Indian TrANslational GlomerulonephrItis BioLogy nEtwork (I-TANGIBLE): Design and Methods

Background and Aim

Primary glomerular disease accounts for one-sixth of all chronic kidney diseases (CKDs) in India. We remain limited in our ability to effectively treat these conditions because of lack of understanding of the disease mechanisms and lack of predictors to identify the clinical course and therapeutic responsiveness. We propose to develop a network of investigators in glomerular diseases, collect information in a systematic fashion to understand the clinical outcomes, answer translational research questions better, and identify and recruit patients for clinical trials.

Materials and Methods

This is a prospective, observational study. The Indian TrANslational GlomerulonephrItis BioLogy nEtwork (I-TANGIBLE) cohort will enroll patients (>18 years) with biopsy-proven minimal change disease (MCD), focal segmental glomerulonephritis (FSGS), membranous nephropathy (MN), IgA nephropathy (IgAN), or membranoproliferative glomerulonephritis (MPGN) (immune complex- and complement-mediated), with first biopsy taken within 2 years of enrollment. Patients with estimated glomerular filtration (eGFR) rate <15 ml/min/1.73 m2 for >3 months at the time of screening, kidney transplant or bone marrow transplant recipients, patients with active malignancy, and patients with active hepatitis B/C replication or human immunodeficiency virus (HIV)-I/II will be excluded. Clinical details including history, medication history and details, and family history will be obtained. Consenting patient's blood and urine samples will be collected and stored, aligned to their clinical follow-up.

Expected Outcomes

The network will allow accurate ascertainment of disease burden of glomerular diseases across study sites, establishment of the treatment pattern of common glomerular diseases, investigation of medium- and long-term outcomes (remission, relapse, rate of eGFR decline), and building a suitable infrastructure to carry out clinical trials in primary glomerular disease.

Renin-angiotensin blocker use is associated with improved cardiovascular mortality in Indian patients with mild-moderate chronic kidney disease-findings from the ICKD study

Introduction

Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are the antihypertensive drug class of choice in patients with chronic kidney disease (CKD). Head-to-head comparisons of the renal or non-renal outcomes between ACEI/ARB users and nonusers have not been conducted in all population groups. We examined the renal and cardiovascular outcomes in users and nonusers enrolled in the Indian Chronic Kidney Disease (ICKD) Study.

Methods

A total of 4,056 patients with mild-moderate CKD were studied. Patients were categorized as ACEI/ARB users or nonusers. Major adverse kidney events [ESKD (end stage kidney disease), ≥50% decline in eGFR and kidney death], all-cause mortality, and cardiovascular mortality were analyzed over a median follow-up period of 2.64 (1.40, 3.89) years between the two groups.

Results

Out of a total of 4,056 patients, 3,487 (87%) were hypertensive. The adjusted sub-hazard ratio (SHR) and 95 % CI for ACEI /ARB users was 0.85 (0.71, 1.02) for MAKE, 0.80 (0.64, 0.99) for a 50% decline in eGFR, and 0.72 (0.58, 0.90) for ESKD. For cardiovascular mortality, ACEI/ARB users were at lower risk (SHR = 0.55, 95% CI: 0.34, 0.88). Diuretic users were at increased risk of all-cause mortality (HR = 1.95, 95% CI: 1.50, 2.53) and cardiovascular mortality (adjusted SHR = 1.73, 95% CI: 1.09, 2.73). There was non-significant association between the use of other antihypertensives and any of the end points.

Discussion

ACEI/ARB use is associated with slower rate of decline in eGFR in those with CKD stage 1-3. ACEI/ARB users had a significantly lower risk of renal outcomes, and cardiovascular mortality.

The Indian Chronic Kidney Disease (ICKD) study: baseline characteristics

Background

Chronic kidney disease (CKD) is an important cause of morbidity and mortality worldwide. There is a lack of information on epidemiology and progression of CKD in low–middle income countries. The Indian Chronic Kidney Disease (ICKD) study aims to identify factors that associate with CKD progression, and development of kidney failure and cardiovascular disease (CVD) in Indian patients with CKD.

Methods

ICKD study is prospective, multicentric cohort study enrolling patients with estimated glomerular filtration rate (eGFR) 15–60 mL/min/1.73 m², or >60 mL/min/1.73 m² with proteinuria. Clinical details and biological samples are collected at annual visits. We analysed the baseline characteristics including socio-demographic details, risk factors, disease characteristics and laboratory measurements. In addition, we compared characteristics between urban and rural participants.

Results

A total of 4056 patients have been enrolled up to 31 March 2020. The mean ± SD age was 50.3 ± 11.8 years, 67.2% were males, two-thirds of patients lived in rural areas and the median eGFR was 40 mL/min/1.73 m². About 87% were hypertensive, 37% had diabetes, 22% had CVD, 6.7% had past history of acute kidney injury and 23% reported prior use of alternative drugs. Diabetic kidney disease, chronic interstitial nephritis (CIN) and CKD-cause unknown (CKDu) were the leading causes. Rural participants had more occupational exposure and tobacco use but lower educational status and income. CIN and unknown categories were leading causes in rural participants.

Conclusions

The ICKD study is the only large cohort study of patients with mild-to-moderate CKD in a lower middle income country. Baseline characteristics of study population reveal differences as compared with other cohorts from high-income countries.

Epidemiology and outcomes of dialysis requiring acute kidney injury: A single-center study

OBJECTIVES

Acute kidney injury (AKI) is a common diagnosis in hospitalized patients. Dialysis requiring AKI (AKI-D) is associated with adverse outcomes. This study aims to know the clinical profile and short-term outcomes at 3 months, in patients with AKI-D, at our center.

METHODS

A prospective observational study was done of all the patients admitted with AKI-D for 2 years, from July 2018 to June 2020. We recorded clinical parameters at baseline and postdischarge follow-up at 3 months.

RESULTS

One hundred twenty-eight patients had AKI-D over 2 years. Then, 116 (90.6%) patients had community-acquired AKI (CAAKI), and 12 (9.4%) patients had hospital-acquired AKI. The underlying causes of AKI-D were: toxins in 48 (37.5%), sepsis in 31 (24.2%), acute kidney disease in 15 (11.7%), acute gastroenteritis (AGE) in 9 (7%), and cardiogenic shock in 7 (5.5%) patients. The mean values of intact parathyroid hormone (available in 32% of patients) were 268 pg/mL. Intermittent hemodialysis was the commonest mode of dialysis (85.2%). A kidney biopsy was done in 23 (18%) patients. The most common diagnosis on kidney biopsy was glomerulonephritis (GN) in 12 patients (crescentic GN-9 and IgA nephropathy-3), followed by acute tubule-interstitial nephritis in 6 patients. In-hospital mortality was 29.7%. Overall, 39% regained serum creatinine in the normal range at 3 months, 36.7% died, 14.1% reached chronic kidney disease (CKD), 7.8% lost to follow-up, and 2.3% had reached end-stage renal disease.

CONCLUSION

The majority of AKI-D at our center was CAAKI. A significant chunk of AKI-D (68.7%) was caused by preventable causes like toxins, sepsis, and AGE. Dysregulation of mineral metabolism was conspicuous. In chemical toxin vs. biological toxins and undifferentiated sepsis vs. the identifiable cause of sepsis, formers had significantly more in-hospital mortality than the latter ones. AKI-D is associated with high in-hospital mortality, total mortality, and risk of progression to CKD at 3 months.

Prescription Practices in Patients With Mild to Moderate CKD in India

Introduction

Patients with chronic kidney disease (CKD) require multiple medications. There is no information on prescription patterns or the use of evidence-based therapies for management of CKD from low-middle-income countries. Using baseline data from the Indian CKD (ICKD) cohort, we describe the drug prescription practices in patients with mild to moderate CKD.

Methods

The ICKD study is a prospective, observational cohort study of mild to moderate kidney disease across 11 centers in India. We analyzed all the prescriptions captured at enrollment in the ICKD study. Drugs were categorized into 11 different groups. We provide descriptive data on prescription details and evaluate the appropriateness of medication use.

Results

Complete prescription data were available in 3966 out of 4056 (97.8%) subjects enrolled in the ICKD database. Most patients had stage 3 CKD, 24.9% had diabetic kidney disease, 87% had hypertension, and 25.5% had moderate to severe proteinuria. Renin-angiotensin-aldosterone system blockers were prescribed in less than half (47.9%) and in 58.8% of patients with proteinuric CKD. Metformin was prescribed in 25.7% of diabetic subjects with CKD. Only 40.4% of patients were taking statins; 31.1% and 2.8% subjects with anemia were receiving iron and erythropoiesis-stimulating agents, respectively.

Conclusion

This study highlights the missed opportunities for improving outcomes through appropriate prescriptions of drugs in patients with CKD. There is need for dissemination of evidence-based guidelines and institution of sustainable implementation practices for improving the overall health of patients with CKD.

Coronavirus Disease 2019 and the Kidney

Coronaviruses are ubiquitous pathogens and have caused epidemics in the recent past. Coupled with globalization, they have the potential to transform into the pandemic, as is the case of coronavirus disease 2019 (COVID-19). Primarily to start as a respiratory illness, they are known to cause systemic disease and affect many organ systems. Due to the lack of, universally proven, specific anti-viral therapy, the mainstay of treatment is "supportive care" and some of the patients afflicted with it, require intensive care and organ support for lungs and/or kidneys. Patients with the diseases of the kidney, particularly those on dialysis and kidney transplant recipients, are predisposed to the worst outcomes with COVID-19. It also leads to acute kidney injury, which is an important and independent determinant of prognosis in these patients. It also creates a huge demand for the delivery of renal replacement therapy. COVID-19 is an emerging and evolving disease, and so, it is important to understand the mechanism and management of kidney diseases in COVID-19.

A case report of pleuro-pericardial effusion in a patient on hemodialysis and a cardiac pacemaker

There are multiple causes of pleuro-pericardial effusion (PPEF) and more so in a patient with end-stage renal disease (ESRD). Postcardiac injury syndrome (PCIS) is a loosely defined term for occurrence of pericardial and/or pleural effusion (PLEF), low-grade fever, with or without systemic upset, which occurs after myocardial infarction (MI), and other cardiac interventions. PPEF is one of its salient manifestations. We report occurrence of PCIS, presenting as pericardial effusion and massive PLEF, after insertion of cardiac pacemaker in a patient with ESRD, on maintenance hemodialysis (MHD). It was successfully managed with a short course of oral steroids.

Clinical Profile and Outcome of IgA Nephropathy from a Tertiary Care Hospital in North India

AIM

To study the clinical profile and outcome of the patients with kidney biopsy diagnosis of IgA Nephropathy (IgAN).

METHODS

A retrospective study of the patients diagnosed IgAN over a period of three and half years.

RESULTS

Sixty (13.5%) had a diagnosis of IgAN. Twenty four (40%) had a clinical diagnosis of rapidly progressive glomerulonephritis (RPGN), 20 (33.3%) chronic kidney disease (CKD), 11 (18.3%) nephrotic syndrome, three (5%) acute glomerulonephritis and two (3.3%) asymptomatic urinary abnormalities. Fifty-six (93.4%) patients had hypertension; 15 (25%) patients were presenting as a hypertensive crisis with malignant hypertension in two. Fifteen of the RPGN patients presented with the hypertensive crisis, and all of them had evidence of thrombotic microangiopathy (TMA) on biopsy. Three (5%) patients had secondary IgAN. Patients with the nephrotic syndrome responded to treatment and had a significantly higher renal survival. Patients with interstitial fibrosis and tubular atrophy (IFTA) ≥25% and mesangial hypercellularity score of >0.5 did not respond to treatment.

CONCLUSION

RPGN, CKD, and nephrotic syndrome were the typical manifestation of IgAN. Hypertension and hypertensive crisis were common. Response to treatment was seen in nephrotic syndrome whereas those with IFTA ≥25% and mesangial hypercellularity score of > 0.5 did not respond to treatment.

Etiological spectrum of anemia in non-dialysis-dependent chronic kidney disease: A single-center study from India

A retrospective study was conducted over seven years and it aimed to find out various causes of anemia among patients with chronic kidney disease (CKD). The study included nondialysis-dependent adult CKD patients who underwent anemia evaluation. A total of 584 patients were studied. Three hundred and twenty-one (55%) patients were male and 263 (45%) were female. The mean age of the patients was 55.5 ± 14 years. One hundred and seventy-eight (30.5%) had a diabetic CKD and 406 (69.5%) had a nondiabetic CKD. Seventy-two (12.3%) patients were in CKD Stage 3, 193 (33%) patients in CKD Stage 4, and 319 (54.6%) patients in CKD Stage 5. The mean hemoglobin was 9.2 ± 2.2 g/dL. There was a progressive fall in hemoglobin with increasing severity of CKD and in CKD Stage 3, 4, and 5 the mean hemoglobin was 10 ± 2.2, 9.4 ± 2.1, and 8.4 ± 1.9 g/dL, respectively (P = 0.001). Most (47.4%) patients had moderate anemia followed by anemia of mild (31.4%) and severe (21.4%) degrees. Three hundred and seven (52.6%) patients had percent transferrin saturation (TSAT) <20% (functional iron deficiency). One hundred and sixty-two (27.7%) patients had serum ferritin <100 ng/mL (absolute iron deficiency); 334 (57.2%) patients had serum ferritin 100-500 ng/mL, but in 175 (52.4%) of them, TSAT was <20%; 88 (15.1%) patients had serum ferritin >500 ng/mL (58 (65.6%) were C-reactive protein (CRP) + and 55 (62.5%) had TSAT <20%). Overall, 392 (67.1%) patients had functional or absolute iron deficiency. One-third of the patients had elevated CRP levels. The anemia was macrocytic in 20.4% suggesting deficiency of folic acid and/or Vitamin B₁₂. A high proportion (74.6%) of patients with normocytic anemia had iron deficiency. In the majority of nondialysis-dependent CKD patients, the etiology of anemia may be multifactorial; therefore, the treatment should be determined by documented causes of anemia.

Nonmedical Factors and Health-Related Quality of Life in CKD in India

BACKGROUND AND OBJECTIVES

Patient-reported outcomes have gained prominence in the management of chronic noncommunicable diseases. Measurement of health-related quality of life is being increasingly incorporated into medical decision making and health care delivery processes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Indian Chronic Kidney Disease Study is a prospective cohort of participants with mild to moderate CKD. Baseline health-related quality of life scores, determined by the standardized Kidney Disease Quality of Life 36 item instrument, are presented for the inception cohort (n=2919). Scores are presented on five subscales: mental component summary, physical component summary, burden, effect of kidney disease, and symptom and problems; each is scored 0-100. The associations of socioeconomic and clinical parameters with the five subscale scores and lower quality of life (defined as subscale score <1 SD of the sample mean) were examined. The main socioeconomic factors studied were sex, education, occupation, and income. The key medical factors studied were age, eGFR, diabetes, hypertension, and albuminuria.

RESULTS

The mean (SD) subscale scores were physical component summary score, 43±9; mental component summary score, 48±10; burden, 61±33; effects, 87±13; and symptoms, 90±20. Among the socioeconomic variables, women, lower education, and lower income were negatively associated with reduced scores across all subscales. For instance, the respective β-coefficients (SD) for association with the physical component summary subscale were -2.6 (-3.4 to -1.8), -1.5 (-2.2 to -0.7), and -1.6 (-2.7 to -0.5). Medical factors had inconsistent or no association with subscale scores. The quality of life scores also displayed regional variations.

CONCLUSIONS

In this first of its kind analysis from India, predominantly socioeconomic factors were associated with quality of life scores in patients with CKD.

Lentiform fork sign: Uremia alone or multifactorial causation?

Neurological complications are common in patients with acute or chronic renal failure, especially when there is marked reduction in the glomerular filtration rate (GFR). One such clinical syndrome, uremic encephalopathy (UE), occurs due to widespread dysfunction of central nervous system (CNS). It manifests with myriad clinical features and usually is suggested by bedside elicitation of asterixis (flapping tremor). Symptomatic involvement of the basal ganglia manifesting as choreoathetosis and clinical and radiological resolution with hemodialysis has been reported in the medical literature, but only rarely. The present report details such a case.

Clinical profile of tuberculosis in patients with chronic kidney disease: A report from an endemic Country

The objective is to study the clinical profile of tuberculosis (TB) in chronic kidney disease (CKD). This is retrospective study of CKD patients who were diagnosed to have TB over a period of seven years at a tertiary care hospital. TB was diagnosed in 115 patients with an incidence of 4200/100,000. Mean age of the patients was 46.9 ± 16 years. Sixty-two patients (53.9%) were male. Causes of CKD were diabetic nephropathy and hypertension in 11.3% each, chronic glomerulonephritis in 31.3%, chronic tubulointerstitial nephritis in 39.1%, autosomal dominant polycystic kidney disease, and post-renal transplant CKD in 3.5% each. About 68.7% of patients with TB had advanced CKD stage of 4-5D, whereas 31.3% of patients had early CKD stage 1-3. Twenty percent of patients were on dialysis. Three-fourths of the patients had extrapulmonary TB. Pleuropulmonary (41.8%), kidney and urinary tract (20%), and abdomen and lymph node (13% each) were the most common sites for TB. The main clinical presentation of TB was: fever/pyrexia of unknown origin in 24.3%, constitutional symptoms of anorexia, fever, night sweats, and weight loss in 27.8%, abnormal chest radiograph in 31.2%, ascites/peritonitis in 13.9%, pleural effusion in 25.2%, lymphadenopathy in 20%, and sterile pyuria/hematuria/chronic pyelonephritis in 13%. Microbiological and/or histopathological diagnoses were made in 45.2% and in the other 54.8%, diagnosis of TB was made on clinical grounds. Adverse effects of anti-TB drugs were seen in 9.6% of patients. Ninety-three percent completed the treatment and survived. Eight patients (7%), all in CKD stage 5D, died. The incidence of TB was high among CKD stages 4 and 5 and in those receiving dialysis. Extrapulmonary disease such as pleuropulmonary, renal, peritoneal, and lymph node were the common forms of TB.

Epidemiology and outcome of acute kidney injury due to venomous animals from a subtropical region of India

AIM

To study the epidemiology and outcome of acute kidney injury (AKI) caused by venomous animals.

METHODS

A retrospective study of patients admitted at Indira Gandhi Medical College Hospital, Shimla, with AKI due to venomous animals over a period of 15 years (January 2003-December 2017). Medical records were evaluated for patient information on demographic factors, clinical characteristics, complications, and outcome. Outcomes of requirement for intensive care unit (ICU) support, treatment with dialysis, survival, and mortality were analyzed. The survival and non-survival groups were compared to see the difference in the demographic factors, laboratory results, clinical characteristics, and complications.

RESULTS

One hundred and eighty-one patients were diagnosed with AKI caused by venomous creatures. Mean age was 44 ± 15.4 years, and the majority (54.1%) was women. Snakebite (77.9%) and wasp stings (19.9%) were the leading causes of AKI. Clinical details were available in 148 patients. The median duration of arrival at hospital was two days. 81.8% had oliguria, and 54.7% had a history of hematuria or having passed red or brown colored urine. The hematological and biochemical laboratory abnormalities were as follows: anemia (75%), leukocytosis (75.7%), hyperkalemia (35.8%), severe metabolic acidosis (46.6%), hepatic dysfunction (54.7%), hemolysis (85.8%), and rhabdomyolysis (65.5%). Main complications were as follows: gastrointestinal bleed (9.5%), seizure/encephalopathy (10.8%), and pneumonia/acute respiratory distress syndrome (ARDS) (11.5%). 82.3% of the patients required dialysis. 154 (85.1%) patient survived, and 27 (14.9%) patients died. As compared to the survival group, the white blood cell count, serum bilirubin, aspartate aminotransferase, alanine aminotransferase, creatine kinase, and lactate dehydrogenase were significantly higher, and serum albumin levels were significantly lower in patients who died. The proportion of patients with leukocytosis, hyperkalemia, metabolic acidosis, pneumonia/ARDS, seizure/encephalopathy, need for ICU support, and dialysis was significantly higher in patients who died.

CONCLUSIONS

Snakebite and multiple Hymenoptera stings (bees and wasps) were the leading causes of AKI due to venomous animals. AKI was severe, a high proportion required dialysis, and the mortality was high.

Tuberculosis in dialysis: Clinical spectrum and outcome from an endemic region

INTRODUCTION

Tuberculosis (TB) is a significant health problem in developing countries. There are limited data on TB among end stage renal disease (ESRD) patients on maintenance dialysis in India. Clinical profile and outcome of TB in dialysis were studied.

METHODS

Retrospective study of ESRD patients who were on maintenance dialysis (either peritoneal dialysis [PD] or hemodialysis (HD]) and diagnosed to have TB over a period of 11 years.

FINDINGS

Thirty-two patients had a diagnosis of TB. Mean age of the patients was 50.3 ±13.9 years. The majority (56.2%) of the patients were female. The modality of dialysis was HD in 53.1% and PD in 46.9%. Mean duration of dialysis at the diagnosis of TB was 15.1 ± 13.9 months. Over three-quarter of the patients had an extrapulmonary involvement. Pleuro-pulmonary (40.6%), peritoneum (34.4%), and lymph node (15.6%) were the most common sites for TB. About 6.3%patients had disseminated TB, and 3.1% had pericardial TB. The clinical presentation of TB was: fever/pyrexia of unknown origin 28.1%, constitutional symptoms of anorexia, fever, night sweats and weight loss 34.4%, abnormal chest radiograph 37.5%, ascites/peritonitis 34.4%, pleural effusion 25%, lymphadenopathy 18.8%, meningoencephalitis 6.3%, and pericardial effusion 3.1%. Peritoneal TB presented as nonresolving peritonitis in PD and ascites in HD. The diagnosis was a microbiological/histological in 50% and rest 50% only on clinical grounds. Nine (29%) patients had adverse effects of anti-TB drugs. Four patients of TB peritonitis had a poor gastrointestinal tolerance of anti-TB drugs and defaulted on the treatment and had an adverse outcome. About 53.1% of the patients survived, and 46.9% died.

DISCUSSION

TB in dialysis is mostly extrapulmonary. Early diagnosis is difficult, and the adverse effects of anti-TB medications complicate the treatment. TB in dialysis carries high morbidity and mortality. TB peritonitis has a poor prognosis.

Current status of lupus nephritis

Systemic lupus erythematosus (SLE) is a systemic disease of unknown aetiology with variable course and prognosis. Lupus nephritis (LN) is one of the important disease manifestations of SLE with considerable influence on patient outcomes. Immunosuppression therapy has made it possible to control the disease with improved life expectancy and quality of life. In the last few decades, various studies across the globe have clarified the role, dose and duration of immunosuppression currently in use and also provided evidence for new agents such as mycophenolate mofetil, calcineurin inhibitors and rituximab. However, there is still a need to develop new and specific therapy with less adverse effects. In this review, the current evidence of the treatment of LN and its evolution, and new classification criteria for SLE have been discussed. Also, rationale for low-dose intravenous cyclophosphamide as induction agent followed by azathioprine as maintenance agent has been provided with emphasis on individualized and holistic approach.

A Study of Continuous Renal Replacement Therapy and Acute Peritoneal Dialysis in Hemodynamic Unstable Patients

Objective:

The objective of the following study was to assess the outcome of continuous renal replacement therapy (CRRT) and acute peritoneal dialysis (PD) in dialysis-requiring renal failure in patients with hemodynamic instability.

Materials and Methods:

A retrospective analysis of all the patients who received CRRT and acute PD over a period of 1 year at our institute, a tertiary care center, was done for diagnosis, type of renal replacement therapy (RRT), and survival outcome. The indications for administering either of the therapy were usual indications of doing hemodialysis with the presence of hemodynamic instability (systolic blood pressure <90 mm of Hg even with inotropes).

Results:

Forty patients, 22 in CRRT and 18 in acute PD group were studied. All these patients required inotropes to maintain desired blood pressure. Twenty-five (62.5%) patients had acute kidney injury (AKI), and 15 (37.5%) had chronic kidney disease (CKD) superimposed over other primary diagnosis. A total of 8 (20%) patients (4 in CRRT, 4 in acute PD) survived at the time of discharge from hospital. The mean age of survivors was approximately a decade less than nonsurvivors (P = 0.15). Overall, there were no survivors in CKD group and all the patients who survived at the time of discharge from hospital had underlying AKI (P = 0.016).

Conclusion:

This study showing comparable survival outcome in acute PD and CRRT gives evidence that either of the modalities can be adopted in hemodynamically unstable patients requiring RRT depending on the resources available.

Clinicopathological spectrum of snake bite-induced acute kidney injury from India

AIM

To study the clinico-pathological spectrum of snake bite-induced acute kidney injury (AKI).

METHODS

A retrospective study of patients admitted at Indira Gandhi Medical College Hospital, Shimla with snake bite-induced AKI from July 2003 to June 2016. Medical records were evaluated for patient’s information on demographic, clinical characteristics, complications and outcome. Outcomes of duration of hospital stay, requirement for intensive care unit support, treatment with dialysis, survival and mortality were analyzed. The survival and non survival groups were compared to see the difference in the demographic factors, clinical characteristics, laboratory results, and complications. In patients subjected to kidney biopsy, the findings of histopathological examination of the kidney biopsies were also analyzed.

RESULTS

One hundred and twenty-one patients were diagnosed with snake bite-induced AKI. Mean age was 42.2 ± 15.1 years and majority (58%) were women. Clinical details were available in 88 patients. The mean duration of arrival at hospital was 3.4 ± 3.7 d with a range of 1 to 30 d. Eighty percent had oliguria and 55% had history of having passed red or brown colored urine. Coagulation defect was seen in 89% patients. The hematological and biochemical laboratory abnormalities were: Anemia (80.7%), leukocytosis (75%), thrombocytopenia (47.7%), hyperkalemia (25%), severe metabolic acidosis (39.8%), hepatic dysfunction (40.9%), hemolysis (85.2%) and rhabdomyolysis (68.2%). Main complications were: Gastrointestinal bleed (12.5%), seizure/encephalopathy (10.2%), hypertension, pneumonia/acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (9.1% each), hypotension and multi organ failure (MOF) (4.5% each). Eighty-two percent patients required renal replacement therapy. One hundred and ten (90.9%) patient survived and 11 (9.1%) patients died. As compared to the survival group, the white blood cell count (P = 0.023) and bilirubin levels (P = 0.006) were significant higher and albumin levels were significantly lower (0.005) in patients who died. The proportion of patients with pneumonia/ARDS (P = 0.001), seizure/encephalopathy (P = 0.005), MOF (P = 0.05) and need for intensive care unit support (0.001) was significantly higher and duration of hospital stay was significantly shorter (P = 0.012) in patients who died. Kidney biopsy was done in total of 22 patients. Predominant lesion on kidney biopsy was acute tubular necrosis (ATN) in 20 (91%) cases. In 11 cases had severe ATN and in other nine (41%) cases kidney biopsy showed features of ATN associated with mild to moderate acute interstitial nephritis (AIN). One patient only had moderate AIN and one had patchy renal cortical necrosis (RCN).

CONCLUSION

AKI due to snake bite is severe and a high proportion requires renal replacement therapy. On renal histology ATN and AIN are common, RCN is rare.

Acute kidney injury due to multiple Hymenoptera stings-a clinicopathological study

Background

Acute kidney injury (AKI) after multiple Hymenoptera stings is well known but still a rare phenomenon.

Methods

We conducted a retrospective study of the clinicopathological spectrum of AKI due to multiple Hymenoptera stings over 13 years (July 2003-June 2016).

Results

A total of 35 patients were diagnosed with AKI due to multiple Hymenoptera stings. The mean age of the patients was 44.7 ± 17.4 years and the majority (60%) were men. Haematological and biochemical laboratory abnormalities included anaemia (97.1%), leucocytosis (54.3%), hyperkalaemia (68.6%), severe metabolic acidosis (51.4%), hepatic dysfunction (74.3%), haemolysis (91.4%) and rhabdomyolysis (62.9%). The main complications included acute respiratory distress syndrome (ARDS) and encephalopathy in four (11.4%) patients each; gastrointestinal bleeding, hypertension and panniculitis in two (5.7%) patients each and one (2.9%) patient each developed intra-abdominal bleeding, stroke and polyserositis. Twenty-nine (83%) patients required dialysis. Ten (29%) patients died. A higher white blood cell count (P = 0.05) and the complications of ARDS (P = 0.004) and encephalopathy (P = 0.004) were associated with mortality. The kidney functions normalized at 5.5 ± 2.6 weeks in patients who survived. Kidney biopsy was done in 13 patients. The predominant lesion was acute tubular necrosis (ATN) with or without pigmented granular cast in 10 (77%) patients. In four (30.8%) patients, the kidney biopsy showed severe ATN and in the other six (46.2%), the kidney biopsy showed features of ATN associated with mild to moderate acute interstitial nephritis (AIN). In three (23%) patients the histopathological examination revealed only moderate AIN and these patients were treated with a short course of steroids.

Conclusions

AKI due to multiple Hymenoptera stings is severe and is associated with high mortality. On renal histology, ATN and AIN are common.

Snake Bite-Induced Acute Kidney Injury: Report of a Successful Outcome During Pregnancy

AbstractSnake bite is an important health hazard in tropics. Snake envenomation in pregnancy may cause fetal death and maternal mortality or morbidity. However, little is known about the toxic effects and optimal management during pregnancy after snake envenomation because of the rarity of cases. Herein, we report a case of a pregnant woman who was successfully treated for snake bite-induced acute kidney injury during the third trimester. She was treated with equine-derived polyvalent anti-snake venom without development of any adverse effects, hemodialysis, and supportive therapy. She fully recovered and subsequently gave birth to a healthy child.

Prevalence and severity of disordered mineral metabolism in patients with chronic kidney disease: A study from a tertiary care hospital in India

BACKGROUND

Disordered mineral metabolism is common complications of chronic kidney disease (CKD). However, there are limited data on the pattern of these disturbances in Indian CKD population.

MATERIALS AND METHODS

This was a prospective observational study of CKD-mineral and bone disorder (CKD-MBD) over a period of 3 years. The biochemical markers of CKD-MBD, namely, calcium, phosphorus, alkaline phosphatase, intact parathyroid hormone (iPTH), and 25-hydoxyvitamin Vitamin D3 (25OHD), were measured in newly diagnosed CKD Stage 3-5 and prevalent CKD Stage 5D adult patients.

RESULTS

A total of 462 patients of CKD Stage 3-5D were studied. The frequency of various biochemical abnormalities was hypocalcemia (23.8%), hypercalcemia (5.4%), hypophosphatemia (2.8%), hyperphosphatemia (55.4%), raised alkaline phosphatase (56.9%), secondary hyperparathyroidism (82.7%), and hypoparathyroidism (1.5%). 25OHD was done in 335 (72.5%) patients and 90.4% were found to have Vitamin D deficiency. About 70.6% of the patients had iPTH levels were above kidney disease outcomes quality initiative (KDOQI) target range. Nondiabetic CKD as compared to diabetic CKD had a higher alkaline phosphatase (P = 0.016), a higher iPTH (P = 0.001) a higher proportion of patients with iPTH above KDOQI target range (P = 0.09), and an elevated alkaline phosphatase (P = 0.004). The 25OHD levels were suggestive of severe Vitamin D deficiency in 33.7%, Vitamin D deficiency in 45.4%, and Vitamin D insufficiency in 11.3% patients. There was a significant positive correlation between iPTH with alkaline phosphatase (r = 0.572, P = 0.001), creatinine (r = 0.424, P = 0.001), and phosphorus (r = 0.241, P = 0.001) and a significant negative correlation with hemoglobin (r = -0.325, 0.001), age (r = -0.169, P = 0.002), and 25OHD (r = -0.126, P = 0.021). On multivariate logistic regression analysis, an elevated alkaline phosphatase was a significant predictor of hyperparathyroidism (odds ratio 9.7, 95% confidence interval 4.9-19.2, P = 0.001).

CONCLUSIONS

There was a high prevalence of CKD-MBD in Indian CKD patients. CKD-MBD is more common and more severe and has an early onset as compared to the western populations.

Volkmann's ischemic contracture: An unusual complication of arterio-venous fistula

Native arterio-venous fistulae (AVF) are vascular access of first choice for chronic hemodialysis. However, AVF are also associated with many adverse events like: primary or secondary failure, infection, lymphedema, stenosis, thrombosis, and ischemia of distal extremities. The most common ischemia related complications of AVF are: ischemic neuropathy and steal syndrome with its consequences like pain and peripheral necrosis. Ischemic muscle contracture is a rare complication of AVF. Herein, we are reporting a case of Volkmann's ischemic contracture developing after creation of brachiocephalic AVF.

The safety and efficacy of high dose ferric carboxymaltose in patients with chronic kidney disease: A single center study

Ferric carboxymaltose (FCM) is a parenteral, dextran-free iron formulation designed to overcome the limitations of existing intravenous (IV) iron preparations. We investigated the safety and efficacy of high dose administration of FCM in our anemic chronic kidney disease (CKD) patients. It was a prospective observational study from June 2011 to August 2013. FCM was administered as IV infusion 1000 mg in 250 ml of normal saline over 15-30 min. Efficacy was evaluated by comparing the Hb and/or serum iron status at the first follow-up visit after the infusion with that at the baseline. A total of 500 infusions were administered to 450 patients. All patients had a successful administration of the FCM. None of the patients had any serious drug-related AE. AE of mild to moderate severity observed or reported after the infusion were: accelerated hypertension (0.2%), feeling abnormal (0.6%), headache and bodyaches (0.6% each), and infusion site reaction (0.8%). 261 patients had a follow up Hb, which showed an increase of 1.7 ± 1.5 g/dl after a period of 11 ± 7.2 weeks (P = 0.001); 188 (72%) patients had a rise in Hb of ≥1 g/dl. The increase in Hb was observed uniformly across all stages of CKD. Proportions of patients with an Hb of above 10 and 11 g/dl increased from 30.2% to 62.8% and 16.1% to 37.9%, respectively (P = 0.001). Iron status evaluation done in 44 patients after a follow up period of 15.1 ± 11.5 weeks showed increases in Hb of 1.6 ± 2.2 g/dl (P = 0.001), transferrin saturation of 9.1 ± 16.9% (P = 0.001), and ferritin of 406 ± 449 ng/ml (P = 0.001). We conclude high dose administration of FCM is safe and well-tolerated. It was effective in the treatment of iron deficiency in nondialysis and peritoneal dialysis CKD patients.

Sodium stibogluconate-associated acute interstitial nephritis in a patient treated for visceral leishmaniasis

The spectrum of side-effects of sodium stibogluconate is well described. Patients treated with sodium stibogluconate can develop varied manifestations of renal toxicity, ranging from renal cell casts, proteinuria, renal tubular acidosis and acute tubular necrosis, resulting in acute kidney injury (AKI). We describe a 32-year-old male patient who was treated for visceral leishmaniasis with sodium stibogluconate. The patient was readmitted two weeks after completion of the treatment for evaluation of AKI. Kidney biopsy revealed marked acute interstitial nephritis. The renal dysfunction reversed totally after a course of corticosteroids. Antimonials should be recognized as a new class of agents as a possible cause of drug-induced acute interstitial nephritis.

Long-term clinical outcomes of peritoneal dialysis patients: 9-year experience of a single center from north India

OBJECTIVE

There is a paucity of published data on the outcome of maintenance peritoneal dialysis (PD) since the initiation of continuous ambulatory PD (CAPD) in India in 1991. The purpose of this study is to report long-term clinical outcomes of PD patients at a single center.

DESIGN

Retrospective study.

SETTING

A government-owned tertiary-care hospital in North India.

PATIENTS

Patients who were initiated on CAPD between October 2002 and June 2011, and who survived and/or had more than 6 months' follow-up on this treatment with last follow-up till December 31, 2011, were studied.

RESULTS

A total of 60 patients were included in the analysis. The mean age of the patients was 60.2 ± 9.2 years. The majority (65%) of the patients lived in rural areas. A high proportion (47%) were diabetic and 62% had ≥ 2 comorbidities. Total duration on peritoneal dialysis treatment was 1,773 patient-months (148 patient-years) with a mean duration of 29.6 ± 23 patient-months and median duration of 25 patient-months (range 6 - 110 patient-months). Overall patient and technique survival at 1, 2, 3, 4 and 5 years was 77%, 53%, 25%, 15%, and 10% respectively. Patient survival of diabetics vs non-diabetics at 1, 2, 3, 4, and 5 years was 68% vs 84%, 54% vs 53%, 14% vs 34%, 11% vs 19%, and 11% vs 13%, respectively. The mortality in non-diabetics (16/32) was less than that in diabetic (18/28) patients (p = not significant). The main cause of mortality in these patients was cardiac followed by sepsis. There were 58 episodes of peritonitis. The rate of peritonitis was 1 episode per 30.6 patient-months or 0.39 episodes per patient-year. Furthermore, the total number of episodes of peritonitis and number of episodes of peritonitis per patient were higher in the non-survival group (p < 0.05). The incidence of tuberculosis (TB), herpes zoster (HZ) and hernias was 15%, 10% and 5% respectively.

CONCLUSION

The study reports long-term outcomes of the PD patients, the majority of whom were elderly with a high burden of comorbidities. There was a high proportion of diabetics. The survival of diabetic vs non-diabetic and elderly vs non-elderly PD patients was similar in our study. The mortality in non-diabetics was less than that in diabetic patients. TB and HZ were common causes of morbidity. Peritonitis was associated with mortality in these patients.

Scrub typhus associated acute kidney injury--a study from a tertiary care hospital from western Himalayan State of India

OBJECTIVE

To report the clinical profile of acute kidney injury (AKI) associated with scrub typhus.

METHODS

Retrospective study of hospitalized patients of acute febrile illness who were diagnosed scrub typhus and had AKI.

RESULTS

174 (35%) patients (75.9% female), mean age (41.4 ± 15.9 years) were studied. The laboratory abnormalities were: anemia (63.2%), leukocytosis (44.3%), thrombocytopenia (61.5%), hyponatremia (35.6%), hypernatremia (2.9%), and hypokalemia (12.1%), hyperkalemia (11.5%), hypoalbuminemia (56.9%), hepatic dysfunction (70%) and metabolic acidosis (28.7%). The complications of hypotension (5.7%), septic shock (3.4%), pneumonia (10.9%), acute respiratory distress syndrome (ARDS) (11.5%), meningoencephalitis (6.9%), encephalopathy (5.2%), gastrointestinal bleed (1.3%), myocarditis (3.4%), disseminated intravascular coagulation (2.9%) and multi organ failure (MOF) (10.3%) developed during course of hospitalization in these patients. Twenty-five (14.4%) patients required intensive care support (ICU) support and seven (4%) patients were dialyzed. 146 (83.9%) patients survived. Twenty-eight (16.1%) patients died. There was a significant difference in the age, various hematological & biochemical abnormalities, complications and need for ICU support in the non-survival group as compared the survival group.

CONCLUSION

This study shows that AKI in scrub typhus is common and a severe disease. Age, a shorter hospital stay, severities of leukocytosis, thrombocytopenia, azotemia, hypoalbuminemia, hepatic dysfunction and the complications of ARDS, encephalopathy, MOF and need for ICU support are the factors associated with mortality.

Hypothyroidism presenting as reversible renal impairment: an interesting case report

We describe an interesting case of reversible renal impairment secondary to hypothyroidism. A 57-years-old man was referred from peripheral institution for evaluation of elevated serum creatinine. He had vague complaints of weakness, lethargy and muscle ache but no urinary symptoms. He was found to have hypothyroidism, and thyroid hormone replacement therapy (THRT) was started which resulted in reversal of the renal dysfunction. There was marked improvement in estimated glomerular filtration rate. 99mTc DTPA renal scans done before and after THRT suggested hypothyroidism responsible for this reversible renal impairment. Several studies have described the pathophysiology of diminished renal function in hypothyroidism. Few studies or case reports have shown total amelioration of renal impairment as seen in our patient. The etiology is presumed to be multifactorial, in which hemodynamic effects and a direct effect of thyroid hormone on the kidney play an important role. We suggest that patients with renal impairment of unknown cause have thyroid function tests undertaken as part of routine investigation.

Microbiological aspects of peritonitis in patients on continuous ambulatory peritoneal dialysis

The objective of the study was to identify the microbiological spectrum and drug-sensitivity pattern of peritonitis in patients on continuous ambulatory peritoneal dialysis. This was a prospective study done over a period of a year-and-a-half at a tertiary-care hospital in a hilly state of India. The effluent dialysate bags from 36 consecutive patients with peritonitis were studied. One hunderd ml dialysate fluid was processed under aseptic conditions by lysis centrifugation method. Microscopy and culture was done from the deposits for bacteriological, fungal, and mycobacterial isolates. They were identified by colony morphology and their biochemical reactions. Drug susceptibility testing was done by Kirby-Bauer disc diffusion method. In 36 dialysates, 33 (91.6%) dialysates were culture-positive and in 3 (8.4%), the culture was negative. A total of 36 microorganisms were isolated in 33 cultures. Among the 36 microorganisms, 19 (52.8%) isolates were gram-positive, 10 (27.8%) were gram-negative, 5 (13.9%) were fungi, and 2 (5.6%) were mycobacterial isolates. All gram-positive organisms were sensitive to ampicillin, amoxi-clavulanic acid, cefazolin, clindamycin, and vancomycin. Neither a methicillin-resistant Staphylococci aureus nor a vancomycin-resistant Enterococcus was isolated in gram-positive isolates. Gram-negative organisms were sensitive to ciprofloxacin, ceftriaxone, ceftazidime, cefepime, gentamicin, piperacillin–tazobactam and imipenem. One of the gram-negative isolate was an extended spectrum beta-lactamase producer. Gram-positive peritonitis was more frequent than gram-negative peritonitis in our continuous ambulatory peritoneal dialysis patients. Mycobacterial causes were responsible for peritonitis in patients with culture-negative peritonitis which was not responding to the conventional antimicrobial therapy.

Spectrum of acute kidney injury in the Himalayan region

Acute kidney injury (AKI) is common in hospitalized patients and is an important cause of mortality. This is a descriptive study of AKI in patients from Himachal Pradesh, India, located in Western Himalayan region. Over a period of 1 year, 102 patients with clinical and laboratory evidence of azotemia were included. Out of 102 patients, 84.3% had community acquired AKI and 15.7% had hospital acquired AKI. Medical causes were leading contributors (85.3%), with septicemia being the main factor (33.3%). Multiorgan failure was present in 59.8% patients. The overall mortality was 29.2%, and community acquired AKI was associated with higher mortality as compared to hospital-acquired AKI (22.5% vs 6.7%). AKI is still common in community and associated with high mortality. Septicemia, volume depletion and nephrotoxins were the leading cause of AKI in our study. Our study highlights the presence of hypotension, multiorgan failure and oliguria with mortality. Community-acquired AKI had higher mortality than hospital-acquired AKI.