Santosh Varughese

Chronic kidney disease hotspots in developing countries in South Asia

In many developing countries in the South Asian region, screening for chronic diseases in the community has shown a widely varying prevalence. However, certain geographical regions have shown a high prevalence of chronic kidney disease (CKD) of unknown etiology. This predominantly affects the young and middle-aged population with a lower socioeconomic status. Here, we describe the hotspots of CKD of undiagnosed etiology in South Asian countries including the North, Central and Eastern provinces of Sri Lanka and the coastal region of the state of Andhra Pradesh in India. Screening of these populations has revealed cases of CKD in various stages. Race has also been shown to be a factor, with a much lower prevalence of CKD in whites compared to Asians, which could be related to the known influence of ethnicity on CKD development as well as environmental factors. The difference between developed and developing nations is most stark in the realm of healthcare, which translates into CKD hotspots in many regions of South Asian countries. Additionally, the burden of CKD stage G5 remains unknown due to the lack of registry reports, poor access to healthcare and lack of an organized chronic disease management program. The population receiving various forms of renal replacement therapy has dramatically increased in the last decade due to better access to point of care, despite the disproportionate increase in nephrology manpower. In this article we will discuss the nephrology care provided in various countries in South Asia, including India, Bangladesh, Pakistan, Nepal, Bhutan, Sri Lanka and Afghanistan.

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.

Extensive emphysematous pyelonephritis in a renal allograft treated conservatively: case report and review of the literature.

Emphysematous pyelonephritis (EPN) is a rare occurrence in renal allografts. An aggressive approach resulting in transplant nephrectomy is viewed as the standard of care. Over the recent years, treatment with percutaneous drainage (PCD) of the renal and perinephric collections and appropriate antibiotics has been reported with good success in lesser grades of this infection. Only 4 cases of extensive EPN disease with Escherichia coli, treated with conservative management, are reported in the English‐language literature. We present a case of severe EPN caused by Klebsiella pneumoniae, successfully managed with early PCD, and propose a step‐up strategy aimed toward graft preservation.

A Patient with Amphotericin-Resistant Curvularia lunata Peritonitis

1. Kovacs G, Burghardt J, Pradella S, Schumann P, Stackebrandt E, Marialigeti K. Kocuria palustris sp. nov. and Kocuria rhizophila sp. nov., isolated from the rhizo plane of the narrow-leaved cattail (Typha angustifolia). Int J Syst Bacteriol 1999; 49(pt 1):167–73. 2. Altuntas F, Yildiz O, Eser B, Gündogan K, Sumerkan B, Cetin M. Catheter-related bacteremia due to Kocuria rosea in a patient undergoing peripheral blood stem cell transplantation. BMC Infect Dis 2004; 4:62. 3. Basaglia G, Carretto E, Barbarini D, Moras L, Scalone S, Marone P, et al. Catheter-related bacteremia due to Kocuria kristinae in a patient with ovarian cancer. J Clin Microbiol 2002; 40:311–13. 4. Becker K, Rutsch F, Uekotter A, Kipp F, Konig J, Marquardt T, et al. Kocuria rhizophila adds to the emerging spectrum of micrococcal species involved in human infections. J Clin Microbiol 2008; 46:3537–9. 5. Ma ES, Wong CL, Lai KT, Chan EC, Yam WC, Chan AC. Kocuria kristinae infection associated with acute cholecystitis. BMC Infect Dis 2005; 5:60. 6. Tsai CY, Su SH, Cheng YH, Chou YL, Tsai TH, Lieu AS. Kocuria varians infection associated with brain abscess: a case report. BMC Infect Dis 2010; 10:102. 7. Lee JY, Kim SH, Jeong HS, Oh SH, Kim HR, Kim YH, et al. Two cases of peritonitis caused by Kocuria marina in patients undergoing continuous ambulatory peritoneal dialysis. J Clin Microbiol 2009; 47:3376–8. doi:10.3747/pdi.2010.00125

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.

Posterior reversible encephalopathy syndrome in a renal allograft recipient: A complication of immunosuppression?

Posterior reversible encephalopathy syndrome (PRES) is an uncommon post-renal transplant complication. We report a 16-year-old boy who had an acute cellular rejection immediate post-transplant and was given intravenous methylprednisolone along with an increase in tacrolimus dose. He was diagnosed to have PRES based on clinical and radiological features within 6 h of intensified immunosuppression. This is an unusual case report of successfully managing PRES with continuation of the intensified immunosuppression as warranted by the clinical situation, along with aggressive blood pressure control. After 6 weeks, magnetic resonance imaging showed complete resolution of lesions. He has good graft function and no residual neurological deficits while on small doses of three antihypertensives, 12 months after transplantation.

The increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990–2016

Summary Background The burden of diabetes is increasing rapidly in India but a systematic understanding of its distribution and time trends is not available for every state of India. We present a comprehensive analysis of the time trends and heterogeneity in the distribution of diabetes burden across all states of India between 1990 and 2016. Methods We analysed the prevalence and disability-adjusted life-years (DALYs) of diabetes in the states of India from 1990 to 2016 using all available data sources that could be accessed as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, and assessed heterogeneity across the states. The states were placed in four groups based on epidemiological transition level (ETL), defined on the basis of the ratio of DALYs from communicable diseases to those from non-communicable diseases and injuries combined, with a low ratio denoting high ETL and vice versa. We assessed the contribution of risk factors to diabetes DALYs and the relation of overweight (body-mass index 25 kg/m2 or more) with diabetes prevalence. We calculated 95% uncertainty intervals (UIs) for the point estimates. Findings The number of people with diabetes in India increased from 26·0 million (95% UI 23·4–28·6) in 1990 to 65·0 million (58·7–71·1) in 2016. The prevalence of diabetes in adults aged 20 years or older in India increased from 5·5% (4·9–6·1) in 1990 to 7·7% (6·9–8·4) in 2016. The prevalence in 2016 was highest in Tamil Nadu and Kerala (high ETL) and Delhi (higher-middle ETL), followed by Punjab and Goa (high ETL) and Karnataka (higher-middle ETL). The age-standardised DALY rate for diabetes increased in India by 39·6% (32·1–46·7) from 1990 to 2016, which was the highest increase among major non-communicable diseases. The age-standardised diabetes prevalence and DALYs increased in every state, with the percentage increase among the highest in several states in the low and lower-middle ETL state groups. The most important risk factor for diabetes in India was overweight to which 36·0% (22·6–49·2) of the diabetes DALYs in 2016 could be attributed. The prevalence of overweight in adults in India increased from 9·0% (8·7–9·3) in 1990 to 20·4% (19·9–20·8) in 2016; this prevalence increased in every state of the country. For every 100 overweight adults aged 20 years or older in India, there were 38 adults (34–42) with diabetes, compared with the global average of 19 adults (17–21) in 2016. Interpretation The increase in health loss from diabetes since 1990 in India is the highest among major non-communicable diseases. With this increase observed in every state of the country, and the relative rate of increase highest in several less developed low ETL states, policy action that takes these state-level differences into account is needed urgently to control this potentially explosive public health situation. Funding Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Indian chronic kidney disease study: Design and methods.

The rate and factors that influence progression of chronic kidney disease (CKD) in developing countries like India are unknown. A pan‐country prospective, observational cohort study is needed to address these knowledge gaps.

Renal allograft recipient with melioidosis of the urinary tract

S. Varughese, A. Mohapatra, R. Sahni, V. Balaji, V. Tamilarasi. Renal allograft recipient with melioidosis of the urinary tract.
Transpl Infect Dis 2011: 13: 95–96. All rights reserved

Jejunal Mesenteric Artery Laceration Following Blind Peritoneal Catheter Insertion Using the Trocar Method

Editor: Percutaneous peritoneal catheter insertion for peritoneal dialysis (PD) is widely used and success rates similar to those with open placement are reported. Percutaneous insertion is typically done using either a Seldinger technique or the Trocar method. We report a case where blind percutaneous catheter insertion using the Trocar method resulted in jejunal mesenteric arterial laceration and severe intra-abdominal bleeding. A 56-year-old man with diabetic nephropathy, chronic kidney disease stage 5, and ischemic heart disease presented with fluid overload. He was stabilized with ultrafiltration and hemodialysis over 2 weeks. A month later, he underwent blind percutaneous PD catheter insertion in which the trocar and cannula method was used. After a dose of preoperative intravenous vancomycin and sedation with intramuscular pentazocine, a midline incision 2.5 cm long was made about 2 cm below the umbilicus. The peritoneal cavity was filled with 1.5 L saline using an 18F intravenous cannula. The trocar and cannula were vertically maneuvered to make a point incision in the linea alba big enough to admit the lubricated permanent PD catheter, which was then secured in place by purse-string proline sutures. About 1 L PD fluid was instilled in the peritoneal cavity via the PD catheter. The drain was initially mildly blood tinged. The subcutaneous tunnel was made and the distal end of the catheter exteriorized. The incision wound was closed in layers. The effluent continued to be blood tinged and the patient’s blood pressure began to decrease. Despite two units of whole blood and fluids, the patient continued to be in hypovolemic shock. At laparotomy, the peritoneal cavity was filled with blood: a laceration of the jejunal mesenteric artery was identified and ligated. Further blood transfusions after surgery stabilized the patient. The catheter position and tunnel were left untouched. The laparotomy incision was made in the midline immediately below the incision made for catheter insertion. The patient subsequently underwent regular PD exchanges without any impediment to either inflow or drainage of PD fluid. This is the only such complication that has been experienced in over 30 percutaneous catheter insertions. Blind percutaneous PD catheter insertion is a relatively easy procedure that can be done by nephrologists without requiring a dedicated operation theater and anesthesia time. The procedure is safe when done by experienced personnel. There are two percutaneous techniques. The more common is the procedure using a peel-away sheath with the Seldinger technique (1). The other, using a trocar and cannula, is employed at our center. The laparoscopic and open surgical techniques require obtaining specialized surgical and anesthetic services, are more expensive, and increase the duration of hospital stay. The open surgical method is routinely preferred in those with prior abdominal surgeries with likelihood of adhesions. However, in the blind procedures, there always exists the unavoidable risk of misadventure and surgical backup is necessar y. The technique of catheter insertion using the peel-away sheath obviates the need of the sharp trocar and is less likely to cause injury to viscera. The fluoroscopy-guided procedure is perhaps safer and, although the two have not been directly compared, results and safety are comparable to the directly visualized surgical method (2). While the usefulness remains unproven, the surgical method has been more commonly employed in obese patients (3) and we began to adopt this practice after the occurrence of this complication. Minor hemorrhage following PD catheter placement is usually caused by abdominal wall blood vessel injury and can easily be controlled. Mital et al. (4) reported a retrospective case series of surgical placement of 292 catheters where there was major hemorrhage in 6 patients (2%). However, this was due to perioperative anticoagulation, aspirin use, or thrombocytopenia in all but 1 patient. Smith et al. reported the occurrence of bleeding associated with percutaneous placement of PD catheters in 2 of 31 (6.4%) catheter placements (5). Neither patient required exploration or blood transfusions but settled with PD fluid exchanges. One required transfusion of platelets for thrombocytopenia. When the effluent is bloody with hemodynamic compromise, as in our patient, immediate explorative