Srinivas Kosuru

Impact of body mass index on progression of primary immunoglobulin a nephropathy

The role of obesity in the progression of primary glomerular diseases is controversial. A few studies report overweight/obesity as a risk factor for disease progression in immunoglobulin A nephropathy (IgAN), and the real impact of it still remains unclear. The aim of this study was to elucidate the effect of body mass index (BMI) on disease progression and proteinuria in patients with IgAN in Indian population. A cohort of biopsy-proven primary IgAN patients diagnosed between March 2010 and February 2015 who had a follow-up for a minimum of 12 months were included in the study. We defined two groups of patients according to the BMI value at diagnosis: non-obese group (Group N) with BMI <23 Kg/m2 and the overweight/obese group (Group O) with BMI >23 Kg/m2 as per Asia-Pacific task force criteria. Baseline characteristics were compared between the groups. The estimated glomerular filtration rate (eGFR) and urine protein-creatinine ratio (UPCR) were followed up at entry time, 6 months, 12 months, and at the end of follow-up. Outcomes studied were change in eGFR, proteinuria, and progression to end-stage renal disease. Statistical analysis was done using the Statistical Package for the Social Sciences version 15.0. Of 51 patients, 25 (49%) had BMI <23 kg/m2 (Group N) and 26 (51%) had BMI >23 kg/m2 (Group O) (P = 0.01). The baseline clinical, histopathological, and treatment characteristics of both the groups were comparable. The BMI at the time of diagnosis did not have any significant effect on eGFR (P = 0.41) or proteinuria (P = 0.99) at presentation. At the end of follow-up, both the groups had a similar reduction of proteinuria (UPCR) (P = 0.46) and eGFR (P = 0.20). Two patients in each group have reached chronic kidney disease Stage 5. In the present study, BMI at presentation did not have any impact on eGFR or proteinuria, either at diagnosis or at follow-up. It needs further large multicenter randomized control studies to see the effect of BMI on progression of IgAN.

The left mediastinal hemodialysis catheter

Complications due to hemodialysis (HD) catheter insertion can be minimized with ultrasound guidance. Pneumothorax, arterial puncture, and arterial cannulation in particular are avoided by prelocalization or real-time ultrasound guidance. Anomalies of the central venous system, though rare, may result in procedural complications ranging from the benign left superior vena cava (LSVC) placement to perforation and extravascular positioning of the catheter. Central venous anomalies are as a rule asymptomatic and are not detected by chest radiography or ultrasonography. The persistent LSVC with or without a right SVC is the commonest anomaly of the central venous system with an incidence of 0.3-0.5% and can be present along with other congenital heart anomalies (4%) (1, 2, 3). We report a persistent LSVC as a probable cause of HD catheter malposition along the left mediastinal border and discuss the approach to evaluating such a malposition. A 68-year-old male with end-stage kidney disease due to chronic glomerulonephritis and hypertension was admitted for continuous ambulatory peritoneal dialysis (CAPD) catheter insertion. He had been hemodialysed through a right Internal jugular HD catheter for a month and this had just been removed due to probable catheter-related blood stream infection (CRBSI). He required HD prior to PD catheter insertion due to volume overload and hyperkalemia. A left internal jugular HD catheter was inserted without event and a chest radiograph was taken after the procedure (Fig. 1). The catheter was seen running along the left mediastinal border. Aortic cannulation was excluded by recording a venous pattern on blood gas analysis of the aspirate from both the ports and the absence of an arterial waveform when connected to a blood pressure transducer. Moreover, the patient’s oxygenation and hemodynamic parameters were stable. He refused to undergo another catheter insertion. A lateral chest radiograph was taken (Fig. 2), which showed the catheter tip to be just anterior to the hilum in the middle mediastinum. Extravascular placement was considered unlikely, as there was no hydropneumothorax and blood was aspirated from both ports easily. Hemodialysis was performed for 4 h through the catheter with a blood pump flow of more than 250 ml/min with an adequate fall in serum urea, creatinine, and potassium allowing the patient to undergo the surgery safely. Early break in CAPD was commenced on the fifth day after the PD catheter insertion and the HD catheter was removed the next day. By the eighth week of gestation, the two anterior cardinal veins draining the upper half of the body fuse to form the left brachiocephalic vein( innominate vein) and the SVC that runs down the right border of the superior mediastinum and enters the right atrium at the level of the third costal cartilage (4). In 0.3-0.5% of healthy individuals, the rudimentary left anterior cardinal vein may persist as the LSVC and end in the coronary sinus, which eventually drains into the right atrium (1, 2). The LSVC when present runs along the left mediastinal Fig. 1 Chest radiograph PA view showing the HD catheter along the left mediastinal border.