Vascular Calcification in Chronic Kidney Disease Patients on Hemodialysis: Prevalence and Correlation with Vascular Disease Events

Introduction: With declining kidney function, the prevalence of vascular calcifications increases and calcification occurs years earlier and is more severe in chronic kidney disease (CKD) patients than in general population. We did this study to find the prevalence of vascular calcification in patients on maintenance hemodialysis using simple and inexpensive radiological method and to find out the correlation of vascular calcification score with vascular disease events, cardiovascular and all-cause mortality over a follow-up period of 1 year. Materials and methods: This prospective, observational, comparative, follow-up, single-center study of maintenance hemodialysis patients was performed at a tertiary care center in Haryana. Seventy-one patients on maintenance hemodialysis for more than 3 months were included in the study. Patients who were 18 years of age or below, CKD stage 5 patients not on dialysis and those who had previous history of parathyroidectomy were excluded. Adragao score for vascular calcification was calculated by evaluating bilateral iliac, femoral and radial arteries in plain radiographic films of pelvis and hands. Statistical analyses were performed with the SPSS System 10.0. Results: Seventy-one patients were enrolled in this study out of which, 45 were male and 26 were female. Mean age of patients was 61.92 ± 10.77 years. Majority of patients were elderly (age group ?60 years). Out of 71 patients, 66 (92.9%) were hypertensive and 26 (36.6%) patients were diabetic. Twenty-two (30.9%) patients had cardiovascular disease (CVD) at baseline. Coronary artery disease (CAD) was present in 20 (28.1%) patients, cerebrovascular disease was present in 2 (2.8%) patients and peripheral artery disease (PAD) was present in only 1 patient at baseline. Average dialysis duration received by patients was 21.35 ± 21.17 months. Out of 71 patients, 16 (22.5%) received calcium-containing phosphate binder, 51 (71.8%) received noncalcium-containing phosphate binder and 4 patients received no phosphate binder. Fifty-five (77.4%) patients received therapeutic or prophylactic vitamin D3 therapy during the study period. Vascular calcification detected with plain X-ray of pelvis and both wrists was found in 56.3% of patients on maintenance hemodialysis. The prevalence and severity of vascular calcification was higher with increasing age. Diabetes was found to be significantly associated with the presence of vascular calcification (p < 0.0005). CAD at the time of enrollment was significantly associated with vascular calcification (p = 0.009). Serum levels of calcium, phosphate, vitamin D3, intact parathyroid hormone (PTH), calcium-phosphate product or use of phosphate binders or the types or vitamin D therapy did not correlate clinically with presence of vascular calcification. Hemodialysis duration did not correlate with the presence of vascular calcification (p = 0.113). Presence of vascular calcifications in hemodialysis patients predicted future vascular disease events over 1 year follow-up (p = 0.013) but did not correlate with cardiovascular and all-cause mortality. Conclusion: There is a high prevalence of vascular calcification in maintenance hemodialysis patients in our center. The risk factors of vascular calcification were higher age, diabetes and CAD. These patients should be followed-up regularly for vascular events. We also want to reiterate with this study that plain X-ray is sufficient to rule out vascular calcification in CKD patients and should be employed regularly in dialysis clinics.

Etiology of Chronic Kidney Disease in Nigeria and Management Challenges

The prevalence of chronic kidney disease (CKD) is increasing globally and is one of the noncommunicable diseases associated with increase mortality globally in the last two decades. The prevalence of CKD in Nigeria, it is 1.6% to 12.4%. Ninety percent of end-stage renal disease (ESRD) patients are said to die within 3 months of commencing dialysis. Indices are even worse in resource poor countries like Nigeria where prevention and adequate intervention are usually hampered by funds. In regions like Nigeria, it will be cheaper to prevent CKD than treating its complications. Hence, it is important to identify the common etiologies of CKD in Nigeria and prevent or promptly address them before causing irreversible damage to the kidneys. The most common cause of CKD in Nigeria includes hypertension, glomerulonephritis and diabetes mellitus. Many of these etiologies are preventable/treatable and should be looked for as a major way to reduce the incidence of CKD in Nigeria. Challenges identified in Nigeria, propagating CKD include westernization, inadequate manpower, late presentation, diagnostic challenge and poorly equipped facilities. Interventions like encouraging healthy lifestyle, making available essential drugs, training of health personnel, subsidized cost of treatment, legislation and policies to curb drug abuse. Therefore, resource-poor settings should focus on creating more awareness and making legislations and/or policies focused on these preventable causes of CKD as this is more realistic and effective in these settings.

Vascular Calcification in Chronic Kidney Disease

Cardiovascular disease (CVD) is the major cause of death in chronic kidney disease (CKD). Of the various risk factors, vascular calcification has only recently come into prominence. CKD is associated with an increased risk of vascular calcification. In routine practice, clinicians usually overlook this finding. Screening for vascular calcification is often missed during first contact with nephrologists. With this article, we would like to reiterate the importance of preventing vascular calcification in early stages of CKD and once it starts appearing, its progression needs to be halted early with individualized treatment. The prevalence, sites of involvement, detection, quantification, pathogenesis, risk factors, clinical manifestations and management options have been discussed.

Vitrector-assisted anterior capsulorhexis in adult intumescent cataract

Performing capsulorhexis in white intumescent cataracts during phacoemulsification surgery is challenging for cataract surgeons because of high intralenticular pressure and reduced red reflex. Capsulorhexis extension to the periphery of the lens is a common occurrence due to lens intumescence. We used a vitrectomy cutter to create an initial tear in the anterior capsule and simultaneously remove a part of milky fluid coming out of the intumescent lens. Once the lens was decompressed, capsulorhexis was completed using capsulorhexis forceps. This technique helped in controlling capsulorhexis in eyes with intumescent cataracts by reducing the intralenticular pressure and thereby preventing unexpected radial capsular tear

A simple modification of the Farnsworth-Munsell 100-Hue test for much faster assessment of color vision.

Purpose: The Farnsworth‑Munsell (FM) 100‑hue test is well known but is also time consuming, especially its analytical component. To reduce this needless time‑waste during precious working hours, a simple modification was devised. Design: Prospective, comparative, observational study. Materials and Methods: A transparent clear plastic carrier box replaced the opaque one, allowing ready digital photodocumentation of top and bottom without even opening the box, or handling/inverting the caps - 200 reportedly normals and 50 known color vision defectives could be easily tested on this modified‑FM and results stored, allowing rapid turnover. The captured scores with patient ID were analyzed, at leisure, outside hospital time, saving 45-60 minutes/ patient. After recording, the box was promptly handed over to the next subject for rearrangement. Times taken for test/patient were recorded. Results: Running time was reduced from 60-75 min to ~15 min/patient with no waste of invaluable lab hours. Turnover time is limited to capturing two photographs (~60 sec). The box is relatively cheap and easy to maintain. Conclusions: Our simplified FM 100‑hue test allowed rapid assessment of color visions with easy data storage of both top and bottom.

Effect of different adjuvants in equines for the production of equine rabies immunoglobulin.

BACKGROUND: Implementation of the recommended post-exposure prophylaxis by vaccination and specific immunoglobulin therapy for rabies is largely hampered by its high cost and inadequate production. Therefore, the development and availability of an economic preparation of rabies immunoglobulin is a high priority for India, where rabies is a major cause of death. We studied the efficacy of four different adjuvants in raising antibodies to rabies antigen in older, discarded equines. METHODS: Eleven equines, 23-26 years old, were divided into 4 groups to receive four different adjuvants in small amounts (1-2 ml)-Freund complete adjuvant with Mycobacterium tuberculosis, Freund complete adjuvant with M. butyricum, Freund incomplete adjuvant and bentonite--along with purified chick embryo cell vaccine. The immunization schedule was spread over 105 days and the antibody titres were measured on days 56, 91 and 119. RESULTS: On day 119 (third sampling), Freund complete adjuvant with M. tuberculosis provided a geometric mean titre of 654.03 IU/ml in comparison with a titre of 459.19 IU/ml with Freund complete adjuvant with M. butyricum, 630.95 IU/ ml with Freund incomplete adjuvant and 172.18 IU/ml with bentonite. CONCLUSION: Purified chick embryo cell vaccine in combination with Freund complete adjuvant containing M. tuberculosis and Freund incomplete adjuvant were better at eliciting an immune response. The low quantity of adjuvants used possibly helped by causing very few side-effects but without compromising the antibody titres.