Sanjib Kumar Sharma

Role of Remission Clinics in the Longitudinal Treatment of CKD

Heavy proteinuria is a major determinant of progression to ESRD for patients with chronic nephropathies and reducing proteinuria should be a key target for renoprotective therapy. In the Remission Clinic, we applied a multimodal intervention to target urinary proteins in 56 consecutive patients who had >3 g proteinuria/d despite angiotensin-converting enzyme inhibitor therapy. We compared the rate of GFR decline and incidence of ESRD in this cohort with 56 matched historical reference subjects who had received conventional therapy titrated to a target BP. During a median follow-up of 4 yr, the monthly rate of GFR decline was significantly lower in the Remission Clinic cohort (median -0.17 versus -0.56 ml/min per 1.73 m2; P < 0.0001), and ESRD events were significantly reduced (3.6 versus 30.4% reached ESRD). Follow-up BP, cholesterol, and proteinuria were lower in Remission Clinic patients than in reference subjects, such that disease remission or regression was achieved in up to 50% of patients who would have been otherwise expected to progress rapidly to ESRD on conventional therapy. Proteinuria reduction independently predicted a slower rate of GFR decline and ESRD incidence, but response to treatment differed depending on the underlying disease. Regarding safety, no patient was with drawn because of hyperkalemia. In summary, multidrug treatment titrated to urinary protein level can be safely and effectively applied to normalize proteinuria and to slow the loss of renal function significantly,especially among patients without type 2 diabetes and with otherwise rapidly progressing chronic nephropathies.

Burden of CKD, Proteinuria, and Cardiovascular Risk Among Chinese, Mongolian, and Nepalese Participants in the International Society of Nephrology Screening Programs

BACKGROUND In 2007, the International Society of Nephrology funded the Kidney Disease Data Center database to house data from sponsored programs aimed at preventing chronic kidney disease and its complications in developing nations. This study compares baseline characteristics and burden of illness among participants from centers in China, Mongolia, and Nepal. An important secondary objective is to show the feasibility of screening for chronic kidney disease and its major risk factors in a diverse group of lower income settings. STUDY DESIGN Cross-sectional screening study. SETTING & PARTICIPANTS Participants from Nepal (n = 8,398), China (n = 1,999), and Mongolia (n = 997). Screening was open to the public for participants in China and Nepal; referral from a general practitioner was required for participants in Mongolia. OUTCOMES Estimated glomerular filtration rate (eGFR), proteinuria, hypertension, diabetes, obesity, cardiovascular risk. MEASUREMENT Demographic and clinical data were collected prospectively using a standard format. Blood and urine specimens were provided according to local protocol. RESULTS Of 11,394 participants, decreased eGFR (<60 mL/min/1.73 m(2)) was present in 7.3%-14% of participants across centers; proteinuria (≥1+) on dipstick (2.4%-10%), hypertension (26%-36%), diabetes (3%-8%), and obesity (body mass index ≥30 kg/m(2); 2%-20%) were all common. Predicted 5-year cardiovascular risk ≥10% ranged from 20%-89%. Numbers needed to screen to detect a new case of eGFR <60 mL/min/1.73 m(2), hypertension, or diabetes were 2.6 (95% CI, 2.5-2.7), 3.4 (95% CI, 3.1-3.7), and 4.7 (95% CI, 3.3-8.0) for Nepal, China, and Mongolia, respectively. LIMITATIONS May not be representative of the general population. CONCLUSIONS The acceptable diagnostic yield of abnormalities across these 3 diverse settings suggests that trials of targeted screening and intervention are feasible and warranted in such countries.

Asian chronic kidney disease best practice recommendations: Positional statements for early detection of chronic kidney disease from Asian Forum for Chronic Kidney Disease Initiatives (AFCKDI)

1. Targets

Chronic kidney disease and cardiovascular risk in six regions of the world (ISN-KDDC): a cross-sectional study

BACKGROUND Chronic kidney disease is an important cause of global mortality and morbidity. Data for epidemiological features of chronic kidney disease and its risk factors are limited for low-income and middle-income countries. The International Society of Nephrologys Kidney Disease Data Center (ISN-KDDC) aimed to assess the prevalence and awareness of chronic kidney disease and its risk factors, and to investigate the risk of cardiovascular disease, in countries of low and middle income. METHODS We did a cross-sectional study in 12 countries from six world regions: Bangladesh, Bolivia, Bosnia and Herzegovina, China, Egypt, Georgia, India, Iran, Moldova, Mongolia, Nepal, and Nigeria. We analysed data from screening programmes in these countries, matching eight general and four high-risk population cohorts collected in the ISN-KDDC database. High-risk cohorts were individuals at risk of or with a diagnosis of either chronic kidney disease, hypertension, diabetes, or cardiovascular disease. Participants completed a self-report questionnaire, had their blood pressure measured, and blood and urine samples taken. We defined chronic kidney disease according to modified KDIGO (Kidney Disease: Improving Global Outcomes) criteria; risk of cardiovascular disease development was estimated with the Framingham risk score. FINDINGS 75,058 individuals were included in the study. The prevalence of chronic kidney disease was 14·3% (95% CI 14·0-14·5) in general populations and 36·1% (34·7-37·6) in high-risk populations. Overall awareness of chronic kidney disease was low, with 409 (6%) of 6631 individuals in general populations and 150 (10%) of 1524 participants from high-risk populations aware they had chronic kidney disease. Moreover, in the general population, 5600 (44%) of 12,751 individuals with hypertension did not know they had the disorder, and 973 (31%) of 3130 people with diabetes were unaware they had that disease. The number of participants at high risk of cardiovascular disease, according to the Framingham risk score, was underestimated compared with KDIGO guidelines. For example, all individuals with chronic kidney disease should be considered at high risk of cardiovascular disease, but the Framingham risk score detects only 23% in the general population, and only 38% in high-risk cohorts. INTERPRETATION Prevalence of chronic kidney disease was high in general and high-risk populations from countries of low and middle income. Moreover, awareness of chronic kidney disease and other non-communicable diseases was low, and a substantial number of individuals who knew they were ill did not receive treatment. Prospective programmes with repeat testing are needed to confirm the diagnosis of chronic kidney disease and its risk factors. Furthermore, in general, health-care workforces in countries of low and middle income need strengthening. FUNDING International Society of Nephrology.

Prevention programmes of progressive renal disease in developing nations (Review Article)

SUMMARY:  Development of strategies for the early detection and prevention of non‐communicable diseases, including kidney disease, is the only realistic strategy to avert an imminent global health and economic crisis and enhance equity in health care worldwide. In this article, we briefly examine the burden of non‐communicable diseases, including diabetes, hypertension, cardiovascular disease and how chronic kidney disease (CKD) represents a key integrated element in the setting, even in developing countries. A possible explanation of the increasing number of people who have or are at risk to develop CKD in poor countries is also given. A survey of major screening and intervention programmes performed or ongoing globally is then presented, highlighting differences and hurdles of projects planned in developed or developing nations as well as in unprivileged communities in developed countries. Finally, some recommendations on future steps to implement prevention programmes in emerging worlds are provided.

Snakebite-reappraisal of the situation in Eastern Nepal

Four thousand and seventy eight cases of snakebite, occurring between January and December 2000, were analysed for clinical and epidemiological features. Cases of about 379 had features of envenoming and 81 died. All the victims with systemic envenoming had neurotoxicity. No case with coagulopathy was recorded. Snakebite was more frequent between the ages of 10 and 40 years (76%) and in males (73%). The majority (80%) of the snakebites were observed during the monsoon. Seventy percent of the bites with clinical features of envenoming occurred between 1400 and 2200 h. Five thousand eight hundred and fifty nine vials of polyvalent antisnake venom were used. Case fatality rate varied in the ten centres surveyed. It was as low as 3% in some to as high as 58% in others. Overall death rate among all snakebite cases was 2%.

Preventing renal and cardiovascular risk by renal function assessment: insights from a cross-sectional study in low-income countries and the USA

Objective To assess the prevalence of microalbuminuria and kidney dysfunction in low-income countries and in the USA. Design Cross-sectional study of screening programmes in five countries. Setting Screening programmes in Nepal, Bolivia, the USA (National Health and Nutrition Examination Survey (NHANES) 2005–2008) Bangladesh and Georgia. Participants General population in Nepal (n=20 811), Bolivia (n=3436) and in the USA (n=4299) and high-risk subjects in Bangladesh (n=1518) and Georgia (n=1549). Primary and secondary outcome measures Estimated glomerular filtration rate (eGFR)<60ml/min/1.73 m2 and microalbuminuria (defined as urinary albumin creatinine ratio values of 30–300 mg/g) were the main outcome measures. The cardiovascular (CV) risk was also evaluated on the basis of demographic, clinical and blood data. Results The prevalence of eGFR<60ml/min/1.73 m2 was 19%, 3.2% and 7% in Nepal, Bolivia and the USA, respectively. In Nepal, 7% of subjects were microalbuminuric compared to 8.6% in the USA. The prevalence of participants with predicted 10-year CV disease (CVD) risk ≥10% was 16.9%, 9.4% and 17% in Nepal, Bolivia and in the USA, respectively. In Bangladesh and Georgia, subjects with eGFR<60 ml/min/1.73 m2 were 8.6% and 4.9%, whereas those with microalbuminuria were 45.4% and 56.5%, respectively. Predicted 10-year CVD risk ≥10% was 25.4% and 25% in Bangladesh and Georgia, respectively. Conclusions Renal abnormalities are common among low-income countries and in the USA. Prevention programmes, particularly focused on those with renal abnormalities, should be established worldwide to prevent CVD and progression to end-stage renal disease.

Pattern of skin and nail changes in chronic renal failure in Nepal: A hospital-based study

Chronic renal failure, regardless of its cause, often produces specific dermatological abnormalities, which can develop long before failure manifests clinically. Our aim was to study the clinical pattern of skin and nail changes in chronic renal failure and also study the associations of these changes with age, sex, etiology and duration of the chronic renal failure. A total of 104 diagnosed cases of chronic renal failure were included in the study over a period of 1 year. Equal numbers of age‐ and sex‐matched individuals were taken as controls. The male : female ratio was 1.4:1. The mean duration of chronic renal failure was 19 ± 20 months. Among cases and controls, 72% and 16% had skin changes, respectively. Xerosis was the most common of the skin changes (28%), followed by hyperpigmentation (20%), pruritus (15%), infectious diseases (5%) and other skin changes (33%) in chronic renal failure patients. Abnormal nail changes were seen in 82% of the cases compared to only 8% of the controls. In the cases, white nail was most common followed by brown and half‐and‐half nail. Pruritus was significantly higher in the dialysis group whereas the nail changes were significantly higher in the non‐dialysis group. The skin and nail changes were common in chronic renal failure and manifested in various forms. Thus, thorough inspection of the integument might reveal markers of occult renal disease.

Scorpion sting envenomation presenting with pulmonary edema in adults: a report of seven cases from Nepal.

Scorpion sting is a common problem in villages of Eastern Nepal. The life-threatening complications of myocarditis and pulmonary edema is known in red scorpion in India but not reported in Nepal. This condition requires urgent attention and ICU care from few hours to days. Delay in recognition and the hypoxemia increase the morbidity and mortality. Illiteracy, ignorance, poverty, traditional faith healers trying treatment in remote areas, lack of transport in difficult terrains and the non availability of ventilation facility in nearby hospital, add to delay in appropriate treatment. Seven young adult patients admitted in a span of two years with history of scorpion sting presenting with pulmonary edema required ICU care. They were successfully managed with the positive pressure ventilation with PEEP, cardiac support with inotropes and fluid balance. Magnitude of problem, clinical presentation and management done is emphasized.

Primary Amoebic Meningoencephalitis in a Patient with Systemic Lupus Erythematosus

This report describes a case of primary amoebic meningoencephalitis in a patient with systemic lupus erythematosus. No specific exposure was identified. Treatment with intravenous amphotericin B was associated with marked clinical improvement, but subsequent fatal relapse while still on therapy.