is morbid and costly, and the recurrence rates may be as high as 30-50% after 5 years. Efforts to prevent stone formation are, therefore, essential. Dietary factors play an important role in kidney stone formation. Tailored dietary recommendations based on metabolic evaluation should be offered to patients for the prevention of recurrence of stone formation. Dietary intervention and subsequent evaluations of therapeutic efficacy should be based on results from multiple 24-h urine collections. Urine flow of >1 ml/kg/h almost eliminates the risk of supersaturation for calcium oxalate, calcium phosphate and uric acid, thus protecting from the formation of corresponding kidney stones. In patients with cystenuria, the required urine flow may even be higher and, in cases such as primary xanthinuria, high fluid intake is required. Milk intake in these patients should be within the RDA of calcium and protein. In children, recommendation of a high fluid intake has only limited success. Nevertheless, each patient should be advised about adequate fluid intake to increase urine volume in accordance with body size. Although children with hypocitraturia may benefit from therapeutic agents that raise the urine citrate concentration, all children bearing residual fragments should be counseled on adequate fluid intake along with potassium citrate treatment to prevent stone regrowth or formation.

Growth Retardation in Thalassemia Major Patients

Abstract Regular blood transfusion followed by iron chelation therapy is just a supportive treatment for thalassemia major which is associated with serious complications. Growth disturbances are a major clinical feature of untreated patients with thalassemia. The increasing mean survival age is indicative of the fact that modern therapies are generally safe and effective but it is becoming increasingly clear that as thalassemic patients approach the age of puberty, many develop growth retardation and pubertal failure. The main objective of present study was to examine longitudinally the growth pattern of thalassemic patients on hypertransfusion regimen over a period of three years and to document disproportion in body segments. Material and Methods: Height, weight, sitting height vertex, trunk and leg length of 90 patients (57 male, 33 female) aged between 2 and 18 years were measured every two months over a period of 3 years. Results: This study supports the fact that thalassemic patients are short, have low rate of growth and BMI and have either delayed or absent pubertal spurt, which is related to low hemoglobin and high ferritin levels and sub-optimal iron chelation therapy. Growth faltering sets in at a much younger age and becomes apparent by 8 years of age. Poor socioeconomic background compounds the problem.

Association of IL-6, IL-10, and TNF-α Gene Polymorphism with Malnutrition Inflammation Syndrome and Survival Among End Stage Renal Disease Patients

During end stage renal disease (ESRD) inflammatory pathways are activated which may lead to malnutrition inflammation syndrome (MIS). In the present study, 257 ESRD patients and 200 controls were included. Cytokine levels and genotyping was done by polymerase chain reaction-restriction fragment length polymorphism and enzyme-linked immunosorbent assay (ELISA). Risk was estimated through binary logistic regression. Cox proportional hazards regression and Kaplan-Meier were used for survival analysis. Tumor necrosis factor TNF-α-308 AA conferred 3.6-fold higher susceptibility (P=0.001) and higher TNF-α levels (P=0.05). TNF-α-238 AA was associated with 3.3-fold higher susceptibility to ESRD (P=0.002). IL-6-174 CC genotype conferred 3-fold risk to disease (P=0.001) along with higher IL-6 levels (P=0.001). IL-10-1082 GG genotype exhibited 2.2-fold higher susceptibility to disease (P=0.013). IL-10-592 AA/-819 TT genotypes were associated with high C reactive protein (P=0.02) and low IL-10 (P=0.03) levels. TNF-α-308 A allele was significantly associated with 2.3-fold higher risk of malnutrition. TNF-α-GAC, AGC and IL-6-CC were risk haplotypes associated with higher disease susceptibility. Combined analysis revealed 1.6-fold higher susceptibility to disease (P=0.02), there was 2-fold higher susceptibility to malnutrition (P=0.02) in high inflammation group. TNF-α-238 AA genotype was associated with 2.5-fold higher death hazard risk (P=0.02). Our study suggests that TNF-α and its genetic variants are major contributors to susceptibility to MIS in ESRD patients.

Confounding Effect of Comorbidities and Malnutrition on Survival of Peritoneal Dialysis Patients

BACKGROUND AND OBJECTIVES Malnutrition and comorbid diseases are strong predictors of mortality in patients on continuous ambulatory peritoneal dialysis (CAPD). We undertook this study to analyze the confounding impact of comorbidities and malnutrition on the survival of CAPD patients. METHODS In this prospective, observational study, 342 CAPD patients (179 diabetics, 250 male, aged 51.5 ± 14 years) were followed for 21.62 ± 14.38 S.D. patient-months. Based on nutritional status and comorbidities, patients were categorized into four groups: (1), normal nutrition without comorbidities (n = 61, 17.8%); (2), normal nutrition with comorbidities (n = 26, 7.6%); (3), malnutrition with comorbidities (n = 160, 46.8%); and (4), malnutrition without comorbidities (n = 95, 27.8%). The risk ratios of mortality and predictors of survival were analyzed in the different groups. RESULTS Of 342 patients, 186 (54.4%) patients had one or more comorbidities, and 156 (45.6%) patients had no comorbidities. Of 186 patients with comorbidities, 160 (86%) patients were malnourished, and only 26 (14%) had normal nutritional status. Of 156 patients without comorbidities, 95 (61%) were malnourished, and 61 (39%) had normal nutritional status. The relative risk of developing malnutrition in patients with comorbidities was significantly high, compared with patients without comorbidities (risk ratio, 3.9; 95% confidence interval [CI], 2.3 to 6.6; P = .001). According to time-dependent multivariate Cox regression analysis, the hazard ratio of mortality was 3.6 (95% CI, 1.1 to 11.7; P = .03) in patients with normal nutrition with comorbidities; 2.9 (95% CI, 1.1 to 7.8; P = .03) in patients with malnutrition without comorbidities; and 6.6 (95% CI, 2.6 to 16.5; P = .001) in patients with both malnutrition and comorbidities. The risk ratio of mortality in patients with both malnutrition and comorbidities was 3.7 times higher than in patients with malnutrition without comorbidities. CONCLUSIONS Patients with comorbidities are at high risk of developing malnutrition. Comorbidities and malnutrition, alone or together, constitute independent predictors of survival in these patients. Patients with both malnutrition and comorbidities demonstrate the worst survival. Malnutrition and comorbidities seem to exert a confounding effect on the survival of CAPD patients.

Advanced glycation end products and diabetic retinopathy

Studies have established hyperglycemia as the most important factor in the progress of vascular complications. Formation of advanced glycation end products (AGEs) correlates with glycemic control. The AGE hypothesis proposes that hyperglycemia contributes to the pathogenesis of diabetic complications including retinopathy. However, their role in diabetic retinopathy remains largely unknown. This review discusses the chemistry of AGEs formation and their patho-biochemistry particularly in relation to diabetic retinopathy. AGEs exert deleterious effects by acting directly to induce cross-linking of long-lived proteins to promote vascular stiffness, altering vascular structure and function and interacting with receptor for AGE, to induce intracellular signaling leading to enhanced oxidative stress and elaboration of key proinflammatory and prosclerotic cytokines. Novel anti-AGE strategies are being developed hoping that in next few years, some of these promising therapies will be successfully evaluated in clinical context aiming to reduce the major economical and medical burden caused by diabetic retinopathy.

Dietary management in acute kidney injury

Abstract Acute kidney injury (AKI) is recognized as a systemic inflammatory syndrome, a pro-oxidative, proinflammatory, and hypermetabolic state exerting a profound impact on the course of the disease that is associated with AKI. Despite advances in intensive care and dialytic technology, the mortality rate for AKI still remains high. Nutritional and metabolic management present a cornerstone in the care of these patients. Since, patients with AKI are at high-risk for developing malnutrition as a result of coexisting catabolic illness, therefore, protein-calorie wasting (PCW) is an important factor which influences the outcome of AKI. In fact, AKI is associated with specific changes in protein, carbohydrate, and lipid metabolism, combining together to cause a general disruption of the ‘internal milieu’: catabolism of skeletal muscle proteins with increased amino acid turnover and negative nitrogen balance, hyperglycaemia, and insulin resistance, altered lipid metabolism, water, electrolyte, and acid-base metabolism unbalances.

Hypertension in post-renal transplant patients: pilot study.

Post-transplant hypertension is a major risk factor for graft loss and patient survival; therefore, hypertension following renal transplantation must be treated strictly. There seems to be a strong association between hypertension, total body water (TBW) and dry weight. In this study, we report the relationship of body water and body composition with hypertension in post-renal transplant patients. Forty-five post-transplant patients were enrolled in the study. Blood pressure (BP) was labeled as controlled if BP was 120/80 mm Hg and not under good control if BP was above 120/80 mm Hg. Based on the number of antihypertensive medications a patient was taking, patients were divided into two groups: Group 1 patients on one antihypertensive drug and Group 2 patients on more than one antihypertensive drug. Nutritional status of the patients was assessed. Body composition (water compartments, body fat and lean mass) was assessed using bioelectrical impedance analysis (BIA). Patient data were compared with 30 healthy volunteers. In patients, systolic BP was associated with TBW (P = 0.016), extracellular water (ECW Lt; r = 0.99), ECW% (r = 0.78) and diastolic BP with TBW% (P = 0.003), dry weight (r = 0.76) ECW% (r = 0.95) and percent intracellular water (ICW%) (r = 0.79). Compared with controls, ECW and ECW% was higher in patients, and the ICW% was less in patients. There was significant difference in the actual weight of the patients and BIA-derived dry weight, although patients were clinically not edematous. The study showed a significant increase in diastolic BP with increase in dry weight. Significant difference in TBW was observed when the patients were grouped on the basis of the antihypertensive medication a patient was taking (one antihypertensive drug versus more than one antihypertensive drug). This study also showed an association between hypertension and overhydration. BIA may be a useful tool for the clinical assessment of overhydration in non-edematous patients.

Graft function and nutritional parameters in stable postrenal transplant patients.

Bioelectrical impedance analysis (BIA) is a method for the assessment of nutritional status. We studied the effect of graft function on nutritional status in postrenal 45 transplant patients with borderline to good allograft function using BIA. The patients had a mean serum creatinine of 1.42 ± 0.42 mg% and mean glomerular filtration rate (GFR) of 45.1 ± 14.1 mL/min. Based on BIA-derived GFR, the patients were divided into two groups; group 1: borderline graft function GFR <40 mL/min and a mean of 27.34 ± 9.1 mL/min and group 2: good graft function GFR ≥40 mL/min and a mean of 51.60 ± 9.16 mL/min. The patient data were compared with 30 healthy individuals. There was a significant difference between healthy controls and the posttransplant patients. There were significant differences between the study groups in body weight (P <0.01), serum creatinine (P <0.005), body mass index (BMI) (P <0.000), fat free mass (FFM) (P <0.003), fat mass (FM) (P <0.003), body cell mass (P <0.000), and dry weight (P <0.001). Group 1 had significantly lower body weight, BMI, FFM, FM, and dry weight, indicating poorer nutritional status compared with those in group 2. Based on phase angle, there were significant differences between group A (phase angle <4.0) and group B (phase angle >4.0) in extracellular water (P <0.015), intracellular water (P <0.002), plasma fluid (P <0.016), interstitial fluid (P <0.016), and body cell mass (P <0.024). Subjective global assessment (SGA) scores showed that transplant patients had normal nutritional status, but when compared with healthy individuals as assessed by BIA, there were significant differences in FM, FFM, and body cell mass. In conclusion, BIA was more sensitive to evaluate nutritional depletion than SGA in transplant patients with borderline.

Non-invasive method for preventing intradialytic hypotension: A pilot study.

Intradialytic hypotension (IDH) is a life-threatening condition. We evaluated the feasibility of blood volume monitoring (BVM) and blood temperature monitoring (BTM) in preventing IDH in patients prone to the same. Fourteen hemodynamically unstable end-stage renal disease patients who were prone to IDH and unable to achieve dry weight were given BVM treatment twice weekly for two weeks. Forty patients who were not on BVM treatment served as controls. Patients were anemic, had low serum albumin (3.4 ± 0.43 g/dL) and fluid overload and were edematous. Of the 40 patients in the control group, 18 patients experienced IDH and dialysis had to be terminated. The incidence of IDH was 5% in the control group. In the BVM group, the total volume of fluid removed during hemodialysis was between 2.0 and 4.5 L (mean 3.2 L). By the end of dialysis, the hemo-concentration increased by 34.8%. With use of BVM and BTM, the blood pressure did not drop below 120/80 mm Hg, the dialysis sessions were uneventful and none of the patients suffered symptoms of hypotension. There was a difference of 3 kg between weight achieved and dry weight of the patient, although there was a 14.2% reduction in extracellular water (ECW), 14.5% in plasma fluid and 14.5% decrease in interstitial fluid. Blood volume significantly correlated with post-dialysis intracellular water (ICW) (r = 0.722, P = 0.008) and ECW/ICW ratio (r = 0.698, P = 0.012). There was a significant correlation between systolic blood pressure and ECW (r = 0.615, P = 0.033). Diastolic blood pressure significantly correlated with post-dialysis ECW (r = 0.690, P = 0.008), plasma fluid post-dialysis (r = 0.632, P = 0.027) and interstitial fluid (r = 0.604, P = 0.038). The ECW/ICW ratio was high (1.13 ± 0.48; control 0.74), implying overhydration and expanded extracellular fluid. BVM should be included in the dialysis protocol where patient compliance to maintenance hemodialysis is poor and patients are constantly in volume overload.

Global Prevalence of Protein-Energy Wasting in Kidney Disease: A Meta-analysis of Contemporary Observational Studies From the International Society of Renal Nutrition and Metabolism

OBJECTIVE To better define the prevalence of protein-energy wasting (PEW) in kidney disease is poorly defined. METHODS We performed a meta-analysis of PEW prevalence from contemporary studies including more than 50 subjects with kidney disease, published during 2000-2014 and reporting on PEW prevalence by subjective global assessment or malnutrition-inflammation score. Data were reviewed throughout different strata: (1) acute kidney injury (AKI), (2) pediatric chronic kidney disease (CKD), (3) nondialyzed CKD 3-5, (4) maintenance dialysis, and (5) subjects undergoing kidney transplantation (Tx). Sample size, period of publication, reporting quality, methods, dialysis technique, country, geographical region, and gross national income were a priori considered factors influencing between-study variability. RESULTS Two studies including 189 AKI patients reported a PEW prevalence of 60% and 82%. Five studies including 1776 patients with CKD stages 3-5 reported PEW prevalence ranging from 11% to 54%. Finally, 90 studies from 34 countries including 16,434 patients on maintenance dialysis were identified. The 25th-75th percentiles range in PEW prevalence among dialysis studies was 28-54%. Large variation in PEW prevalence across studies remained even when accounting for moderators. Mixed-effects meta-regression identified geographical region as the only significant moderator explaining 23% of the observed data heterogeneity. Finally, two studies including 1067 Tx patients reported a PEW prevalence of 28% and 52%, and no studies recruiting pediatric CKD patients were identified. CONCLUSION By providing evidence-based ranges of PEW prevalence, we conclude that PEW is a common phenomenon across the spectrum of AKI and CKD. This, together with the well-documented impact of PEW on patient outcomes, justifies the need for increased medical attention.