Shankar Prasad Nagaraju

Pharmaceutical Care for Dialysis Patients

The incidence of end stage renal disease (ESRD) is increasing worldwide. Dialysis centers are overwhelmed by the increased number of patients. When a patient becomes aware that his/her kidneys are nonfunctional, he/she is likely to be confused and depressed. The counseling of the patient in the matter of drugs, disease, and lifestyle forms an important necessity, which can help the patient′s confidence and motivate the patient for self-care of his/her condition. The counseling of the patient and dispelling the myths regarding ESRD and dialysis is vital for all patients on a continuous basis. This can be achieved by practicing the pharmaceutical care in ESRD patients on dialysis. In this article, the knowhow and the significance of self-management of ESRD patients on dialysis is discussed.

Acute kidney injury in patients with cirrhosis of liver: Clinical profile and predictors of outcome

BackgroundAcute kidney injury (AKI) is a common complication of liver cirrhosis and is associated with poor survival. We studied the clinical profile and predictors of in-hospital mortality in patients with cirrhosis of the liver with AKI.MethodsThis retrospective cohort study examined patients at a tertiary care hospital. AKI staging was done based on the new 2015 Ascites Club Criteria. Patients were grouped into three types of AKI: pre-renal azotemia (PRA), hepatorenal syndrome (HRS), and acute tubular necrosis (ATN).ResultsData of 123 patients with cirrhosis and AKI were analyzed. Most patients had AKI stage 3 (57.7%). ATN (42.3%) and HRS (43.9) were the predominant types of AKI followed by PRA (13.8%). The overall in-hospital mortality in our study was 44.7%. The mortality increased with increasing severity of AKI (p = 0.0001) and was the highest in AKI stage 3 (p = 0.001) and those who required hemodialysis (p = 0.001). There was a significant in-hospital mortality in patients with ATN and HRS in comparison to PRA (p = 0.001). On multivariate analysis, the factors predicting in-hospital mortality were AKI stage 3, and oliguria (p = 0.0001).ConclusionsAcute kidney injury in cirrhosis of liver carries high in-hospital mortality. Pre-renal AKI has a better survival compared to ATN and HRS. The higher stage of AKI at presentation and the presence of oliguria are two important predictors of in-hospital mortality.

Clinicopathological characteristics and outcomes of diffuse crescentic glomerulonephritis - A single center experience from southern India

Introduction Diffuse Crescentic glomerulonephritis (CrGN) is characterized by rapidly progressive renal failure and has grave prognosis. There is significant regional and temporal variation in aetiology, prevalence and prognosis of diffuse crescentic glomerulonephritis (CrGN) with limited data available in adult Indian population. Aim This study aims to identify the aetiology, clinico-pathological features and outcomes of diffuse CrGN in south Indian population. Materials and Methods In this retrospective study, clinical records of all adults (>18 years) over a 5-year period (2010-2014) with a histopathological diagnosis of diffuse CrGN (>50% crescents) were reviewed. Clinical, serological, biochemical and histopathological data were collected. Follow-up data at six months including renal outcome and mortality were studied. Data was analysed using SPSS version 15. Results There were 29 cases of diffuse CrGN accounting for an incidence of 2.9% among 1016 non-transplant kidney biopsies. The most common cause was pauci-immune crescentic GN. The median creatinine at admission was 7.2 mg/dl {(interquartile range (IR) 3.3 - 10.4)} and 75.9% of patients required haemodialysis at admission. Complete/partial recovery was seen in 34.5%. At the end of six months 31% were dialysis dependent and the mortality was 27.6%. On univariate analysis, the significant predictors of renal loss and mortality were oliguria (p=0.02), requirement of haemodialysis and serum creatinine (p=0.001) at admission (>5.5mg/dl) (p=0.003). Histopathological features did not influence the outcome in our study. Conclusion In our cohort, the most common cause for diffuse CrGN is pauci-immune CrGN. Diffuse CrGN carries a poor prognosis. Patients with pauci-immune and AntiGBM disease have worst prognosis compared to immune complex CrGN. The presence of oliguria, high serum creatinine and requirement of haemodialysis at admission are associated with poor outcomes.

Multiple Intra-renal Pathological Injury Patterns in Resistant Myeloma

Renal dysfunction in patients with multiple myeloma has a heterogeneous aetiology ranging from pre-renal, intra-renal to post-renal causes. Common pathological forms of paraproteinemic disease include cast nephropathy,amyloidosis and Immunoglobulin chain deposition disease.Infrequently cryoglobulinemic glomerulonephritis and light chain proximal tubulopathy have also been described. The presence of multiple intra-renal pathological injury patterns has been described only once previously with immunoglobulin light chains. We report a patient with long standing treatment resistant multiple myeloma and new onset progressive renal failure with heavy and light-chain amyloidosis, cast nephropathy and proximal tubulopathy on renal biopsy.

Immune mediated crescentic MPGN secondary to HBV infection: A rare presentation for a common infection.

Hepatitis B virus (HBV) infection presenting as crescentic glomerulonephritis in the absence of cryoglobulinemia is an extremely rare phenomenon. We report a case of a 44-year-old male with HBV infection, who underwent kidney biopsy for rapidly progressive renal failure and nephrotic range proteinuria. Histopathological evaluation of the kidney biopsy was consistent with immune complex mediated crescentic membranoproliferative glomerulonephritis (MPGN). The patient achieved complete renal and virological remission with steroids, plasmapheresis and antiviral therapy. This case report summarises the importance of early initiation of immunosuppression and plasmapheresis under antiviral coverage for improved clinical outcomes.