R. B. Ram

Employment status of patients receiving maintenance dialysis – peritoneal and hemodialysis: A cross-sectional study

The long-term dialysis therapy for end-stage renal disease takes a heavy toll of quality of life of the patient. Several factors such as fatigue and decreased physical capability, impaired social and mental functioning, contribute to this forlorn state. To meld maintenance dialysis treatment with a regular employment can be a serious test. A cross-sectional study of employment of patients on hemodialysis and peritoneal dialysis in a state government tertiary institute in South India was performed between June 2015 and December 2015. Patients who completed 3 months of regular dialysis were only included in the study. The number of patients on hemodialysis was 157 and on peritoneal dialysis was 69. The employment status before the initiation of dialysis was 60% (93 out of 155) and 63.7% (44 out of 69) in hemodialysis and peritoneal dialysis, respectively. After initiation, the loss of employment was observed in 44% (41 out of 93) in hemodialysis and 51.2% (26 out of 44) in peritoneal dialysis (P = 0.2604). Even though there was fall of absolute number of job holders in both the blue and white collar jobs, the proportion of jobholders in the white collar job holders improved. On univariate analysis, the factors which influenced the loss of employment were males, age between 50 and 60 years, number of comorbidities >2, illiteracy and blue collar versus white collar job before the initiation of dialysis. The majority of patients had the scores above 80 on Karnofsky performance scale and the majority belonged upper and middle classes than lower classes on modified Kuppuswamys socioeconomic status scale; however, the loss of employment was also disproportionately high. There appeared a substantial difference in the attitude of the patients toward the employment. There was no difference between hemodialysis and peritoneal dialysis in the loss of employment of our patients.

Amelogenesis imperfecta and nephrocalcinosis syndrome

An 18-year-old boy presented with pain in left flank of 2 days duration. He had no history of oliguria, dysuria, pyuria, hematuria, graveluria or swelling of feet or face. Examination revealed yellow colored teeth. The labial surfaces of lower teeth showed irregular horizontal enamel defects [Figure 1]. Rest of the general and systemic examination was unremarkable. Ultrasound abdomen revealed bilateral nephrocalcinosis. It was confirmed on a computed tomography [Figure 2]. The other investigations showed serum creatinine to be 0.9 mg/dl, blood urea 24 mg/dl, sodium 138 meEq/l, potassium 4.5 mEq/l, calcium 9.2 mg/dl, inorganic phosphate 3.2 mg/dl, alkaline phosphatase 180 IU/l, parathormone 69 pg/ml, vitamin D 25 ng/ml, bicarbonate 24 mmol/l and urine pH: 5.5. His parents’ marriage was a consanguineous one. His elder brother and father also had yellow colored teeth. He was diagnosed amelogenesis imperfecta (AI) of hypoplastic type with nephrocalcinosis syndrome.

Anti-PLA2R antibody in a secondary cause of membranous nephropathy

moderate axial traction, the catheter could not be removed. The line was then shortened more, transfixed with a suture and secured in the bed of the sternocleidomastoid muscle. Blood cultures (from admission) were reported subsequently to be growing Candida parapsilosis, and this was presumed to be from the line. Although she continued to remain clinically well, she was taken back to theatre. Via the original incision line, a surgical cut down to the buried catheter was performed by the surgical team. The line was freed, and 014-inch guide wires (V14, Boston Scientific) were inserted with pre-loaded 5 mm × 100 mm long balloon catheters (Coyote, Boston Scientific) into each lumen via the open-ended dialysis catheter lumina. Using fluoroscopic guidance, the balloons were briefly and simultaneously inflated to 12 atm along the length of the catheter at three overlapping stations. Figure 1 the catheter was then removed with no resistance or difficulty during careful entry site control and with subsequent surgical closure. The catheter was examined and confirmed to be intact. The tip was sent for culture, and this subsequently cultured the same species of Candida. She has remained well, and multiple subsequent blood cultures have remained sterile. Multiple methods for removal of stuck lines have been described in the literature with only modest success with surgical techniques. Catheters can often be left in situ after an unsuccessful procedure, and this poses long-term risks of infection and occlusion as has been our experience. Endo-luminal dilatation is a safer and more effective procedure and, as our case demonstrates, can even be employed on catheters that have been buried. We believe surgery should be undertaken in patients only after failure of radiological techniques.

Tunnel infection diagnosed by 18 F-FDG PET/CT scan

A 65-year-old lady, type 2 diabetic and hypertensive on peritoneal dialysis for end stage renal disease for the past 24 months. She underwent two exchanges per day with 2.5% dextrose dialysis solution on automated peritoneal dialysis. She had 1.5 L of ultrafiltrate and 200 mL of urine per day. The patient membrane transporter status was high average. The weekly kt/v done 6 months before was 1.4. There were no episodes of peritonitis. She presented with an umbilical hernia; a defect of 0.5 cm diameter and pain on tunnel. There was no redness on tunnel. The dialysis fluid was clear and there was no pain abdomen. Cuff extrusion was not present. A tunnel ultrasound revealed collections at several points along the catheter. An ultrasound guided aspiration was done. The aspirate was clear akin to dialysis fluid. There were no cells. There were no organisms on Gram and Ziehl Neelsen staining and KOH mount. The cultures were sterile [1–5]. An 18F-FDG PET/CT scan was done to identify the presence of tunnel infection. It had shown the presence of metabolically active collection in the tunnel (Fig. 1). An ultrasound guided aspiration of the metabolic active collection was done. The culture showed the growth of Staphylococcus aureus. The organism was sensitive to vancomycin, linezolid, ampicillin and doxycycline. She was treated with four doses of injection vancomycin 1.0 g for every 72 h and tablet doxycycline 100 mg per day for 21 days. After 18 days of treatment the extra peritoneal portion of the catheter was changed to right side with a new tunnel formation and simultaneous repair of the umbilical hernia. This step ensured us to prevent peritonitis. Peritonitis occurring in a patient with tunnel infection does not usually respond to antibiotic therapy without catheter removal. Tunnel infections without concomitant peritonitis can be treated with limited surgical intervention and salvage of the infected catheter. Ultrasonography is most commonly employed imaging method for diagnosis of tunnel infections. A low-echo circumferential rim is seen around the catheter under normal circumstances. The tunnel infection is diagnosed if an area of hypoechogenicity (indicative of fluid collection) > 2 mm in width along any portion of the catheter tract. (1) Scintigrams using white blood cells labelled either with In-111 oxine (2) or with Tc-99m exametazime (3) have also been used to image infected catheter tunnels. 18 F-FDG PET/ CT scan had been used to diagnose the aetiology of fever of unknown origin in patients on dialysis. (4) The accuracy of 18 F-FDG PET/CT in diagnosis of tunnel infections is yet to be established. (5) However it is particularly useful when the infectious collection is not obvious as in our patient. 18 F-FDG PET/CT scan is several times expensive than ultrasound.

Tuberculous peritonitis diagnosed with the help of 18 F-FDG PET/CT scan: 18 F-FDG PET/CT scan

we observed in this study. However, our study is limited in several aspects. First, the assessment results of self-reported frailty may be influenced by mis-perception of subjective health, cognitive dysfunction, and an impairment in communication ability accompanying advanced age. In addition, interrater variability is another theoretical concern, although we have minimized this possibility by meticulous training of nurse researchers before study initiation. Finally, low case number and the presence of other unmeasured confounding factors may limit the generalizability of our findings. In conclusion, the assessment of self-report frailty, a simple point-of-care instrument, in ESRD patients thus can aid in the identification of those at higher risk of developing dialysis access failure in the future.

Pheochromocytoma of Urinary Bladder in a Dialysis PatientPheochromocytoma of Urinary Bladder: Pheochromocytoma of urinary bladder

A 43-year-old gentleman underwent bilateral nephrectomy for bilateral renal cell carcinoma in 2011. It was part of vonHippelLindau (VHL) disease. He was on thrice a week haemodialysis. He was on amlodipine, telmisartan and ramipril. After four years of haemodialysis he presented with uncontrolled hypertension and intradialytic hypertension. He required addition of three more antihypertensives. Clonidine, metaprolol and prazosin were added. Patient was specifically evaluated for the causes of hypertension while on regular haemodialysis. There was no paedal odema and facial oedema suggestive of volume overload. The lowering of dry weight produced cramps; therewas no reduction in blood pressure. The echocardiographic volume parameters did not change before and after haemodialysis. The volume reduction during dialysis was carefully matched to weight gain, so as to avoid excess stimulation of the renin-angiotensin-aldosterone system associated with intravascular volume reduction. To avoid removal of antihypertensive medications during dialysis that could precipitate intradialytic hypertension amlodipine, telmisartan, prazosin were prescribed before dialysis and clonidine and metaprolol were prescribed after haemodialysis. Dialysate sodium levels were adjusted to maintain serum sodium at 135mEq/L. Ionized calcium was maintained between 4.4-5.4mg/dL. The dose of erythropoietin was also adjusted to maintain haemoglobin less than 11.0 g/dL. Despite all these measures there was no reduction in blood pressure. An I-131 MIBG (Metaiodobenzylguanidine) scintigraphy was done. I-131 MIBG is taken up by chromaffin tissue anywhere in the body and useful in localizing small tumours. The I-131MIBG scintigraphy revealed abnormal uptake in urinary bladder (when both kidneys removed) and it persisted for 96hours. It suggested the diagnosis of urinary bladder pheochromocytoma (supplementary figure). Cystoscopic biopsy of the lesion showed, polygonal to spindle-shaped chromaffin cells, also called chief cells, clustered with the sustentacular cells into small nests or alveoli (zellballen) by a rich vascular network. The cytoplasm on silver stain has a finely granular appearance, suggesting the appearance of granules containing catecholamines. Partial cystectomy was performed. On follow up he required only two antihypertensives. Urinary bladder pheochromocytoma constitutes less than 0.05% of urinary bladder tumours and less than 1% of all pheochromocytomas. There is no sex predilection, and the mean age of incidence was fourth decade. The common presenting features are episodes of sweating, hypertension, and haematuria and postmicturition syncope. Clinical hallmarks of VHL disease include the development of retinal and central nervous system hemangioblastomas, pheochromocytomas, multiple cysts in the pancreas and kidneys, and an increased risk for malignant transformation of renal cysts into renal cell carcinoma. There was only one published report of pheochromocytoma of urinary bladder in association with VHL disease.

Effect of organic manures, biofertilizers and micronutrients on growth, yield and quality of onion (Allium cepa L.)

A field experiment was conducted during the Rabi season to find out the effect of organic manures, biofertilizers and micronutrients on growth, yield and quality of onion cv. NHRDF Red - 2. There were 13 treatments viz. , T 0 (Recommended dose of fertilizers), T 1 Poultry manure, T 2 vermicompost, T 3 Azotobacter , T 4 VAM, T 5 Azotobacter +RDF (50%)+zinc, T 6 Azotobacter +RDF(75%)+zinc, T 7 VAM+RDF(50%)+boron, T 8 VAM+RDF (75%)+boron, T 9 RDF (25%)+VAM+poultry manure (50%)+ Azotobacter +boron, T 10 (RDF (25%)+VAM+vermicompost (50%)+ Azotobacter +boron, T 11 RDF (25%)+VAM+poultry manure (50%) Azotobacter +zinc, T 12 RDF (25%)+VAM+vermicompost 50% Azotobacter +zinc and the experiment was laid out under RBD with three replications. The study clearly revealed that there were significant effects of various treatments on the growth, yield and quality attributes of onion. The number of leaves per plant (12.15), plant height (73.02cm), neck thickness (22.00mm), bulb length (6.46 cm), bulb diameter (7.20cm), yield (398.36 kg/ha -1 ) were recorded maximum in treatment T 12 whereas T.S.S (14 °B), vitamin C (12.11mg/100g), total sugars (10.52%), reducing sugar (6.23%) and non-reducing sugar (4.28%) were found maximum in T 10 treatment as compared to other treatment. However, T 12 was good for higher yield improvement and T 10 was the best for quality improvement among the all treatments under study, the application of T 12 (RDF (25%)+VAM+Vermicompost 50% Azotobacter +Zinc) may be suggested for successful cultivation of onion in Lucknow.

Association of amelogenesis imperfecta and Bartter's syndrome

Bartters syndrome is an autosomal recessive renal tubular disorder characterized by hypokalemia, hypochloremia, metabolic alkalosis, and hyperreninemia with normal blood pressure. Bartters syndrome is associated with hypercalciuria and nephrocalcinosis. Amelogenesis imperfecta (AI) is a group of hereditary disorders that affect dental enamel. AI could be part of several syndromes. The enamel renal syndrome is the association of AI and nephrocalcinosis. We report two patients of AI with Bartters syndrome.

Toxic epidermal necrolysis and acute kidney injury due to glyphosate ingestion

The literature, particularly from India, is scarce on the renal effects of glyphosate poisoning. Glyphosate causes toxicity not only after its ingestion but also after dermal exposure by inhalation route and on eye exposure. We present a patient report of glyphosate consumption which resulted in toxic epidermal necrolysis – the first report after glyphosate consumption and acute kidney injury.

Genetic variability, heritability and genetic advance studies for physico-chemical characters of apricot germplasm under Ladakh region

On the basis of survey, a total of eighty three accessions were collected from apricot growing areas of Ladakh region scattered in three valleys, namely, Indus, Suru, Nubra and evaluated accordingly. The analysis of variance revealed significant differences in the accessions for all the quantitative and qualitative characters and indicated that noticeable variability is present in the apricot germplasm. All the 26 characters showed positive phenotypic variance (PV) as well as genotypic variance (GV). It was found that PV was higher than GV in all the characters under study except in five characters, viz., kernel cheek diameter, kernel weight, kernel volume, acidity and reducing sugars were PV and GV was found to be equal. It was also noticed that except three characters, i.e., pH of juice, acidity and reducing sugar, all the characters showed higher magnitude of phenotypic coefficient of variation (PCV) than genotypic coefficient of variance (GCV). The Maximum heritability was recorded in acidity (79.75) followed by kernel cheek diameter (99.40) with least heritability percentage was recorded in leaf petiole length (69.39). The trait kernel cheek diameter (89.601) showed highest genetic advance followed by pulp weight (71.00), fruit volume (67.32) and fruit weight (66.98) with a lowest of 2.93 for kernel volume, respectively.