Milly Mathew

A review of acute and chronic peritoneal dialysis in developing countries

Various modalities of renal replacement therapy (RRT) are available for the management of acute kidney injury (AKI) and end-stage renal disease (ESRD). While developed countries mainly use hemodialysis as a form of RRT, peritoneal dialysis (PD) has been increasingly utilized in developing countries. Chronic PD offers various benefits including lower cost, home-based therapy, single access, less requirement of highly trained personnel and major infrastructure, higher number of patients under a single nephrologist with probably improved quality of life and freedom of activities. PD has been found to be lifesaving in the management of AKI in patients in developing countries where facilities for other forms of RRT are not readily available. The International Society of Peritoneal Dialysis has published guidelines regarding the use of PD in AKI, which has helped in ensuring uniformity. PD has also been successfully used in certain special situations of AKI due to snake bite, malaria, febrile illness, following cardiac surgery and in poisoning. Hemodialysis is the most common form of RRT used in ESRD worldwide, but some countries have begun to adopt a ‘PD first’ policy to reduce healthcare costs of RRT and ensure that it reaches the underserved population.

Secondary sternal Aspergillus osteomyelitis in a diabetic hemodialysis patient with previous allograft rejection

A 29‐year‐old diabetic woman who had a previously failed renal allograft on maintenance hemodialysis developed sternal aspergillosis with Aspergillus terreus following a pericardiectomy. She was successfully treated with surgical debridement and a combination of antifungal agents including amphotericin B, caspofungin, and voriconizole. The diagnostic difficulties and management are discussed.

Renal transplantation in the elderly: South Indian experience

In developing countries, renal transplantation is offered to young end-stage renal disease (ESRD) patients, while the older ones face limitations due to higher mortality risk. We retrospectively analyzed 225 patients who underwent renal transplantation from living donors, aged 40–60xa0years (Group A) and >60xa0years (Group B), focusing on their survival outcome. Group A (nxa0=xa0181) had mean creatinine (mg/dL) 1.41xa0±xa00.84, 1.30xa0±xa00.65 and 1.40xa0±xa00.60 and mean eGFR (mL/min/1.73 m2) of 65.32xa0±xa023.03, 69.14xa0±xa032.65 and 59.21xa0±xa022.79 at 0, 3 and 6xa0months post-transplantation. Death-censored graft survival was 93.1% in first year followed by 91.2% in subsequent 4xa0years. Patient survival was 92.5% in first year, 90.7% in the next 2xa0years, and 89.2% in 4th year. Highest cumulative graft survival was 86.7% in the first year with 83.4%, 82.7% and 82.4% during the subsequent 3xa0years. Group B (nxa0=xa044) had mean creatinine (mg/dL) of 1.46xa0±xa01.02, 1.29xa0±xa00.23 and 1.2xa0±xa00.29 with a mean eGFR (mL/min/1.73 m2) of 67.90xa0±xa023.48, 67.02xa0±xa012.76 and 75.23xa0±xa015.19 at 0, 3 and 6xa0months. Highest death-censored graft survival was 97.4% in the first year with 94.7% in next 3xa0years. Patient survival was 88.1% throughout 4xa0years post-transplantation. Cumulative graft survival was 84.1% during 4xa0years. Biopsy-proven acute rejection rate was 28.7% in group A and 15.9% in group B (Pxa0=xa00.058). There was higher mortality rate in group B with death mainly due to infections and cardiovascular complication. Cardiovascular risk assessment, pre-transplant cancer screening and judicious use of immunosuppressive agents should help minimize adverse events, balanced with an inherently reduced risk of acute rejection, hence the graft survival advantage and is the way forward to maximize patient and renal allograft survival in elderly patients.

Risk factors of chronic kidney disease influencing cardiac calcification.

We sought to determine the influence of risk factors of chronic kidney disease (CKD) on cardiac calcification. We studied the correlation between coronary artery calcium score (CACS) and the type and duration of dialysis as well as the presence of diabetes mellitus and hypertension. The relation between calcium score and mortality was also analyzed. Patients with CKD attending the outpatient department or admitted in our hospital were included. They were subjected to high-resolution computerized tomography of the thorax to determine their CACS. Serum levels of intact parathyroid hormone (iPTH), highly sensitive C-reactive protein (hCRP), homocysteine, calcium, phosphorus, and calcium × phosphorus product were measured. Out of the 50 patients studied, 39 were hypertensive (78%), 32 were diabetic (64.4%), 20 were on hemodialysis, and 13 were on continuous ambulatory peritoneal dialysis. The mean CACS was 388.6. Twenty-nine patients had high iPTH levels and 92.9% of them had calcium score >400 (P = 0.013). Twenty-eight patients had high hCRP and 85.7% of these patients had calcium score >400 (P = 0.048). Patients on dialysis for more than two years had higher calcium score >400 (P = 0.035). 43% of diabetics had calcium score >400 (P = 0.008). All the six patients who died had calcium score >400 (P = 0). There was statistically no significant association noted between hypertension, high calcium x phosphorus product, and high homocysteine levels, and high calcium score. Our study suggests that higher values of iPTH, hCRP, and longer duration on dialysis are associated with accelerated cardiac calcification. Calcification scores >400 are associated with increased mortality.

An Indian model for cost-effective CAPD with minimal man power and economic resources

Only 3–5% of all patients with end-stage renal disease (ESRD) in India get some form of RRT from the existing pool of 900 nephrologists [2, 3]. As referral pattern varies widely in India for uremia therapy, there is no robust national database on the prevalence and incidence of dialysis therapy except for isolated reports. The cost of maintenance hemodialysis (MHD) for a single session varies from US

Recurrent hypertension from stent fracture

10 to 65 and most patients are maintained on twice-aweek dialysis. One-third of the 30 000 MHD patients are in the major metropolitan cities of Chennai, Delhi, Mumbai and Kolkata, whereas the majority of the Indian population lives in small towns and villages far away from cities. The hidden cost of travel to the hemodialysis (HD) center and loss of daily wages for the patient and the accompanying person is not usually calculated when the cost of HD is taken into consideration. The unmet needs of RRT must be covered by continuous ambulatory peritoneal dialysis (CAPD) that is available even in remote places in the country. There are ~7000 prevalent patients on chronic peritoneal dialysis in India. The cost is substantially less with PD, and the four industries which are involved in CAPD in India have network systems to deliver dialysis supplies to the residence without any additional cost. The use of erythropoietin (EPO) and iron is comparatively lower in CAPD patients compared to HD patients in India to the advantage of CAPD as a favorable RRT.

Is there a genetic predisposition to new-onset diabetes after kidney transplantation?

A 20-year-old man with Takayasus arteritis with poor response to steroids and persistently high blood pressure (BP) was referred to our institution for control of his hypertension. The right radial pulse was absent, BP was 156/110xa0mm Hg, and an abdominal bruit was noted. Serum creatinine was 0.8xa0mg per 100xa0ml with normal serum electrolytes, and two-dimensional echo showed dilated cardiac chambers with mild left ventricular systolic dysfunction. Arteriography revealed total occlusion of right subclavian artery, bilateral renal artery stenosis with 90% occlusion at the origins, and 100% occlusion of proximal right coronary artery. He underwent percutaneous transluminal angioplasty with stenting of both the renal arteries using a non-drug-eluting renal bridge stent. He continued on furosemide 40xa0mg once daily (OD), amlodipine 5xa0mg OD, and atenolol 50xa0mg OD, and his BP normalized and antihypertensive requirement came down gradually in course of time. He was initiated on aspirin 150xa0mg OD and clopidogrel 75xa0mg OD. Two years later he came back with BP of 160/110xa0mm Hg, serum creatinine was 0.7xa0mg per 100xa0ml, and urine output was 1600xa0mlxa0day- 1. A duplex ultrasonography of the renal arteries showed in-stent restenosis of the left renal artery. Renal arteriogram revealed bilateral renal artery stent fracture causing significant in-stent restenosis in the left renal artery and non-flow-limiting restenosis in the right side. Patient underwent plain balloon angioplasty for in-stent restenosis of left renal artery and as the final angiography showed non-flow-limiting residual stenosis. Post-intervention BP was 130/90xa0mm Hg. In-stent restenosis can occur usually secondary to progression of disease process, failure of antiplatelet therapy, and very rarely stent fracture as in our case. Thus, a surveillance duplex ultrasonography needs to be performed every 6 months after stent placement. The finding of restenosis during screening warrants immediate reintervention. Long-term follow-up of Takayasus arteritis patients who have undergone stenting for renal artery stenosis is required to validate the beneficial effect and rate of restenosis. To our knowledge, this is the first reported case of bilateral renal artery stent fracture (Figure 1).

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

Kidney transplant recipients may develop new-onset diabetes after transplantation (NODAT) and transplant-associated hyperglycemia (TAH) (NODAT or new-onset impaired glucose tolerance-IGT). We studied 251 consecutive renal transplant South Asian recipients for incidence of NODAT and its risk factors between June 2004 and January 2009. Pre-transplant glucose tolerance test (GTT) identified non-diabetics (n = 102, IGT-24, NGT-78) for analysis. Baseline immunosuppression along with either cyclosporine (CsA) (n = 70) or tacrolimus (Tac) (n = 32) was given. Patients underwent GTT 20 days (mean) post-transplant to identify NODAT, normal (N) or IGT. TAH was observed in 40.2% of the patients (40% in CsA and 40.6% in Tac) (P = 0.5). NODAT developed in 13.7% of the patients (12.9% in CsA and 15.6% in Tac) (P = 0.5). Overall, Hepatitis C (P = 0.007), human leukocyte antigen (HLA) B52 (P = 0.03) and lack of HLA A28 (A68/69) (P = 0.03) were associated with TAH. In the Tac group, higher Day 1 dosage (P <0.001), HLA A1 (P = 0.04), B13 (P = 0.03) and lack of DR2 (P = 0.004) increased the risk of TAH. In the CsA group, HLA A10 (P = 0.03), failure of triglyceride (P = 0.001) or low-density lipoprotein (LDL) (P = 0.03) to lower or high-density lipoprotein to rise (P = 0.001), and higher post-transplant LDL (P <0.001) and cholesterol levels (P = 0.02) were associated with NODAT or TAH. Post-transplant fasting plasma glucose on Day 1 had sensitivity-54.5%, specificity-50.1%, positive predictive value-18.1% and negative predictive value-84.8% for detecting NODAT. In conclusion, there is a genetic predisposition to NODAT and TAH in South Asia as seen by the HLA associations, and a predisposition exists to the individual diabetogenic effects of Tac and CsA based on HLA type. This could lead to more careful selection of calcineurin inhibitors based on HLA types in the South Asian population.

Obstructive uropathy from Ascaris lumbricoides

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 (nu2009=u2009100), BPL CKD-D (nu2009=u200998), and APL CKD-ND (nu2009=u200992) patients, based on a cut-off of per capita income US

Culture-Negative Aspergillus Peritonitis Diagnosed by Peritoneal Biopsy

1.25u2009a day. Patients were enquired by a qualified renal dietitian about their pattern of diet, and daily energy and protein intake by 24u2009h 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 (32.44444u2009±u20096.279961u2009g/L; pu2009=u20090.017) and 41.83% of them were underweight. The APL CKD-ND group registered the lowest mean daily energy (22.576u2009±u20096.289u2009kcal/kg/day) and protein intake (0.71u2009±u20090.06u2009g/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 (pu2009=u20090.001), triceps skin fold thickness (pu2009<u20090.001), and serum hemoglobin (pu2009<u20090.001). 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.