Objective: To evaluate whether there is a circadian pattern in the onset of acute myocardial infa... more Objective: To evaluate whether there is a circadian pattern in the onset of acute myocardial infarction. Methods: This study included 60 patients. Diagnosis of myocardial infarction was by ECG and/or enzyme abnormalities. Patients were sub-grouped based on age, sex, prior history of ischaemic heart disease, hypertension, and diabetes mellitus. Time of onset of symptoms was noted. For calculation of frequency of onset of symptoms, the day was divided into 4 quarters. Results: Statistically significant peaks were observed in the second and third quarter of the day. Highest number of patients had onset of events in 2nd quarter of day. Similar pattern of distribution was observed in females, patients above and below 60 years, diabetics, hypertensives, and ischaemic heart disease patients. In males, highest frequency was seen in 3rd quarter. Conclusion: There were statistically significant peaks in the onset of acute myocardial infarction in the 2nd and 3rd quarter of the day.
Background: We evaluated if the course of recovery from sepsis-induced acute kidney injury (AKI) ... more Background: We evaluated if the course of recovery from sepsis-induced acute kidney injury (AKI) can be predicted using variables collected at admission. Methods: A total of 63 patients admitted for sepsis-induced AKI in our Mangalore ICU were evaluated and baseline demographic and clinical/laboratory parameters, including serum creatinine (SCr), base excess (BE), Plethysmographic Variability Index (PVI), Caval Index, R wave variability index (RVI), mean arterial pressure (MAP) and renal resistivity index (RI) using renal doppler and need for inotropes were assessed on admission. Patients were managed as per standard protocol. After six hours of fluid resuscitation, patients were classified as volume responders or non-responders. Re-assessment was done at 24 hours and 72 hours after admission. Primary outcome was persistent AKI after 72 hours. Secondary outcome was initiation of dialysis or death within 15 days of admission. Results: A total of 34 subjects recovered from AKI, of who...
Acute kidney injury (AKI) is a particularly common complication in the intensive care setting, an... more Acute kidney injury (AKI) is a particularly common complication in the intensive care setting, and often requires the use of renal replacement therapy. Before implementation of dialysis unit in Burundi the mortality rate of patients with AKI in Intensive Care Unit of Kamenge University hospital was 45.2%. Since 2014 dialysis treatment was initiated. We conducted a study with the objective of to determine the prognosis of AKI in the era of hemodialysis in Burundi. Methods: This was a retrospective multicenter study of 46patients with AKI and treated with hemodialysis at Burundi Kidney Care Clinic,
Aims. We sought to determine outcome and evaluate performance of Acute Physiology and Chronic Hea... more Aims. We sought to determine outcome and evaluate performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores upon admission in predicting 30-day mortality of end-stage renal disease (ESRD) patients admitted in ICU. Methods. This prospective observational cohort study examined 73 consecutive ESRD patients admitted in an ICU of a tertiary care institute over 15 months. Primary outcome measure was 30-day mortality. Data on patient characteristics, reason for ICU admission, cause of ESRD, mode of renal replacement, and use of mechanical ventilation (MV) or inotropes were recorded. The APACHE 2 and SOFA scores were calculated based on admission characteristics. Results. First-day median APACHE II, SOFA, and APACHE II-predicted hospital mortality rates were 26 (14-49), 7 (4-17), and 56.9% (18.6-97.4%), respectively. Observed ICU and 30-day mortality rates were 27.4%, and 41.1%, respectively. During the ICU course, MV and inotropic support was required in 27 (37%) and 23 (35.1%) patients, respectively. Need for MV (p < 0.001) and inotropic support (p < 0.001) were predictors of 30-day mortality in univariate analysis. Area under receiver operating characteristic curve for APACHE II in predicting 30-day mortality was 0.86 (95% CI, 0.76-0.93) compared with 0.92 (95% CI, 0.83-0.97) for SOFA score (p = 0.16). Conclusions. Outcome of ESRD patients admitted to ICU is poor, especially if they require other organ support. APACHE II and SOFA scores perform well as predictors of 30-day mortality.
Giornale italiano di nefrologia : organo ufficiale della Societa italiana di nefrologia, 2014
The Hepato Renal Syndrome (HRS) remains a diagnostic and therapeutic conundrum. Controversies per... more The Hepato Renal Syndrome (HRS) remains a diagnostic and therapeutic conundrum. Controversies persist in the definition, understanding of pathophysiological mechanisms, diagnosis, and therapy of renal dysfunction complicating End Stage Liver Disease (ESLD).While ESLD is complicated by dysfunction in multiple organs, renal disease holds particular bearing on long term outcomes. Liver transplantation is the therapy of choice for ESLD-and co existing renal dysfunction makes it more difficult and challenging. Given that a bare minimum of patients with ESLD will ultimately receive a liver transplant, especially in the developing world, renal dysfunction may ultimately portend untimely death in a many of these patients. It is also critical to recognize the fact that HRS is not the sole cause of renal failure in ESLD. Hence, early recognition and therapy may prolong life even in those who will not receive a transplant for multitude of reasons. Renal Replacement Therapy (RRT) is also a chal...
Giornale italiano di nefrologia : organo ufficiale della Società italiana di nefrologia, 2014
La Sindrome Epato-Renale (SER) rimane un enigma dal punto di vista diagnostico e terapeutico. Per... more La Sindrome Epato-Renale (SER) rimane un enigma dal punto di vista diagnostico e terapeutico. Permangono, infatti, numerose controversie riguardanti la definizione, la comprensione dei meccanismi fisiopatologici, la diagnosi e la terapia della disfunzione renale che complica il decorso dell’insufficienza epatica terminale (End Stage Liver Disease–ESLD). Mentre l’ESLD e complicata da una disfunzione multiorgano, la malattia renale e caratterizzata da un particolare comportamento sugli outcomes a lungo termine. Il trapianto di rene e la terapia di scelta dell’ESLD e la coesistenza di insufficienza renale ne rende la gestione piu complicata ed impegnativa. Visto che una minoranza di pazienti con ESLD riceve alla fine un trapianto di fegato, soprattutto nei paesi in via di sviluppo, la comparsa di insufficienza renale puo lasciar prevedere una morte precoce in molti di questi pazienti. Inoltre, e fondamentale riconoscere che la SER non e l’unica causa di insufficienza renale nell’ESLD. ...
Developing countries like India face a resource crunch when dealing with healthcare expenses. Ren... more Developing countries like India face a resource crunch when dealing with healthcare expenses. Renal Replacement Therapy (RRT) invariably suffers as a consequence of this resource crunch. As a result a large number of patients go with little or zero access to RRT. Additional difficulties faced in a large and diverse country like India include difficult terrain, poor literacy, cultural, social and religious issues. CAPD is thought to be effective in bridging some of these gaps if effectively utilized, as demonstrated by the PD first Policy in Thailand, a country quite similar to India. Cost effective RRT should aim at best possible utilization of existing facilities apart from ease and patient satisfaction with the procedure. To explore whether CAPD could resolve some of the issues facing RRT in India, the Govt of Karnataka State embarked on a CAPD pilot project, notifying 2 centres with 20 patients each and a fixed budget, with a Public -Private Partnership (PPP) model. We present ou...
Introduction Limitations in finance and education is thought to translate into poor technique , u... more Introduction Limitations in finance and education is thought to translate into poor technique , understanding and thereby into higher incidence of peritonitis and ultimately poor patient and technique survival. This notion sometimes leads to such patients being denied Continuous Ambulatory Peritoneal Dialysis (CAPD). Methods: In 2013, 20 patients were initiated on CAPD under a Public Private Partnership (PPP) model project in Karnataka province, India. By regulation, they were required to belong to Below Poverty Line (BPL ) category which is a measure of extreme poverty. BPL is the equivalent of earning less than a dollar per day. They were followed up for peritonitis, technique and patient survival besides overall performance. Results: 20 patients were included ( Male: 60%, Mean age 56.7 years, Diabetic Nephropathy 48%). Peritonitis rate was 1 in 33.8 patient –months, with 3 episodes of Fungal Peritonitis (FP) including one of Candida Hemolunii. All FP led to termination of CAPD. C...
Abstract Background There is limited evidence to provide an insight on the VEMP characteristics t... more Abstract Background There is limited evidence to provide an insight on the VEMP characteristics to explain the association between chronic renal disease (CRD) and its effect on otolith structures. Objective To compare the otolithic function of individuals with CRD and individuals with no known CRD. To investigate the relationship between disease duration and VEMP and creatine level and VEMP among individuals with CRD. Method A cross-sectional study design using convenient sampling method was adapted for the present study. A total of 50 adults aged between 40 and 60 years participated in the study. Group 1 included 25 individuals with CRD undergoing hemodialysis and Group 2 included 25 individuals with no known CRD. cVEMP and oVEMP were recorded from participants in both groups. Results cVEMP and oVEMP was absent in 28% and 44% of individuals with CRD respectively, while, both VEMPs were present among all participants in group 2. Further, peak-to-peak amplitude of VEMP was reduced in individuals with CRD suggesting abnormal otolith function. In addition, a negative correlation was found between disease duration and the peak-to-peak amplitude of VEMP. Conclusion The abnormal VEMP findings in individuals with CRD shows presence of otolithic dysfunction along with amplitude is found to decrease with an increase in the disease duration.
International Journal of Contemporary Medical Research [IJCMR], Dec 1, 2019
Introduction: Hyponatremia is a state of electrolyte imbalance with a high prevalence rate, it is... more Introduction: Hyponatremia is a state of electrolyte imbalance with a high prevalence rate, it is one of the leading cause of morbidity and mortality in our settings. The aim of this study was to evaluate the clinical features and etiology of hyponatremia in patients admitted in our government hospital. Material and methods: A 1-year prospective cross-sectional observational study was conducted on adult patients with moderate-to-severe hyponatremia admitted to the hospital. Patients demographics were recorded and investigations were documented. Data were analyzed using independent sample t-test. Results: Vomiting (28) followed by confusion (26) was the most common complaint. Confusion was significantly high in patients with severe hyponatremia as compared to patients with moderate. Increased urine sodium levels were observed in these patients Conclusion: Patients with hyponatremia secondary to an infectious cause should be meticulously screened and timely and effective treatment of hyponatremia is determined by the effective understanding of pathophysiology and associated risk factors of hyponatremia.
Background: Tacrolimus exposure is estimated by trough levels (C0). Recent studies suggest that C... more Background: Tacrolimus exposure is estimated by trough levels (C0). Recent studies suggest that C0 may not accurately reflect the area under the curve (AUC) and may not correlate with clinical events like acute rejection (AR) and nephrotoxicity. Materials and Methods: In an open, prospective, single-center study, 29 consecutive recipients of renal transplantation underwent C0 along with 2-h (C2), 4-h (C4), and 6-h (C6) estimation of blood tacrolimus levels by enzyme-linked immunosorbent assay, 72 h after initiation with tacrolimus or after a change in its dosage. AUC was estimated by trapezoidal method. C0, C2, C4, and C6 levels were correlated with the AUC. Results: Thirty-six AUC estimations were made over a 2-year period. The best correlate was C6. Correlation coefficients were C0 – 0.868, C2 – 0.788, C4 – 0.839, and C6 – 0.904. C6 values accounted for 79% of the variability of the AUC. Six patients experienced AR, with 5 having C0 within the target range. C6 values correlated best with AUC in these patients (C0 – 0.970, C2 – 0.833, C4 – 0.942, and C6 – 0.970). This was statistically significant. Three patients developed tacrolimus toxicity. In these patients, the correlation coefficients were C0 – 0.551, C2 – 0.556, C4 – 0.77, and C6 – 0.941. By regression analysis, we developed predictive equations. The equation AUC = 12.126 + 2.81 × C0 + 2.92 × C6 best predicted the AUC. Conclusions: Overall C6 levels were more predictive of the AUC, accurately predicting AR and nephrotoxicity. Incorporating C6 may improve tacrolimus therapeutic drug monitoring.
Peritoneal Dialysis (PD) has been an underutilized modality in the treatment of Acute Kidney Inju... more Peritoneal Dialysis (PD) has been an underutilized modality in the treatment of Acute Kidney Injury (AKI). Concerns regarding clearance, fluid removal, infection, complications of therapy, and the hypercatabolic state of AKI has led to PD falling into disrepute. Recent studies have challenged this notion of ineffectiveness. The lower cost, and simplicity of the procedure makes it a particularly attractive option for the developing world which may lack even basic HD facilities, and patients continue to die for want of Renal Replacement Therapy (RRT). We present a review of the available literature about PD in the AKI setting with special reference to the developing world, including the procedure, costs, and effectiveness of the treatment. We also describe the procedure in detail to help ‘hand hold’ physicians interested in performing this lifesaving procedure.
Peritoneal Dialysis (PD) has been an underutilized modality in the treatment of Acute Kidney Inju... more Peritoneal Dialysis (PD) has been an underutilized modality in the treatment of Acute Kidney Injury (AKI). Concerns regarding clearance, fluid removal, infection, complications of therapy, and the hypercatabolic state of AKI has led to PD falling into disrepute. Recent studies have challenged this notion of ineffectiveness. The lower cost, and simplicity of the procedure makes it a particularly attractive option for the developing world which may lack even basic HD facilities, and patients continue to die for want of Renal Replacement Therapy (RRT). We present a review of the available literature about PD in the AKI setting with special reference to the developing world, including the procedure, costs, and effectiveness of the treatment. We also describe the procedure in detail to help ‘hand hold’ physicians interested in performing this lifesaving procedure.
In the tropics, the triad of fever, thrombocytopenia, and AKI portends a grim prognosis with high... more In the tropics, the triad of fever, thrombocytopenia, and AKI portends a grim prognosis with high mortality and a severe strain on already-stretched resources. Malaria, dengue, and leptospirosis account for most cases. We undertook a review of cases to determine factors accounting for adverse prognosis. All patients presenting to the emergency room (ER) with a history of fever, thrombocytopenia, and renal failure were included in the study. Patients were followed until discharge or death, and end points looked at were 1-week and 30-day mortality, and renal function upon discharge. Parameters like liver function test (LFT), renal function, and platelet count upon discharge were also documented. A total of 43 patients was included in the study. Mean age was 42.5 years with 86% males. Mean APACHE and SOFA scores on admission were 23.89 and 15.42, respectively. Mean admission platelet counts were 41,000. Mean serum creatinine was 4.1, and bilirubin was 9.94. A platelet count of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 34,000, serum creatinine of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Â 4, albumin of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Â 2.3, SOFA score of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Â 20, and APACHE score of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Â 32.2 were significantly predictive of 1Â week mortality. Need for mechanical ventilation, oliguria on admission, and need for dialysis all were highly predictive of 30-day mortality. In addition, a serum bicarbonate of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 12, INR of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Â 1.5, hemoglobin of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 9.5 were highly predictive of higher 30 day mortality. Overall, 1-week mortality was 16.3%, of which 48% was accounted for by patients with leptospirosis. Factors like low platelet count, oliguria, need for dialysis, high APACHE and SOFA scores on admission, need for mechanical ventilation, and low serum albumin portend a grave prognosis. There is need for randomized control trials (RCT) to further determine adverse prognostic factors in this subsect of patients.
Peritoneal dialysis (PD) is acknowledged worldwide as a well-accepted form of renal replacement t... more Peritoneal dialysis (PD) is acknowledged worldwide as a well-accepted form of renal replacement therapy (RRT) for end-stage renal disease (ESRD). Ideally, PD should be the preferred modality of RRT for ESRD in developing countries due to its many inherent advantages. Some of these are cost savings (especially if PD fluids are manufactured locally or in a neighboring country), superior rehabilitation and quality of life (QOL), home-based therapy even in rural settings, avoidance of hospital based treatment and the need for expensive machinery, and freedom from serious infections (hepatitis B and C). However, this is not the ground reality, due to certain preconceived notions of the health care givers and governmental agencies in these countries. With an inexplicable stagnation or decline of PD numbers in the developed world, the future of PD will depend on its popularization in Latin America and in Asia especially countries such as China and India, with a combined population of 2.5 b...
Anemia is a significant cause of morbidity and lowers the quality of life of patients suffering f... more Anemia is a significant cause of morbidity and lowers the quality of life of patients suffering from chronic kidney disease (CKD). Iron deficiency is the most important cause of erythropoietin (EPO) hyporesponsiveness in CKD. EPO administration significantly increases the costs of CKD management. It follows that paramount importance must be given to enhancing responsiveness to EPO thereby ensuring that the patient derives maximum benefit. Intravenous iron (IVI) administration has been used for decades to replenish body iron stores. Multiple preparations of Iron are available in the market. However, IVI administration is fraught with dangers like adverse drug reactions, susceptibility to infection, and, as recently postulated, direct cellular toxicity. Traditional approaches to IVI administration have focused on multiple administrations of lower doses for fear of adverse reactions. However, recent studies have demonstrated that higher doses can be safely administered in a single infu...
Objective: To evaluate whether there is a circadian pattern in the onset of acute myocardial infa... more Objective: To evaluate whether there is a circadian pattern in the onset of acute myocardial infarction. Methods: This study included 60 patients. Diagnosis of myocardial infarction was by ECG and/or enzyme abnormalities. Patients were sub-grouped based on age, sex, prior history of ischaemic heart disease, hypertension, and diabetes mellitus. Time of onset of symptoms was noted. For calculation of frequency of onset of symptoms, the day was divided into 4 quarters. Results: Statistically significant peaks were observed in the second and third quarter of the day. Highest number of patients had onset of events in 2nd quarter of day. Similar pattern of distribution was observed in females, patients above and below 60 years, diabetics, hypertensives, and ischaemic heart disease patients. In males, highest frequency was seen in 3rd quarter. Conclusion: There were statistically significant peaks in the onset of acute myocardial infarction in the 2nd and 3rd quarter of the day.
Background: We evaluated if the course of recovery from sepsis-induced acute kidney injury (AKI) ... more Background: We evaluated if the course of recovery from sepsis-induced acute kidney injury (AKI) can be predicted using variables collected at admission. Methods: A total of 63 patients admitted for sepsis-induced AKI in our Mangalore ICU were evaluated and baseline demographic and clinical/laboratory parameters, including serum creatinine (SCr), base excess (BE), Plethysmographic Variability Index (PVI), Caval Index, R wave variability index (RVI), mean arterial pressure (MAP) and renal resistivity index (RI) using renal doppler and need for inotropes were assessed on admission. Patients were managed as per standard protocol. After six hours of fluid resuscitation, patients were classified as volume responders or non-responders. Re-assessment was done at 24 hours and 72 hours after admission. Primary outcome was persistent AKI after 72 hours. Secondary outcome was initiation of dialysis or death within 15 days of admission. Results: A total of 34 subjects recovered from AKI, of who...
Acute kidney injury (AKI) is a particularly common complication in the intensive care setting, an... more Acute kidney injury (AKI) is a particularly common complication in the intensive care setting, and often requires the use of renal replacement therapy. Before implementation of dialysis unit in Burundi the mortality rate of patients with AKI in Intensive Care Unit of Kamenge University hospital was 45.2%. Since 2014 dialysis treatment was initiated. We conducted a study with the objective of to determine the prognosis of AKI in the era of hemodialysis in Burundi. Methods: This was a retrospective multicenter study of 46patients with AKI and treated with hemodialysis at Burundi Kidney Care Clinic,
Aims. We sought to determine outcome and evaluate performance of Acute Physiology and Chronic Hea... more Aims. We sought to determine outcome and evaluate performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores upon admission in predicting 30-day mortality of end-stage renal disease (ESRD) patients admitted in ICU. Methods. This prospective observational cohort study examined 73 consecutive ESRD patients admitted in an ICU of a tertiary care institute over 15 months. Primary outcome measure was 30-day mortality. Data on patient characteristics, reason for ICU admission, cause of ESRD, mode of renal replacement, and use of mechanical ventilation (MV) or inotropes were recorded. The APACHE 2 and SOFA scores were calculated based on admission characteristics. Results. First-day median APACHE II, SOFA, and APACHE II-predicted hospital mortality rates were 26 (14-49), 7 (4-17), and 56.9% (18.6-97.4%), respectively. Observed ICU and 30-day mortality rates were 27.4%, and 41.1%, respectively. During the ICU course, MV and inotropic support was required in 27 (37%) and 23 (35.1%) patients, respectively. Need for MV (p < 0.001) and inotropic support (p < 0.001) were predictors of 30-day mortality in univariate analysis. Area under receiver operating characteristic curve for APACHE II in predicting 30-day mortality was 0.86 (95% CI, 0.76-0.93) compared with 0.92 (95% CI, 0.83-0.97) for SOFA score (p = 0.16). Conclusions. Outcome of ESRD patients admitted to ICU is poor, especially if they require other organ support. APACHE II and SOFA scores perform well as predictors of 30-day mortality.
Giornale italiano di nefrologia : organo ufficiale della Societa italiana di nefrologia, 2014
The Hepato Renal Syndrome (HRS) remains a diagnostic and therapeutic conundrum. Controversies per... more The Hepato Renal Syndrome (HRS) remains a diagnostic and therapeutic conundrum. Controversies persist in the definition, understanding of pathophysiological mechanisms, diagnosis, and therapy of renal dysfunction complicating End Stage Liver Disease (ESLD).While ESLD is complicated by dysfunction in multiple organs, renal disease holds particular bearing on long term outcomes. Liver transplantation is the therapy of choice for ESLD-and co existing renal dysfunction makes it more difficult and challenging. Given that a bare minimum of patients with ESLD will ultimately receive a liver transplant, especially in the developing world, renal dysfunction may ultimately portend untimely death in a many of these patients. It is also critical to recognize the fact that HRS is not the sole cause of renal failure in ESLD. Hence, early recognition and therapy may prolong life even in those who will not receive a transplant for multitude of reasons. Renal Replacement Therapy (RRT) is also a chal...
Giornale italiano di nefrologia : organo ufficiale della Società italiana di nefrologia, 2014
La Sindrome Epato-Renale (SER) rimane un enigma dal punto di vista diagnostico e terapeutico. Per... more La Sindrome Epato-Renale (SER) rimane un enigma dal punto di vista diagnostico e terapeutico. Permangono, infatti, numerose controversie riguardanti la definizione, la comprensione dei meccanismi fisiopatologici, la diagnosi e la terapia della disfunzione renale che complica il decorso dell’insufficienza epatica terminale (End Stage Liver Disease–ESLD). Mentre l’ESLD e complicata da una disfunzione multiorgano, la malattia renale e caratterizzata da un particolare comportamento sugli outcomes a lungo termine. Il trapianto di rene e la terapia di scelta dell’ESLD e la coesistenza di insufficienza renale ne rende la gestione piu complicata ed impegnativa. Visto che una minoranza di pazienti con ESLD riceve alla fine un trapianto di fegato, soprattutto nei paesi in via di sviluppo, la comparsa di insufficienza renale puo lasciar prevedere una morte precoce in molti di questi pazienti. Inoltre, e fondamentale riconoscere che la SER non e l’unica causa di insufficienza renale nell’ESLD. ...
Developing countries like India face a resource crunch when dealing with healthcare expenses. Ren... more Developing countries like India face a resource crunch when dealing with healthcare expenses. Renal Replacement Therapy (RRT) invariably suffers as a consequence of this resource crunch. As a result a large number of patients go with little or zero access to RRT. Additional difficulties faced in a large and diverse country like India include difficult terrain, poor literacy, cultural, social and religious issues. CAPD is thought to be effective in bridging some of these gaps if effectively utilized, as demonstrated by the PD first Policy in Thailand, a country quite similar to India. Cost effective RRT should aim at best possible utilization of existing facilities apart from ease and patient satisfaction with the procedure. To explore whether CAPD could resolve some of the issues facing RRT in India, the Govt of Karnataka State embarked on a CAPD pilot project, notifying 2 centres with 20 patients each and a fixed budget, with a Public -Private Partnership (PPP) model. We present ou...
Introduction Limitations in finance and education is thought to translate into poor technique , u... more Introduction Limitations in finance and education is thought to translate into poor technique , understanding and thereby into higher incidence of peritonitis and ultimately poor patient and technique survival. This notion sometimes leads to such patients being denied Continuous Ambulatory Peritoneal Dialysis (CAPD). Methods: In 2013, 20 patients were initiated on CAPD under a Public Private Partnership (PPP) model project in Karnataka province, India. By regulation, they were required to belong to Below Poverty Line (BPL ) category which is a measure of extreme poverty. BPL is the equivalent of earning less than a dollar per day. They were followed up for peritonitis, technique and patient survival besides overall performance. Results: 20 patients were included ( Male: 60%, Mean age 56.7 years, Diabetic Nephropathy 48%). Peritonitis rate was 1 in 33.8 patient –months, with 3 episodes of Fungal Peritonitis (FP) including one of Candida Hemolunii. All FP led to termination of CAPD. C...
Abstract Background There is limited evidence to provide an insight on the VEMP characteristics t... more Abstract Background There is limited evidence to provide an insight on the VEMP characteristics to explain the association between chronic renal disease (CRD) and its effect on otolith structures. Objective To compare the otolithic function of individuals with CRD and individuals with no known CRD. To investigate the relationship between disease duration and VEMP and creatine level and VEMP among individuals with CRD. Method A cross-sectional study design using convenient sampling method was adapted for the present study. A total of 50 adults aged between 40 and 60 years participated in the study. Group 1 included 25 individuals with CRD undergoing hemodialysis and Group 2 included 25 individuals with no known CRD. cVEMP and oVEMP were recorded from participants in both groups. Results cVEMP and oVEMP was absent in 28% and 44% of individuals with CRD respectively, while, both VEMPs were present among all participants in group 2. Further, peak-to-peak amplitude of VEMP was reduced in individuals with CRD suggesting abnormal otolith function. In addition, a negative correlation was found between disease duration and the peak-to-peak amplitude of VEMP. Conclusion The abnormal VEMP findings in individuals with CRD shows presence of otolithic dysfunction along with amplitude is found to decrease with an increase in the disease duration.
International Journal of Contemporary Medical Research [IJCMR], Dec 1, 2019
Introduction: Hyponatremia is a state of electrolyte imbalance with a high prevalence rate, it is... more Introduction: Hyponatremia is a state of electrolyte imbalance with a high prevalence rate, it is one of the leading cause of morbidity and mortality in our settings. The aim of this study was to evaluate the clinical features and etiology of hyponatremia in patients admitted in our government hospital. Material and methods: A 1-year prospective cross-sectional observational study was conducted on adult patients with moderate-to-severe hyponatremia admitted to the hospital. Patients demographics were recorded and investigations were documented. Data were analyzed using independent sample t-test. Results: Vomiting (28) followed by confusion (26) was the most common complaint. Confusion was significantly high in patients with severe hyponatremia as compared to patients with moderate. Increased urine sodium levels were observed in these patients Conclusion: Patients with hyponatremia secondary to an infectious cause should be meticulously screened and timely and effective treatment of hyponatremia is determined by the effective understanding of pathophysiology and associated risk factors of hyponatremia.
Background: Tacrolimus exposure is estimated by trough levels (C0). Recent studies suggest that C... more Background: Tacrolimus exposure is estimated by trough levels (C0). Recent studies suggest that C0 may not accurately reflect the area under the curve (AUC) and may not correlate with clinical events like acute rejection (AR) and nephrotoxicity. Materials and Methods: In an open, prospective, single-center study, 29 consecutive recipients of renal transplantation underwent C0 along with 2-h (C2), 4-h (C4), and 6-h (C6) estimation of blood tacrolimus levels by enzyme-linked immunosorbent assay, 72 h after initiation with tacrolimus or after a change in its dosage. AUC was estimated by trapezoidal method. C0, C2, C4, and C6 levels were correlated with the AUC. Results: Thirty-six AUC estimations were made over a 2-year period. The best correlate was C6. Correlation coefficients were C0 – 0.868, C2 – 0.788, C4 – 0.839, and C6 – 0.904. C6 values accounted for 79% of the variability of the AUC. Six patients experienced AR, with 5 having C0 within the target range. C6 values correlated best with AUC in these patients (C0 – 0.970, C2 – 0.833, C4 – 0.942, and C6 – 0.970). This was statistically significant. Three patients developed tacrolimus toxicity. In these patients, the correlation coefficients were C0 – 0.551, C2 – 0.556, C4 – 0.77, and C6 – 0.941. By regression analysis, we developed predictive equations. The equation AUC = 12.126 + 2.81 × C0 + 2.92 × C6 best predicted the AUC. Conclusions: Overall C6 levels were more predictive of the AUC, accurately predicting AR and nephrotoxicity. Incorporating C6 may improve tacrolimus therapeutic drug monitoring.
Peritoneal Dialysis (PD) has been an underutilized modality in the treatment of Acute Kidney Inju... more Peritoneal Dialysis (PD) has been an underutilized modality in the treatment of Acute Kidney Injury (AKI). Concerns regarding clearance, fluid removal, infection, complications of therapy, and the hypercatabolic state of AKI has led to PD falling into disrepute. Recent studies have challenged this notion of ineffectiveness. The lower cost, and simplicity of the procedure makes it a particularly attractive option for the developing world which may lack even basic HD facilities, and patients continue to die for want of Renal Replacement Therapy (RRT). We present a review of the available literature about PD in the AKI setting with special reference to the developing world, including the procedure, costs, and effectiveness of the treatment. We also describe the procedure in detail to help ‘hand hold’ physicians interested in performing this lifesaving procedure.
Peritoneal Dialysis (PD) has been an underutilized modality in the treatment of Acute Kidney Inju... more Peritoneal Dialysis (PD) has been an underutilized modality in the treatment of Acute Kidney Injury (AKI). Concerns regarding clearance, fluid removal, infection, complications of therapy, and the hypercatabolic state of AKI has led to PD falling into disrepute. Recent studies have challenged this notion of ineffectiveness. The lower cost, and simplicity of the procedure makes it a particularly attractive option for the developing world which may lack even basic HD facilities, and patients continue to die for want of Renal Replacement Therapy (RRT). We present a review of the available literature about PD in the AKI setting with special reference to the developing world, including the procedure, costs, and effectiveness of the treatment. We also describe the procedure in detail to help ‘hand hold’ physicians interested in performing this lifesaving procedure.
In the tropics, the triad of fever, thrombocytopenia, and AKI portends a grim prognosis with high... more In the tropics, the triad of fever, thrombocytopenia, and AKI portends a grim prognosis with high mortality and a severe strain on already-stretched resources. Malaria, dengue, and leptospirosis account for most cases. We undertook a review of cases to determine factors accounting for adverse prognosis. All patients presenting to the emergency room (ER) with a history of fever, thrombocytopenia, and renal failure were included in the study. Patients were followed until discharge or death, and end points looked at were 1-week and 30-day mortality, and renal function upon discharge. Parameters like liver function test (LFT), renal function, and platelet count upon discharge were also documented. A total of 43 patients was included in the study. Mean age was 42.5 years with 86% males. Mean APACHE and SOFA scores on admission were 23.89 and 15.42, respectively. Mean admission platelet counts were 41,000. Mean serum creatinine was 4.1, and bilirubin was 9.94. A platelet count of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 34,000, serum creatinine of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Â 4, albumin of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Â 2.3, SOFA score of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Â 20, and APACHE score of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Â 32.2 were significantly predictive of 1Â week mortality. Need for mechanical ventilation, oliguria on admission, and need for dialysis all were highly predictive of 30-day mortality. In addition, a serum bicarbonate of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 12, INR of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Â 1.5, hemoglobin of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 9.5 were highly predictive of higher 30 day mortality. Overall, 1-week mortality was 16.3%, of which 48% was accounted for by patients with leptospirosis. Factors like low platelet count, oliguria, need for dialysis, high APACHE and SOFA scores on admission, need for mechanical ventilation, and low serum albumin portend a grave prognosis. There is need for randomized control trials (RCT) to further determine adverse prognostic factors in this subsect of patients.
Peritoneal dialysis (PD) is acknowledged worldwide as a well-accepted form of renal replacement t... more Peritoneal dialysis (PD) is acknowledged worldwide as a well-accepted form of renal replacement therapy (RRT) for end-stage renal disease (ESRD). Ideally, PD should be the preferred modality of RRT for ESRD in developing countries due to its many inherent advantages. Some of these are cost savings (especially if PD fluids are manufactured locally or in a neighboring country), superior rehabilitation and quality of life (QOL), home-based therapy even in rural settings, avoidance of hospital based treatment and the need for expensive machinery, and freedom from serious infections (hepatitis B and C). However, this is not the ground reality, due to certain preconceived notions of the health care givers and governmental agencies in these countries. With an inexplicable stagnation or decline of PD numbers in the developed world, the future of PD will depend on its popularization in Latin America and in Asia especially countries such as China and India, with a combined population of 2.5 b...
Anemia is a significant cause of morbidity and lowers the quality of life of patients suffering f... more Anemia is a significant cause of morbidity and lowers the quality of life of patients suffering from chronic kidney disease (CKD). Iron deficiency is the most important cause of erythropoietin (EPO) hyporesponsiveness in CKD. EPO administration significantly increases the costs of CKD management. It follows that paramount importance must be given to enhancing responsiveness to EPO thereby ensuring that the patient derives maximum benefit. Intravenous iron (IVI) administration has been used for decades to replenish body iron stores. Multiple preparations of Iron are available in the market. However, IVI administration is fraught with dangers like adverse drug reactions, susceptibility to infection, and, as recently postulated, direct cellular toxicity. Traditional approaches to IVI administration have focused on multiple administrations of lower doses for fear of adverse reactions. However, recent studies have demonstrated that higher doses can be safely administered in a single infu...
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