Dharmendra Prasad

Incidence and profile of C3 Glomerulopathy: A single center study.

C3 glomerulopathy has recently been described as a distinct entity. The underlying mechanism is unregulated activation of the alternate pathway of the complement system. The most common presentation is with an acute nephritic syndrome. The diagnosis is made on immunofluoroscence by the presence of isolated or dominant C3 staining. In this retrospective study, renal biopsy data were collected from 2010 to 2013 patients with C3 glomerulopathy identified and their clinical and biochemical parameters analyzed. Out of 514 biopsies available for analysis, the incidence of C3 glomerulopathy was 1.16% (n = 6). The mean age of the presentation was 26 years and the average estimated glomerular filtration rate was 30.65 ml/min/1.73 m2. The most common histopathological pattern was membranoproliferative glomerulonephritis (n = 4).

A comparative study of central versus posterior approach for internal jugular hemodialysis catheter insertion

Internal jugular (IJ) catheter insertion for hemodialysis (HD) is an indispensable procedure in the management of patients with renal failure. The central approach is favored over posterior approach to insert IJ catheters. There are no studies comparing the outcomes between the two approaches. The aim of this study was to compare central approach with posterior approach for IJ HD catheter insertion and to analyze various outcomes like procedure-related complication rates, catheter insertion failure rates, interruptions during dialysis due to blood flow obstruction and catheter infection rates between the two methods among patients receiving HD. All patients requiring IJ HD catheter insertion during a 1-month period were randomly assigned to undergo catheter insertion via either conventional central approach or posterior approach. Patients were followed-up till the removal of the catheter. Among 104 patients included in the study, 54 were assigned to the central approach group and 50 to the posterior approach group. The central approach group had higher rate of procedure-related complications (14.81% vs. 6%, P = 0.04). Catheter insertion failure rates were marginally higher in posterior approach group (20% vs. 12.96%, P = 0.07). One or more instance of interruption during HD due to obstruction in blood flow was more common in posterior approach (46% vs. 9.25%, P < 0.01). Catheter infection rates were similar between the two groups; 16.66% (n = 9) in central group vs. 14% (n = 7) in posterior group. Posterior approach is a reasonable alternative to conventional central approach in IJ cannulation for HD catheter. It is, however, associated with a significantly high rate of interruption in HD blood flow and catheter insertion failure rates. The posterior approach can be used in patients with local exit site infection or in failed attempts to cannulate IJ vein via the conventional central approach.

Gitelman's syndrome presenting with hypocalcemic tetany and hypokalemic periodic paralysis

Gitelmans syndrome is an autosomal recessive renal tubular disorder characterized by hypomagnesemia, hypokalemia, hypocalciuria, and metabolic alkalosis. Hypocalcemic tetany as a presentation of Gitelmans syndrome has rarely been reported in literature. We report a rare case of Gitelmans syndrome presenting with hypocalcemic tetany along with hypokalemic periodic paralysis. A 17-year-old female was admitted to our hospital with a history of perioral numbness and carpal spasms of five days duration with progressive quadriparesis developing over a period of few hours. Past history was significant for three episodes of transient lower limb weakness. On examination, blood pressure was 110/70 mm Hg. Chvosteks sign and Trousseaus sign were positive. Neurologically, she was fully oriented. She had Grade 3 power in all the four limbs with intact sensation. Laboratory tests showed hypocalcemia (7.8 mg/dL), hypokalemia (2.2 mEq/L), hypomagnesemia (0.9 mEq/L), and hypocalciuria (104 mg/day). Arterial blood gas showed mild metabolic alkalosis with respiratory compensation. Thus, a clinical diagnosis of GS was made. The patient made a remarkable recovery after the correction of electrolyte imbalance. The aim of this case report is to re-emphasize the fact that hypocalcemia can rarely occur in Gitelmans syndrome.

Periodic Peritoneal Dialysis in End Stage Renal Disease: Is it Still Relevant? A Single Center Study from India

Background: High cost of maintenance hemodialysis (HD) and continuous ambulatory peritoneal dialysis (PD) in India has made renal replacement therapy out of reach of many patients with end stage renal disease (ESRD). Repeated puncture PD although inferior to HD biochemically, is easily and freely available across Rajasthan, India, and is simple to perform, and does not require sophisticated machines, thus making it an attractive option for dialysis for ESRD. Aim: To analyze the outcomes of periodic PD in patients with ESRD requiring dialysis support. Subjects and Methods: A prospective study analyzing the data of patients who underwent PD between August 2010 and January 2013 in Sawai Man Singh Hospital, Jaipur, India was conducted. Patients were divided into three groups based on the time period between first and second session of PD. Detailed demographic and clinical data during the study period were collected along with PD related complications. The main outcome studied was technique survival 1 year post initiation of PD. Results: 234 patients received an initial session of PD, of which 174 had a good response and were included in the study. 19 patients received the second PD within 7 days of first (Group 1), 45 patients within 8–14 days (Group 2) and 110 patients within 15–21 days (Group 3). The overall 1 year technique survival was 68.4% (91/133), with a rate of 50% (5/10), 56.8% (21/37), and 75.6% (65/86) for Group 1, Group 2, and Group 3, respectively. The time duration between first and second PD proved to be reliable indicator of the subsequent response, with a technique survival rate significantly lower in Group 1 patients compared to Groups 2 and 3 (P = 0.04). Median dialysis free days were 11, 16 and 21 days in Group 1, Group 2, and Group 3, respectively. Peritonitis rate observed was 2.1% (49/2261) during the study period. Conclusion: Periodic PD is a simple, safe and cheap procedure, which can be considered as used as a palliative measure in terminal uremia in underprivileged areas.

Occupational kidney disease: Is exposure to ammonium nitrate a risk factor?

For correspondence: Dr. Mohit Mathur Department of Nephrology, SMS Medical College and Hospital, Jaipur, Rajasthan, India. E-mail: mathur_medico @yahoo.co.in Dear Sir, A 49‐year‐old man was admitted with complaints of progressive swelling over body, anorexia, and easy fatiguability for 1 month. His past medical history was unremarkable. The patient revealed that he had been working in an ammonium nitrate factory for the past 25 years. The factory was involved in making commercial explosives prior to the ban imposed on such explosives and fertilizer‐grade ammonium nitrate since then. On examination, he was hypertensive (160/90 mmHg) and had peripheral edema. Systemic examination and fundoscopy were normal. Laboratory studies revealed a normal complete blood count, blood urea of 65 mg/dL, serum creatinine of 2.6 mg/ dL, and hypoalbuminemia (3 gm/dL). Urinalysis showed active sediment with 24‐h urine protein excretion of 3.2 g. Anti‐nuclear antibody, anti‐ds DNA, rheumatoid factor, Anti neutrophil cytoplasmic antibodies (ANCA), and Anti ‐ Glomerular basement membrane (GBM) antibodies were negative. Serologic markers of hepatitis B, hepatitis C, and HIV were negative. Complement factors 3 and 4 were low. Liver function tests and serum electrophoresis were normal. Ultrasound of abdomen revealed bilateral normal‐sized kidneys. He underwent renal biopsy, which revealed features compatible with type 1 Membranoproliferative glomerulonephritis (MPGN) [Figure 1] without significant tubular atrophy/interstitial fibrosis.

Renal tubular dysfunction presenting as recurrent hypokalemic periodic quadriparesis in systemic lupus erythematosus.

We report recurrent hypokalemic periodic quadriparesis in a 30-year-old woman. Patient had also symptoms of multiple large and small joint pain, recurrent oral ulceration, photosensitivity and hair loss that were persisting since last 6 months and investigations revealed systemic lupus erythematosus (SLE) with distal tubular acidosis. Our patient was successfully treated with oral potassium chloride, sodium bicarbonate, hydroxychloroquine and a short course of steroids. Thus, tubular dysfunction should be carefully assessed in patients with SLE.

Are we Treating or Curing Tuberculosis? Profile of Secondary Renal Amyloidosis in Patients Receiving Anti Tubercular Treatment

Abstract Introduction. Secondary renal amyloidosis due to tuberculosis is a debilitating disease with considerable mortality and morbidity due to renal failure and other manifestations of both amyloidosis and renal failure. Most patients with amyloidosis have been adequately treated with DOTS (Directly observed treatment, Short Course strategy). The aimof our study was to analyze the epidemiological and demographic profile of patients undergoing renal biopsy and found to have renal amyloidosis secondary to tuberculosis. Methods. In this study, retrospective renal biopsy data was collected from 2009-2012 and patients with amyloidosis were identified and their clinical and biochemical parameters were analyzed. Results. Incidence of amyloidosis was 4.66% (n=24/514) among total renal biopsies. Among this, secondary amyloidosis constituted 87.5% of total amyloidosis. The commonest etiology in these patients was pulmonary tuberculosis (73.5%). All patients with tuberculosis had previously received DOTS treatment. 47.5% of patients with amyloidosis had renal impairment and 10.5% developed end-stage renal disease over 12 months and were dialysis dependent. Conclusions. Amyloidosis due to tuberculosis is a well-established, yet under-diagnosed complication of tuberculosis. The duration and treatment status of tuberculosis does not influence the occurrence of amyloidosis, as most of the patients were treated appropriately with DOTS. There are no predictive factors in patients who will develop secondary amyloidosis. At present there is no specific treatment apart from supportive therapy. The prognosis is poor, as most of these patients inexorably progress towards end-stage renal disease (ESRD) with significant mortality and morbidity. To conclude, at present we are only treating tuberculosis, we are yet to cure tuberculosis.