Madhivanan Sundaram

Percutaneous continuous ambulatory peritoneal dialysis (CAPD) catheter insertion--a preferred option for developing countries.

Continuous ambulatory peritoneal dialysis (CAPD) as a modality of renal replacement therapy in patients with chronic kidney disease stage 5 (CKD 5) has the advantage of being a home-based therapy and is a preferred option in patients with inadequate access to haemodialysis and transplantation facilities and in those infected with HIV and other blood-borne viruses. While open surgical CAPD catheter placement has been the conventional mainstay of access placement, percutaneous techniques are being increasingly used with similar success rates. We report our experience over the past two years with blind insertion of the swan neck percutaneous double-cuffed Tenckhoff CAPD catheter using a trocar. There was considerable decrease in hospital stay and surgical costs. There was only one major complication of injury to the jejunal mesenteric artery requiring emergency laparotomy in one patient. In three patients, drain of peritoneal fluid was inadequate, presumably due to omental wrapping around the in-dwelling catheter, and required surgical removal of the omentum.

Tuberculosis in renal transplant recipients.

Infective complications are common after renal transplantation. Tuberculosis (TB) is one of the leading infections following renal transplantation. Reactivation is the most common mode of infection. The factors responsible for this reactivation are chronic liver disease, other coexisting infections, particularly deep mycoses, pneumocystis pneumonia, nocardia, and CMV infections. Cyclosporine use advances the onset of TB to an earlier date. The median onset following transplantation is estimated to be 26 months for those who receive azathioprine and prednisolone as immunosuppression and 11 months for those who receive cyclosporine along with other immunosuppressive agents. Lung is the major site of involvement. Pyrexia of unknown origin is another common presentation. Culture and sensitivity has to be done in all possible cases. Amongst the serological techniques, Interferon alpha production is emerging as the most important. Rifampicin has to be avoided in allograft recipients as it activates cytochrome-P450 enzymes and thereby decreases the therapeutic levels of cyclosporine and prednisolone. The duration of treatment is usually extended for 18 months followed by secondary prophylaxis with isoniazid. Adverse effects of drugs are more often reported in organ recipients and have to be monitored for. Drug resistance is emerging as a problem and appropriate changes in the management have to be carried out.

Trichosporon Surgical Wound Infection in a Renal Allograft Recipient Successfully Treated With Voriconazole

A 39-year-old chronic kidney disease patient underwent a preemptive renal transplantation in November 2009. His native kidney disease was unknown (biopsy performed in 2006 showed diffuse global sclerosis). He reached end stage in 2009 and after that he was worked up for transplantation. He was not a diabetic and did not have any other comorbidity. He did not receive any immunosuppression before renal transplantation. His wife donated the kidney. His immunosuppression included Basiliximab (two doses) for induction along with prednisolone, tacrolimus, and mycophenolate sodium for maintenance. He had a prolonged warm ischemia time because of difficulty in donor nephrectomy. After surgery, he had a slow recovery in renal function for which a graft biopsy was performed on 4th postoperative day. It showed acute tubular necrosis. Tacrolimus levels were found to be high (13 ng/mL), and hence the dose was reduced. Because renal recovery continued to be slow, a second renal biopsy was performed after a week, which showed cortical necrosis at the upper pole. Without any specific intervention, renal function slowly improved to attain a nadir creatinine of 1.4 mg/dL. Dose titration of tacrolimus and mycophenolate sodium was performed in this period with therapeutic drug monitoring. In the postoperative period, he had received ciprofloxacin as treatment for lower respiratory infection and there were no other infective episodes. After suture removal, he was found to have pus discharge from the surgical wound site. A pus swab for culture grew Trichosporon species. It was confirmed by a second culture. An ultrasonogram revealed a small subcutaneous collection. Surgeons considered exploration to be unnecessary and wanted daily dressings only. A small noncompressing lymphocele was also noted near the lower pole of the graft kidney. Imaging studies excluded involvement of other organs. He did not have neutropenia. Antifungal therapy in voriconazole was begun at standard doses (400 mg twice daily on day 1 followed by 200 mg twice daily). Tacrolimus dose was decreased based on new trough levels. Mycophenolate area under the curve was found to be high, and the dose was dropped. He showed response to the treatment with clearing of the discharge. The wound healed within 2 weeks and the subcutaneous collection resolved. Voriconazole was continued for 4 weeks and stopped. His renal function remains stable and the wound is healthy.

Profile of incident chronic kidney disease related-mineral bone disorders in chronic kidney disease Stage 4 and 5: A hospital based cross-sectional survey.

Chronic kidney disease related-mineral bone disorder (CKD-MBD) has been poorly studied in pre-dialysis Indian CKD patients. We aimed to study the clinical, biochemical and extra skeletal manifestations of untreated CKD-MBD in pre-dialysis Stage 4 and 5 CKD patients attending nephrology out-patient clinic at a tertiary care hospital in South India. A hospital based cross-sectional survey including, demographic profile, history of CKD-MBD symptoms, measurement of serum calcium, phosphate, parathyroid hormone, 25 hydroxy vitamin D (25(OH) D) and alkaline phosphatase; lateral abdominal X-rays for abdominal aortic calcification (AAC) and echocardiography for valvular calcification (VC) was carried out. Of the 710 patients surveyed, 45% had no CKD-MBD related symptom. Prevalence of hypocalcemia, hyperphosphatemia, hyperparathyroidism (>150 pg/mL) and 25(OH) D levels <30 ng/mL was 66.3%, 59%, 89.3% and 74.7% respectively. Echocardiography was carried out in 471 patients; 96% of whom had VC (calcification score ≥1). Patients with VC were older and had lower 25(OH) D levels than those without. Lateral abdominal X-rays were obtained in 558 patients, 6.8% of whom were found to have AAC, which was associated with older age. Indian patients with incident CKD-MBD have a high prevalence of hypocalcemia, 25(OH) D deficiency and VC even prior to initiating dialysis while AAC does not appear to be common. The association between 25(OH) D deficiency and VC needs further exploration.

Percutaneous PD catheter insertion after past abdominal surgeries

Sir, The preferred method of initiating renal replacement therapy in developing countries is probably the percutaneous peritoneal dialysis (PD) catheter insertion technique.[1] However, this is seldom practiced in those with a history of previous abdominal surgery,[2] where laparoscopy is preferred, as adhesiolysis can be done if needed.[2] From Christian Medical College, Vellore, we report our experience of successful percutaneous PD catheter insertion in 12 patients who had previous abdominal surgeries.

Diarrhea in a Renal Allograft Recipient in the Tropics

CASE REPORT A50-year-oldBhutanesemaleunderwent a living-related renal transplantation from his six HLA-antigen matched sister. The immunosuppression administered to himincludedBasiliximab(Simulect,Novartis India Limited), prednisolone 20 mg (Wysolone, Wyeth Limited), mycophenolate sodium 900 mg bid (Renfor, Nicholas PiramalIndiaLimited),andtacrolimus2mg bid (Pangraf, Panacea Biotech Limited). In thesecondweekafter transplantation,hedeveloped acute watery diarrhea. Six hours extrapolatedMPAareaunderthecurve(AUC) was 24.1 mg.h/L. Because MPA-induced diarrhea is a common event in the immediate posttransplant setting, it was withheld. Tacrolimus trough concentration was adequate (20.1 ng/mL). Stool microscopy for intestinal parasites, cysts, and Vibrio cholerae werenegative.PP65test forcytomegalovirus proliferation was also negative. The diarrhea persisted despite stopping MPA. A fresh stool examination showed oocysts of cryptosporidium sp. On the third day, the stool culture grew Vibrio cholerae non-O1, non-O139. The patient was treated with doxycycline, and the diarrhea subsided. Mycophenolate sodium was restarted a week later, and the drug was tolerated without diarrhea.