Rabindra Nath Mishra

Changing epidemiology of community-acquired acute kidney injury in developing countries: analysis of 2405 cases in 26 years from eastern India.

Background The epidemiology of acute kidney injury (AKI) differs from country to country and varies from center to center within a country. Owing to the absence of a central registry, data on overall epidemiology of AKI are scanty from India. Methods This study aimed at describing changes in epidemiology of community-acquired AKI (CAAKI) over a time span of 26 years in two study periods, namely, 1983–95 and 1996–2008. Results We studied 2405 (1375 male and 1030 female) cases of AKI in the age range 1–95 (mean: 40.32) years. The incidence of CAAKI in 1983–95 and 1996–2008 was 1.95 and 4.14 per 1000 admission, respectively (P < 0.01). Obstetrical AKI has decreased because of the declining number of post-abortal AKI. Surgical AKI decreased from 13.8% in 1983–95 to 9.17% in 1996–2008(P < 0.01). Malarial AKI increased significantly from 4.7% in the first half of the study to 17% in the later period (P < 0.01). Diarrhea-associated AKI had significantly decreased from 36.83% in 1983–95 to 19% in 1996–2008 (P < 0.01). Sepsis-related AKI had increased from 1.57% in 1983–95 to 11.43% in 1996–2008 (P < 0.01). Nephrotoxic AKI showed an increasing trend in recent years (P < 0.01) and mainly caused by rifampicin and NSAIDs. Liver disease-related AKI increased from 1.73% in 1983–95 to 3.17% in 1996–2008 (P < 0.01). Myeloma-associated acute renal failure (ARF) accounted for 1.25% of the total number of ARF cases in the period 1996–2008. HIV infection contributed to 1.65% of ARF of the total number of AKI cases in the second period (1996–2008). Incidence of renal cortical necrosis (RCN) decreased significantly from 5.8% in 1983–95 to 1.3% in 1996–2008 of the total number of ARF cases (P < 0.01). However, during the same period ARF due to acute tubular necrosis, acute glomerulonephritis and acute interstitial nephritis remained unchanged. The mortality rate from AKI decreased significantly from 20% in 1983–95 to 10.98% in 1996–2008 (P < 0.01). Conclusions The epidemiological characteristics of CAAKI have changed over the past three decades. There has been an increase in the overall incidence of ARF with the changing etiology of AKI in recent years. Incidences of obstetrical, surgical and diarrheal AKI have decreased significantly, whereas those of AKI associated with malaria, sepsis, nephrotoxic drugs and liver disease have increased. RCN has decreased significantly. In contrast to developed nations, community-acquired AKI is more common in developing countries. It often affects younger individuals and is caused by single and preventable diseases.

Prolonged versus standard prednisolone therapy for initial episode of idiopathic nephrotic syndrome.

BACKGROUND The prolongation of steroid therapy for an initial episode of idiopathic nephrotic syndrome may decrease any relapses. Two treatment protocols were compared with the objective of finding the frequency of relapses and side effects of steroid in the following 12-month period. METHODS A hospital-based prospective study was conducted of 80 children allocated randomly to receive prolonged (5-month) or standard (3-month) prednisolone therapy. They were followed quarterly for 12 months during which the numbers of relapses and steroid side effects were noted. RESULTS The mean relapse rate (0.63 vs. 1.54; p=0.011) and cumulative risk of relapse per patient per month (0.05 vs. 0.131) were significantly lower in the prolonged than the standard treatment. Total relapses in patients followed up for 12 months were significantly lower in the prolonged-therapy as compared with the standard-therapy group (21.6% vs. 70.2%; p=0.001). Cumulative percentage of patients with sustained remission at 12 months was significantly higher in the prolonged-therapy than the standard-therapy group (76% vs. 29%). Mean cumulative dose of prednisolone with prolonged therapy was significantly lower than with standard treatment (p=0.033). Steroid side effects such as cushingoid appearance, hirsutism, striae and hypertension were comparable in both treatment groups. CONCLUSIONS A prolonged course of prednisolone therapy for an initial episode of nephrotic syndrome can be considered, as it reduces the rate of relapses without increasing the risk for steroid side effects.

High prevalence of malnutrition and inflammation in undialyzed patients with chronic renal failure in developing countries : A single center experience from Eastern India

Background. Malnutrition is common in patients with chronic renal failure (CRF), and its prevalence before the initiation of dialysis is poorly characterized in these patients in developing countries. There is a paucity of data on the quantification of malnutrition and inflammation in undialyzed patients of CRF from India. This study analyzed the prevalence and causes of malnutrition in patients with CRF before the initiation of dialysis treatment. Material and Methods. In the present study, assessments of nutritional and inflammatory status were carried out in patients with CRF. Serum albumin, body mass index (BMI), triceps skin fold thickness (TST), mid-arm muscle circumference (MAMC), and subjective global assessment (SGA) scoring were used for assessment of nutritional parameters. Serum C-reactive protein and serum ferritin level were used to assess the inflammatory state of the patient. Results. Two hundred and three (146 male, 57 female) patients with CRF were included in the study from August 2004 to April 2006. Overall, the prevalence of malnutrition was 65% (131/203). The age of malnourished patients (93 male, 38 female) ranged from 11–82, with mean age of 52 ± 12.68 years. The mean serum total protein and albumin were also significantly lower in patients with malnutrition in comparison to non malnourished cases (5.50 ± 0.40 gm/dL vs. 5.74 ± 0.38 gm/dL; p < 0.05, and 3.18 ± 0.58 gm/dL vs. 3.68 ± 0.55 gm/dL; p < 0.05). The C-reactive protein and serum ferritin were significantly elevated in the malnourished group as compared to non-malnourished patients (63% vs. 33%; p < 0.05, and 301.2 ± 127.1 mg/dL vs. 212.7 ± 124.9 mg/dL; p < 0.05). Conclusion. Thus, malnutrition was common in patients with CRF before the commencement of dialysis. These data indicate that an emphasis should be placed on the assessment and prevention or correction of malnutrition in patients with CRF because of its documented adverse effect on the outcome on maintenance dialysis.

Lay perceptions of kala‐azar, mosquitoes and bed nets in Bihar, India

Objective  To describe the lay perception of kala‐azar (KA) in an endemic area of Muzaffarpur District, Bihar, India: local names, symptoms, affected persons, perceived severity and modes of transmission, as well as perceived mosquito nuisance, modes of protection and use of bed nets.

Clinico-mycological study of dermatophytic infections and their sensitivity to antifungal drugs in a tertiary care center

Background: Worldwide, dermatophytic infections are running a chronic course either due to ineffective treatment or emerging drug resistance. In the past three decades, there has been an increase in incidence and non-responsiveness to conventional antifungals, which suggests that there is a need of antifungal sensitivity testing. Aims: This study was aimed at identifying clinico-mycological pattern of dermatophytic infections in patients attending thedermatology outpatient department of a tertiary care hospital, and to obtain the sensitivity pattern of isolates against six commonly used oral antifungals (fluconazole, terbinafine, itraconazole, ketoconazole, griseofulvin and voriconazole). Methods: Patients with suspected dermatophytoses attending the outpatient department of Sir Sunderlal Hospital, Varanasi, were enrolled in the study. A detailed history, clinical examination and sample collection for mycological examinations was done. In vitro antifungal sensitivity testing was done on species isolated from culture as per the Clinical and Laboratory Standard Institute M38-A standards, with broth microdilution method. Results: There were 256 patients recruited in the study, with a male: female ratio of 3:1. The most commonly affected age group was 20–40 years (52.4%). Tinea corporis et cruris was the most common type observed (27.2%). Potassium hydroxide positivity was seen in 211 samples (79.6%) and culture positivity was found in 139 samples (52.4%). The most common species identified was Trichophyton mentagrophytes (75.9%). Sensitivity testing was done on fifty isolates of T. mentagrophytes. Minimum inhibitory concentrations of itraconazole, ketoconazole, terbinafine and voriconazole were comparable, while griseofulvin showed the highest minimum inhibitory concentration. Itraconazole was found to be the most effective drug, followed by ketoconazole, terbinafine and fluconazole. Griseofulvin was the least effective drug among the tested antifungals. Limitations: This is a hospital-based study, and may not reflect the true pattern in the community. Sensitivity pattern of only one species T. mentagrophytes was carried out. Conclusion: Inadequate and irregular use of antifungal drugs has led to the emergence of resistant strains, which cause poor treatment outcomes. Thus, it is very important to test for antifungal sensitivity to check for resistance to antifungals.

Can We Predict Relapses in Children with Idiopathic Steroid-Sensitive Nephrotic Syndrome?

The objective of the present study was to find out the predictors of relapse. One hundred fifty children with a first episode of idiopathic nephrotic syndrome were followed for 12 months after initial treatment. Sixty-one (40.7%) children had no relapse, and 89 (59.3%) had relapses. A significantly higher proportion of children with disease onset between 1 and 3 years were relapsers in comparison with those with disease onset at 4-6 (p < 0.03) and 7-13 (p < 0.001) years. Risk of relapse was 2.99 times higher in this 1-3 year age-group as compared with patients aged >6 years (p = 0.001). Children responding between 1 and 2 weeks after start of treatment had a 0.423 times lesser risk of relapse than those who responded after 4 weeks (p = 0.023). Relapsers had significantly higher incidence of infection at relapse than at other time points (p < 0.001). Onset of disease in younger age and delayed response to prednisolone therapy were found as significant predictors for relapse.

Validation of Predictors of Relapse in Steroid Sensitive Idiopathic Nephrotic Syndrome

To the Editor: About 70% of the patients of idiopathic nephrotic syndrome in children experience relapse after treatment of first episode [1]. We found younger age at onset of disease and longer time to response as predictors of relapse and derived formulae using discriminant function analysis tool [2]; however, it needed validation for their prediction. The objectives of the present study were to validate the previously derived formulae on newly prospectively enrolled patients, and also re-derive new formulae by combining previous retrospectively and prospectively enrolled patients’ data and assess their predictive ability for relapses. One hundred patients of first episode of steroid sensitive idiopathic nephrotic syndrome, aged 1–13 y, were enrolled and followed for next 12 mo period after completion of treatment with prednisolone (2 mg/kg/d single dose for 6 wk, followed by 1.5 mg/kg/d single dose every alternate day for 6 wk). The protocol of the study was approved by Institute Ethical Committee. Initially patients were categorised into relapser and non-relapser groups by substituting the age at onset of disease and time to response scores in the following previously derived formulae [2] (for non-relapser, −6.965 + 3.558 age group score + 3.256 time to response score and for relapser, −6.559 + 2.817 age group score + 3.842 time to response score). The scores assigned for age group and time to response were 1 for 1–3 y and 1–2 wk, 2 for 4–6 y and 3–4 wk and 3 for 7–13 y and 5–8 wk, respectively. The formula yielding the higher value indicated the category of patient (non-relapser or relapser). It had 58.5% sensitivity, 89.4% specificity and 73% accuracy for predicting the relapses. Further, the data of 100 cases were combined with previously recorded 150 cases and new formulae (for non-relapser, −7.145 + 3.881 age group score + 3.881 time to response score and for relapser, −6.134 + 2.920 age group score + 3.566 time to response score) were derived, and applied on these total 250 cases. It had modest sensitivity (66.4%), specificity (70.1%) and accuracy (68%) in predicting relapses. Further, out of total of 100 new cases, 64 were predicted as non-relapsers and 36 as relapsers by both the old and new formulae. Constantinescu et al. [3] found that patients who achieved remission within the first week were more likely to be infrequent relapsers. Kabuki et al. [4] observed longer duration of time to response in younger age group of patients. Time to response has been also emphasized as a future prognostic factor by Vivarelli et al. [5]. In our study, old formulae had lower sensitivity but higher specificity and new formulae showed better sensitivity, but relatively lower specificity and almost similar accuracy. This difference could be because of sample size. However, no deviation between the two formulae was observed as regard to their predictive ability. Thus, any of these formulae can be used for prediction of relapses in these patients. This may help the families for better compliance in treatment and follow-up.

Anatomical Anomalies of Femoral Vein are Not Observed in Indian Patients with Renal Failure: Ultrasound-based Study

Background: Femoral vein catheterization is the easiest and safest method for obtaining temporary vascular access in hemodialysis patients. We studied the structure and anatomical variation of femoral veins in uremic patients using ultrasound imaging. Methods: Ultrasonography of femoral vessels was carried out bilaterally in patients with acute renal failure (ARF) and chronic renal failure (CRF). The relationship between ultrasonographic measurements of femoral vessels and anthropometric data were evaluated using Pearson’s method. Results: A total of 157 patients (67 ARF, 90 CRF) were included in the study. The majority of the patients were male (68.8%), and mean age was 43.29 ± 16.74 years. Mean height, weight, and body mass index were 163.94 ± 8.53 cm, 61.96 ± 12.37 kg, and 22.99 ± 3.68 kg/m2 , respectively. Mean depth of the femoral artery was 10.74 ± 4.74 mm on the left side and 9.92 ± 3.98 mm on the right side. Mean diameter of the femoral artery was 7.77 ± 1.57 mm on the left side and 7.64 ± 1.45 mm on the right side. Mean distance of the femoral vein from the skin surface was 13.68 ± 4.98 mm on the left side and 12.76 ± 4.85 mm on the right side. Mean diameter of the femoral vein was 9.47 ± 2.15 mm on the left side and 9.37 ± 2.25 mm on the right side. The femoral vein had adequate diameter (≥ 5 mm) on both sides in all patients. Abnormal location of the femoral vein was not observed in our study. The depth of femoral vasculature was deeper in overweight and obese patients compared to normal weight patients. Femoral artery puncture, multiple attempts before successful catheterization, and hematoma formation were observed in 11.0%, 13.5%, and 5.4% of patients, respectively. Conclusion: Anatomical variation and location anomalies of the femoral vein were not observed in Indian uremic patients. Femoral vein diameter was adequate (≥ 5 mm) in all patients bilaterally. However, there was a slight variation in depth (> 1 mm) and diameter (0.1 mm) of femoral vasculature between the left and right sides (left > right). [Hong Kong J Nephrol 2009;11(1):30–4]