Lifestyle Modifications and Nutritional and Therapeutic Interventions in Delaying the Progression of Chronic Kidney Disease: A Review

Chronic kidney disease (CKD) is a debilitating progressive illness that affects more than 10% of the world's population. In this literature review, we discussed the roles of nutritional interventions, lifestyle modifications, hypertension (HTN) and diabetes mellitus (DM) control, and medications in delaying the progression of CKD. Walking, weight loss, low-protein diet (LPD), adherence to the alternate Mediterranean (aMed) diet, and Alternative Healthy Eating Index (AHEI)-2010 slow the progression of CKD. However, smoking and binge alcohol drinking increase the risk of CKD progression. In addition, hyperglycemia, altered lipid metabolism, low-grade inflammation, over-activation of the renin-angiotensin-aldosterone system (RAAS), and overhydration (OH) increase diabetic CKD progression. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend blood pressure (BP) control of <140/90 mmHg in patients without albuminuria and <130/80 mmHg in patients with albuminuria to prevent CKD progression. Medical therapies aim to target epigenetic alterations, fibrosis, and inflammation. Currently, RAAS blockade, sodium-glucose cotransporter-2 (SGLT2) inhibitors, pentoxifylline, and finerenone are approved for managing CKD. In addition, according to the completed Study of Diabetic Nephropathy with Atrasentan (SONAR), atrasentan, an endothelin receptor antagonist (ERA), decreased the risk of renal events in diabetic CKD patients. However, ongoing trials are studying the role of other agents in slowing the progression of CKD.

Oncosurgery-Related Acute Kidney Injury

Oncosurgery is a surgical specialty that focuses on the diagnosis, staging, and management of cancer and cancer-related complications. Acute kidney injury is a common and important complication related to oncologic surgery, associated with longer hospital length of stay, greater costs, increased risk of incident or progressive chronic kidney disease (CKD), and higher mortality. The pathogenesis of oncosurgery-related acute kidney injury is multifactorial and determined by different variables, including patient characteristics (comorbidities, volume status, age, pre-existing CKD), specific cancer type or location, surgical procedure involved, as well as intrinsic neuroendocrine and hemodynamic responses to anesthesia and/or surgery. Early nephrology evaluation may be helpful to assist with preservation of kidney function and prevention of further kidney injury.

Severe Hyponatremia and Continuous Renal Replacement Therapy: Safety and Effectiveness of Low-Sodium Dialysate

RATIONALE & OBJECTIVE

In patients with severe hyponatremia in the setting of acute kidney injury or end-stage kidney disease, continuous renal replacement therapy (CRRT) using standard-sodium (140 mEq/L) fluids may lead to excessively rapid correction of plasma sodium concentration. Use of dialysate and replacement fluids with reduced sodium concentrations can provide a controlled rate of correction of plasma sodium concentration.

STUDY DESIGN

We performed a single-center retrospective analysis of the safety and effectiveness of this approach in patients with plasma sodium concentrations ≤ 126 mEq/L who underwent CRRT for 24 or more hours using low-sodium (119 or 126 mEq/L) dialysate and replacement fluids. Change in plasma sodium level was assessed at 24 and 48 hours after initiation of low-sodium CRRT and at the end of treatment.

SETTING & PARTICIPANTS

Between January 2016 and June 2018, a total of 23 hyponatremic patients underwent continuous venovenous hemodiafiltration using low-sodium dialysate and replacement fluids; 4 patients were excluded from analysis because of CRRT duration less than <24 hours.

RESULTS

The 19 patients included in the study had a mean age of 56 years, 11 (58%) were men, and 15 (79%) were white. The initial mean plasma sodium level was 121 mEq/L and the initial CRRT effluent dose was 27 mL/kg/h. Only 2 (11%) patients had an increase in plasma sodium concentration > 6 mEq/L at 24 hours. Mean changes in plasma sodium levels at 24 and 48 hours and at the time of CRRT discontinuation were 3, 3, and 6 mEq/L, respectively. None of the patients developed osmotic demyelination syndrome.

LIMITATIONS

Key limitations were small sample size and lack of a control group.

CONCLUSIONS

Use of low-sodium dialysate and replacement fluids is a safe strategy for the prevention of overly rapid correction of plasma sodium levels in hyponatremic patients undergoing CRRT.

Intradural Intramedullary Primary Spinal Melanocytoma: A Rare Case Report

Spinal melanocytomas are rare pigmented tumors of the central nervous system commonly affecting females in their fifth decades. It has been reported in various locations with intradural intramedullary being the rarest. Patients can present with varied symptomatology from mild backache to frank myelopathy. Here we report a case of 34-year-old man with no medical comorbidities with vague backache associated with numbness of anterior aspect of right thigh for 1 year aggravated by activities and relieved by rest. His neurologic examination revealed normal power and sensation in both lower limbs except for decreased temperature sensation in right L2 dermatome. MRI of dorsolumbar spine revealed a well-defined lesion that was hyperintense in T1- and hypointense in T2-weighted image at D11–12 region with uniform bright enhancement in gadolinium-enhanced T1 image. The patient underwent laminectomy of D11 and D12, and an en bloc excision was done. Diagnosis of primary intradural intramedullary melanocytoma was made from histopathologic examination. Spinal melanocytomas should be considered as a differential diagnosis for intradural space-occupying lesions. MRI remains the investigation of choice for diagnosis, but histopathologic examination is required to confirm and differentiate from other pigmented tumors and malignant melanomas. Total surgical excision of the tumor remains the standard treatment with radiotherapy reserved for cases of incomplete excision and recurrences.

Posttraumatic stress disorder after myocardial infarction and coronary artery bypass grafting

Post traumatic stress disorder is a psychiatric disease that is usually precipitated by life threatening stressors. Myocardial infarction, especially in the young can count as one such event. The development of post traumatic stress after a coronary event not only adversely effects psychiatric health, but leads to increased cardiovascular morbidity and mortality. There is increasing evidence that like major depression, post traumatic stress disorder is also a strong coronary risk factor. Early diagnosis and treatment of this disease in patients with acute manifestations of coronary artery disease can improve patient outcomes.

A modified Gaines procedure for spondyloptosis

We present an illustrative case using a modification of the Gaines procedure for the surgical management of patients with spondyloptosis. It involves excision of the inferior half of the body of L5 anteriorly combined with posterior reduction and fusion.

Peripheral odontogenic fibroma with chondroid differentiation

An unusual case of peripheral odontogenic fibroma, presenting as a swelling on gingiva involving hard palate in a 3-year-old female child, is described. Even with cellular stroma and unencapsulation these tumors behave in a benign fashion. To the best of our knowledge, cartilagenous differentiation of stroma as observed in this case has not been reported in English literature so far.

Diagnostic value of gene probes and its correlation with clinical profile of leprosy in children

Clinico-bacteriological profile of 73 leprosy patients below 16 years of age was studied. Majority of the patients were males and fell in 11-16 years age group (p < 0.05). Skin lesions were present in all cases on both exposed as well as unexposed areas and their number increased with advancing age. Cutaneous sensations were affected in most of the patients while nerve thickening was observed in 41. As age increased, the disease moved from the tuberculoid end of spectrum towards the lepromatous end (p < 0.05) and the positivity of the skin smears increased (p < 0.05). Majority of the paucibacillary cases were lepromin positive while most multibacillary cases were lepromin negative (p < 0.01). Two M. leprae specific gene probes were applied in 42 cases to assess their diagnostic value. Eighty one per cent cases were picked up by the probes indicating presence of active bacilli. These included all lepromin positive cases, all smear positive cases, and most of smear negative cases (p < 0.05). Seven children with inconclusive histology were also positive. Drug treatment and inadequate size of biopsy sample could explain the negative probe results in 19% cases. This study highlights the immense potential of gene probes in diagnosing leprosy in children.

Profile of accidents in children

Out of 5031 children admitted to S.N. Hospital, Agra during one year, there were 716 cases (14.2%) of accidents. Most cases were in the age group of 4-9 years; boys were affected more commonly than girls. The maximum cases occurred due to fall (44.4%), followed by road traffic accidents (26.4%) and burns (11.5%). The consequences in terms of morbidity and mortality was also high. Kerosene oil ingestion was the most common encountered form of poisoning. Incriminating environmental factors could be identified in 51.8% cases and included poorly protected roofs (23.7%), poor state of roads (10.0%), defective vehicles (7.5%), and houses opening directly on the streets (7.3%). More than half of the accidents took place at home (58.7%), followed by those on streets (30.3%) or at farmhouses (57%). Injuries caused by sharp and blunt objects were more common in villages. Only 21.4% children had received first aid, often by the family, before reaching the hospital. The overall mortality rate was 53.1/1000, but in cases of burns the mortality was (146.3/1000). This study suggests that falls and traffic accidents have the highest incidence and mortality in childhood accidents and modification of the home environment can be an effective measure to prevent such incidents.

Prevalence of rheumatic heart disease in school children

A total number of 8449 school children, in the 5-15 years old, group were examined clinically for evidence of valvular lesions and confirmed by roentgenographic electrocardiographic and echocardiographic findings. Twelve children (0.14%) were suffering from rheumatic heart disease (RHD). The disease was significantly more (p < 0.05) prevalent in the higher age group of 11-15 years as compared to younger children. Boys (0.18%) were affected more than girls (0.09%). The disease was more frequent among children belonging to economically backward group (0.34%) and those living in large families (0.28%). Children living in the slums had significantly (p < 0.05) higher prevalence (0.41%) than those residing in urban areas (0.06%). Only 3 out of 12 (25%) were previously diagnosed cases and remaining were diagnosed for the first time. Past history of rheumatic activity was seen in 41.67% cases. Mitral valve involvement was most frequent, being detected in 10 (83.33%) cases. Majority of cases (58.33%) had the development of symptomatic RHD within 2 years of having suffered from RF. Our study helped to detect the hitherto undiagnosed cases of RHD and showed that its prevalence was higher in older children and those from urban slums.

Per rectal diazepam therapy in convulsive disorders

One hundred and twenty children with persistent convulsions (lasting > or = 10 min) were treated with per rectal diazepam (dosage: 0.2 to 0.7 mg/kg/dose). Another group of 100 age matched children with convulsions, along with those who did not respond to rectal therapy were given intravenous diazepam in a dosage of 0.2 to 0.3 mg/kg/dose. Rectal treatment was effective in 80.83% cases while intravenous diazepam was effective in 90% cases which is statistically just significant (p < 0.05). No significant difference was observed in the efficacy of two routes of administration in controlling convulsions of different clinical types and various etiological groups (p < 0.05), except for primary generalized type where intravenous route was more effective than the rectal one (p < 0.05). No significant side-effect was observed with rectal therapy. Among the 23 (19.17%) children in whom rectal therapy failed, 12 (10%) responded to intravenous diazepam while the remaining 11 (9.17%) cases were resistant to both routes of administration.

A Study of Blastogenic Transformation Under Phytomaemagglutinin (pha) in Leprosy

The present study was aimed to assess the cell-mediated immune response under PHA stimulus in leprosy patients and healthy contacts. Twenty-one cases suffering from leprosy were included in the study. They were diagnosed clinically by skin biopsy,. smear examination and lepromin reaction. Five cases had lepromatous, 7 borderlines and 9 tuberculoid leprosy. Eleven were healthy contacts. Lepromin reaction was negative in 5 patients in lepromatous group while it was positive in the other patients and healthy contacts. Blastogenic transformation was depressed only in patients with lepromatous leprosy. In tuberculoid and borderline cases, lymphocytes exhibited similar reactivity with PHA as was shown by the controls. Healthy contacts of lepromatous leprosy patients were leprom'm positive and did not show any C M I depression. it is suggested that depression of PHA response may develop after the on set of leprosy infection.