Factors Affecting Insulin Resistance and Its Relation to Vitamin D Status and Clinical Nutritional Parameters in Dialysis Patients: A Single-center Indian Study

The aim of this study was to measure insulin resistance (IR) in dialysis patients and its relation to Vitamin D status and nutritional parameters. We included patients on maintenance dialysis, both hemodialysis and peritoneal dialysis (HD and PD). IR was measured by homeostatic model assessment (HOMA)-IR index defined as fasting serum insulin (μU/L) × fasting blood sugar (mmol/L)/22.5. Baseline Vitamin D levels were measured by chemiluminescence immunoassay (CLIA) method. HOMA-IR index correlated with nutritional parameters such as 7-point subjective global assessment (SGA) and anthropometric measures, for example, body fat percentage, lean body weight (LBW), mid-arm circumference (MAC), and mid-arm muscle circumference (MAMC). A total of 55 patients were studied, of them 74.55% were male with mean age of the study population being 37.44 ± 14.96 years. The prevalence values of Vitamin D deficiency <30 ngm/ml, <20 ngm/ml, and <10 ngm/ml levels were 96.36%, 70.91%, and 23.64%, respectively. Mean HOMA-IR index was 3.14 ± 3.86. The correlation of HOMA-IR with Vitamin D was negative (r = -0.140, 95% confidence interval [CI] = -0.397-0.138 and P = 0.309); however, in subgroup analysis, patients with Vitamin D level <20 ng/ml had significantly high IR compared to those with Vitamin D >20 ng/ml, i.e., 3.74 ± 4.37 and 1.67 ± 1.47, respectively (P = 0.018). The other measured parameter which had a significant positive correlation with IR was serum uric acid (r = 0.303, 95% CI = 0.021-0.534, and P = 0.025). In nutritional assessment, body mass index, MAC, and MAMC had statistically significant positive correlation with HOMA-IR index (P ≤ 0.001, 0.004, and 0.004, respectively) unlike SGA (P = 0.480). The mode of dialysis did not have a significant effect on IR (HD vs. PD, P = 0.227). The majority of the patients on maintenance dialysis are Vitamin D deficient. Low Vitamin D level, especially <20 ng/ml, muscle mass, and high serum uric acid level are likely to have more IR in dialysis-dependent patients.

How Harmful Can Herbal Remedies Be? A Case of Severe Acute Tubulointerstitial Nephritis

Acute interstitial nephritis (AIN) is a condition in which acute kidney injury (AKI) is characterized by the histological finding of interstitial inflammation. Hyponidd is an ayurvedic drug containing Momordica charantia, Gymnema sylvestre, Swertia chirata, etc., used for the treatment of Type 2 diabetes mellitus (DM) and polycystic ovarian disease as an insulin sensitizer. There are no case reports of AIN caused by this drug yet. We report a biopsy-proven case of AKI due to severe AIN associated with the use of hyponidd tablet in a 60-year-old male with DM and hypertension. As these types of various indigenous compounds are used as home remedies in our country, awareness about the possible adverse effects of these agents among physicians is very important in the early diagnosis and management.

Can Analgesic-abuse Nephropathy is a Fertile Groundfor for Rare Collecting Duct (Bellini Duct) Renal Cell Carcinoma or Merely a Coincidence?

Nonsteroid antiinflammatory drugs have been implicated as nephrotoxic drugs, causing both acute and chronic adverse effects that range from reversible ischemia to chronic kidney disease and urothelial tumors to renal cell carcinoma specially papillary subtype. We report one case of collecting duct (Bellini duct) renal cell carcinoma in patient with analgesic-abuse nephropathy. This young individual was suffering from ankylosing spondylitis since the age of 16 years and was consuming diclofenac and paracetamol (acetaminophen) combination for >15 years. He developed hypertension, secondary glomerulopathy, chronic kidney disease and collecting duct renal cell carcinoma.

A comparative study of central versus posterior approach for internal jugular hemodialysis catheter insertion

Internal jugular (IJ) catheter insertion for hemodialysis (HD) is an indispensable procedure in the management of patients with renal failure. The central approach is favored over posterior approach to insert IJ catheters. There are no studies comparing the outcomes between the two approaches. The aim of this study was to compare central approach with posterior approach for IJ HD catheter insertion and to analyze various outcomes like procedure-related complication rates, catheter insertion failure rates, interruptions during dialysis due to blood flow obstruction and catheter infection rates between the two methods among patients receiving HD. All patients requiring IJ HD catheter insertion during a 1-month period were randomly assigned to undergo catheter insertion via either conventional central approach or posterior approach. Patients were followed-up till the removal of the catheter. Among 104 patients included in the study, 54 were assigned to the central approach group and 50 to the posterior approach group. The central approach group had higher rate of procedure-related complications (14.81% vs. 6%, P = 0.04). Catheter insertion failure rates were marginally higher in posterior approach group (20% vs. 12.96%, P = 0.07). One or more instance of interruption during HD due to obstruction in blood flow was more common in posterior approach (46% vs. 9.25%, P < 0.01). Catheter infection rates were similar between the two groups; 16.66% (n = 9) in central group vs. 14% (n = 7) in posterior group. Posterior approach is a reasonable alternative to conventional central approach in IJ cannulation for HD catheter. It is, however, associated with a significantly high rate of interruption in HD blood flow and catheter insertion failure rates. The posterior approach can be used in patients with local exit site infection or in failed attempts to cannulate IJ vein via the conventional central approach.

Periodic Peritoneal Dialysis in End Stage Renal Disease: Is it Still Relevant? A Single Center Study from India

BACKGROUND

High cost of maintenance hemodialysis (HD) and continuous ambulatory peritoneal dialysis (PD) in India has made renal replacement therapy out of reach of many patients with end stage renal disease (ESRD). Repeated puncture PD although inferior to HD biochemically, is easily and freely available across Rajasthan, India, and is simple to perform, and does not require sophisticated machines, thus making it an attractive option for dialysis for ESRD.

AIM

To analyze the outcomes of periodic PD in patients with ESRD requiring dialysis support.

SUBJECTS AND METHODS

A prospective study analyzing the data of patients who underwent PD between August 2010 and January 2013 in Sawai Man Singh Hospital, Jaipur, India was conducted. Patients were divided into three groups based on the time period between first and second session of PD. Detailed demographic and clinical data during the study period were collected along with PD related complications. The main outcome studied was technique survival 1 year post initiation of PD.

RESULTS

234 patients received an initial session of PD, of which 174 had a good response and were included in the study. 19 patients received the second PD within 7 days of first (Group 1), 45 patients within 8-14 days (Group 2) and 110 patients within 15-21 days (Group 3). The overall 1 year technique survival was 68.4% (91/133), with a rate of 50% (5/10), 56.8% (21/37), and 75.6% (65/86) for Group 1, Group 2, and Group 3, respectively. The time duration between first and second PD proved to be reliable indicator of the subsequent response, with a technique survival rate significantly lower in Group 1 patients compared to Groups 2 and 3 (P = 0.04). Median dialysis free days were 11, 16 and 21 days in Group 1, Group 2, and Group 3, respectively. Peritonitis rate observed was 2.1% (49/2261) during the study period.

CONCLUSION

Periodic PD is a simple, safe and cheap procedure, which can be considered as used as a palliative measure in terminal uremia in underprivileged areas.

Incidence and profile of C3 Glomerulopathy: A single center study

C3 glomerulopathy has recently been described as a distinct entity. The underlying mechanism is unregulated activation of the alternate pathway of the complement system. The most common presentation is with an acute nephritic syndrome. The diagnosis is made on immunofluoroscence by the presence of isolated or dominant C3 staining. In this retrospective study, renal biopsy data were collected from 2010 to 2013 patients with C3 glomerulopathy identified and their clinical and biochemical parameters analyzed. Out of 514 biopsies available for analysis, the incidence of C3 glomerulopathy was 1.16% (n = 6). The mean age of the presentation was 26 years and the average estimated glomerular filtration rate was 30.65 ml/min/1.73 m(2). The most common histopathological pattern was membranoproliferative glomerulonephritis (n = 4).

Renal tubular dysfunction presenting as recurrent hypokalemic periodic quadriparesis in systemic lupus erythematosus

We report recurrent hypokalemic periodic quadriparesis in a 30-year-old woman. Patient had also symptoms of multiple large and small joint pain, recurrent oral ulceration, photosensitivity and hair loss that were persisting since last 6 months and investigations revealed systemic lupus erythematosus (SLE) with distal tubular acidosis. Our patient was successfully treated with oral potassium chloride, sodium bicarbonate, hydroxychloroquine and a short course of steroids. Thus, tubular dysfunction should be carefully assessed in patients with SLE.

Esophageal histoplasmosis in a renal allograft recipient

Histoplasmosis is a progressive granulomatous disease caused by the intracellular dimorphic fungus Histoplasma capsulatum. We report a rare case of esophageal histoplasmosis in a renal allograft recipient. A 55-year-old male who received a live, unrelated renal allograft 20 years ago presented with complaints of recurrent fever for ten to 12 months, weight loss over six months, progressive dysphagia more for solids for five to six months and joint pain and swelling involving the bilateral metacarpo-phalangeal and proximal interphalangeal joints. Biopsy from the esophageal ulcers revealed dense inflammation infiltrated with lymphocytes and macrophages with clusters of strongly positive intracellular fungal spores with a clear area or "halo-like" zone suggestive of Histoplasma capsulatum invasion. The patient was treated with intravenous liposomal amphotericin B for ten days and later switched over to oral itraconazole. Repeated endoscopy revealed significant improvement of the lesions.

Nephrotic range proteinuria in c-ANCA-positive crescentic glomerulonephritis with linear immune deposits

The three broad groups of rapidly progressing glomerulonephritis are anti glomerular basement membrane (anti-GBM) disease, renal vasculitis characterized by antineutrophil cytoplasmic antibody positivity, and a heterogeneous group with granular immune deposits. Anti-GBM disease with cytoplasmic antineutrophilic antibodies (c-ANCA) positivity (type III disease) is not known to present with nephrotic syndrome. We report here a rare presentation of nephrotic syndrome in Type III disease. Larger studies are warranted to determine whether the amount and/or type of immune deposits decide the range of proteinuria. These studies are also required to elucidate the impact of immune complex deposition on renal disease in c-ANCA-positive glomerulonephritis and to outline its pathogenetic mechanism.