Yuvaram N.V. Reddy

A multicenter cross-sectional study of mental and physical health depression in MHD patients

Depression is ranked fourth among the disabling diseases affecting people worldwide and is the most common psychological problem in patients with End Stage Renal Disease (ESRD). The aim of this study is to assess the physical and emotional health status of renal dialysis patients, based on the SF-36 scale in relation to their economic status. Sixty maintenance hemodialysis patients, with a mean age of 40±13 years were included in this cross-sectional study using the SF-36 scale. It comprises 36 questions regarding physical and mental functions, body pain, vitality, etc. An SF-36 score of 50 or less was considered as moderate to severe depression and 51–100 as mild depression to good health. 56.81% of the patients who are below poverty line under dialysis had moderate to severe depression with regard to their health status. A physical health score of up to 50 was seen in 63.63% of patients below poverty line 63.63% (P= 0.16). A mental health score of 0–50 was observed in 61.63% of the cohort studied (P = 0.22). Among the patient with diabetes (28.33%) 55.56% had depression. Dialysis duration was directly associated with deteriorating physical health status and inversely proportional to their mental health status (P<0.05). There are problems in other regular activities due to depressed physical and mental health. The factors that were identified in this study that influence depression such as poverty status, increasing age, vintage and frequency of dialysis and treatment with erythropoietin dosage should be addressed and treated accordingly to improve the quality of life. Improving self-esteem with fruitful employment opportunities, concerted rehabilitation by professionals and easing of economic burden by private–public partnership is an achievable goal.

Mineral bone disease in maintenance hemodialysis patients: Association with morbidity and mortality.

There is a paucity of data on mineral bone disease in maintenance hemodialysis (MHD) patients from India. This retrospective analysis was undertaken on 858 (males: 599; females: 259) patients from two medical centers on MHD from 1998 to 2010. Age, gender, months on dialysis, hours per session of dialysis, hemoglobin, serum calcium, inorganic phosphorus, intact parathyroid hormone (iPTH), urine output, erythropoietin dosage per week, blood sugar, blood pressure, urea reduction rate, gain in fluid and fluid removed per session, serum albumin, alkaline phosphatase, vitamin D level, supplemental vitamin D and use of phosphate binder for therapy were documented. Overall, 191 patients died (22%) during the observation period. There was an 86% patient survival rate at 1 year on dialysis and an overall predicted 3-year survival rate of 78%. A relatively higher iPTH (P = 0.012), a need for vitamin D supplementation (P = 0.003), less hours on dialysis per session (P = 0.046) and a non-vegetarian diet (P = 0.022) were significantly associated with mortality.

Risk factors of chronic kidney disease influencing cardiac calcification.

We sought to determine the influence of risk factors of chronic kidney disease (CKD) on cardiac calcification. We studied the correlation between coronary artery calcium score (CACS) and the type and duration of dialysis as well as the presence of diabetes mellitus and hypertension. The relation between calcium score and mortality was also analyzed. Patients with CKD attending the outpatient department or admitted in our hospital were included. They were subjected to high-resolution computerized tomography of the thorax to determine their CACS. Serum levels of intact parathyroid hormone (iPTH), highly sensitive C-reactive protein (hCRP), homocysteine, calcium, phosphorus, and calcium × phosphorus product were measured. Out of the 50 patients studied, 39 were hypertensive (78%), 32 were diabetic (64.4%), 20 were on hemodialysis, and 13 were on continuous ambulatory peritoneal dialysis. The mean CACS was 388.6. Twenty-nine patients had high iPTH levels and 92.9% of them had calcium score >400 (P = 0.013). Twenty-eight patients had high hCRP and 85.7% of these patients had calcium score >400 (P = 0.048). Patients on dialysis for more than two years had higher calcium score >400 (P = 0.035). 43% of diabetics had calcium score >400 (P = 0.008). All the six patients who died had calcium score >400 (P = 0). There was statistically no significant association noted between hypertension, high calcium x phosphorus product, and high homocysteine levels, and high calcium score. Our study suggests that higher values of iPTH, hCRP, and longer duration on dialysis are associated with accelerated cardiac calcification. Calcification scores >400 are associated with increased mortality.

An Indian model for cost-effective CAPD with minimal man power and economic resources

Only 3–5% of all patients with end-stage renal disease (ESRD) in India get some form of RRT from the existing pool of 900 nephrologists [2, 3]. As referral pattern varies widely in India for uremia therapy, there is no robust national database on the prevalence and incidence of dialysis therapy except for isolated reports. The cost of maintenance hemodialysis (MHD) for a single session varies from US

Progressive pulmonary hypertension: Another criterion for expeditious renal transplantation

10 to 65 and most patients are maintained on twice-aweek dialysis. One-third of the 30 000 MHD patients are in the major metropolitan cities of Chennai, Delhi, Mumbai and Kolkata, whereas the majority of the Indian population lives in small towns and villages far away from cities. The hidden cost of travel to the hemodialysis (HD) center and loss of daily wages for the patient and the accompanying person is not usually calculated when the cost of HD is taken into consideration. The unmet needs of RRT must be covered by continuous ambulatory peritoneal dialysis (CAPD) that is available even in remote places in the country. There are ~7000 prevalent patients on chronic peritoneal dialysis in India. The cost is substantially less with PD, and the four industries which are involved in CAPD in India have network systems to deliver dialysis supplies to the residence without any additional cost. The use of erythropoietin (EPO) and iron is comparatively lower in CAPD patients compared to HD patients in India to the advantage of CAPD as a favorable RRT.

Successful management of angiomyolipoma of the left kidney

The aim of this retrospective study was to compare the prevalence of pulmonary hypertension in a cohort of patients with end-stage renal disease (ESRD) prior to and following renal transplantation and to identify the possible risk factors. Of the 425 renal transplantations performed between 2001 and 2007, Doppler echocardiographic findings were available in 124. The echocardiographic data, collected both pre- and post-transplant, included the pulmonary artery pressure (PAP), ejection fraction and left ventricular hypertrophy. The data analyzed included age, gender, hypertension, diabetes, smoking status, along with blood urea, creatinine, glomerular filtration rate, hemoglobin, hemodialysis duration, urine albumin, arterio-venous access and body mass index (BMI). Chi-square test was used for discrete variables and ANOVA was used for continuous variables. Of the patients studied, males comprised 72%; the mean age was 43.3 ± 13.02 years; 87% were hypertensive, 30% were diabetic and 4% were smokers. Statistical analysis revealed a significant reduction of the PAP, irrespective of its severity, following renal transplantation (P <0.05). The PAP had no significant correlation with any of the parameters analyzed, with the exception of BMI (P <0.05). Our study suggests that the PAP gets reduced in patients with ESRD after renal transplantation.

Late post transplant HIV infection with BK viremia and allograft tuberculosis in a renal transplant recipient with Kaposi sarcoma

A 57-year-old woman with a creatinine of 0.8 mg/dL and a normal urine analysis, was investigated with technetium-99m renogram and multidetector computerized tomography (MDCT) as a renal donor for her daughter. The glomerular filtration rate (GFR) was 100 mL/min with the left kidney 42 mL/min and right kidney 58 mL/ min. MDCT revealed a large lipomatous tumour on the renal cortex of the left lower pole with exophytic extension into the perirenal space measuring 7.3 3 5.2 cm (Figure 1). The arterial phase revealed dual arterial supply to the left kidney with the tumour being supplied by a branch from the lower renal artery (Figure 2a). The presence of fat [67 Hounsfield unit (HU)] with interposed soft tissue (42 HU), ectatic vessels and an aneurysm that measured 9 mm 3 8.9 mm with no direct arteriovenous shunting favoured the diagnosis of angiomyolipoma. Superselective catheterization of the feeding artery was performed and the neovascular vessels were embolized. Post-embolization MDCT revealed complete obliteration of the abnormal feeding artery and the aneurysmal lumen (Figure 2b). A week later, the GFR was 107 mL/min, left kidney 43 mL/min and right kidney 64 mL/min. Angiomyolipoma is a benign renal neoplasm with variable amounts of fat, vascular and smooth muscle elements. Attenuation of less than 20 HU on computerized tomography is widely accepted to confirm the presence of fat and this finding confirms the diagnosis of angiomyolipoma [1]. A tumour >4 cm with an aneurysm measuring >5 mm has a high risk of rupture [2].

Late perirenal fluid collection following ovarian hyperstimulation

In this report, we discuss a case of a 51-year-old African renal transplant who presented with metastatic Kaposi sarcoma 1 year after transplant. The Kaposi sarcoma was treated with a switch of immunosuppressants and chemotherapy. Six years after transplant, he presented with chronic allograft nephropathy, allograft tuberculosis, BK viremia, and was diagnosed to have contracted HIV infection.

Deceased-donor renal transplantation program in India.

A 25-year-old primigravida with polycystic ovarian syndrome conceived using assisted reproductive technology with recombinant gonadotropins. She developed ovarian hyperstimulation syndrome (OHSS) and had moderate ascites. Frozen embryo transfer was done 2 months later after complete subsidence of ascites, following which she had a twin pregnancy. She was normotensive with normal baseline serum chemistries and urine analysis. An abdominal ultrasound (US) done during week 16 of gestation was normal.