A case of Gitelman syndrome with severe hyponatraemia and hypophosphataemia

Gitelman syndrome (GS) is a renal tubular disorder of the thiazide-sensitive sodium chloride cotransporter, which is located in the distal tubule of the loop of Henle. We present a rare case of GS complicated by severe hyponatraemia and hypophosphataemia. A 17-year-old boy was admitted to our institution with fever and lethargy. The workup revealed typical features of GS, i.e. hypokalaemia, hypomagnesaemia and metabolic alkalosis. In this report, we discuss the differential diagnoses and rationale for accepting GS as the most likely diagnosis. This case was complicated by severe hyponatraemia (115 mmol/L) and hypophosphataemia (0.32 mmol/L). We concluded that the syndrome of inappropriate secretion of antidiuretic hormones could not be ruled out and that respiratory alkalosis was the most likely aetiology of hypophosphataemia. This case report also generates an interesting discussion on water and electrolyte metabolism.

Clinically significant contrast induced acute kidney injury after non-emergent cardiac catheterization - risk factors and impact on length of hospital stay

To evaluate the frequency and risk factors associated with clinically significant contrast-induced nephropathy [CIN] in patients undergoing non-emergent coronary angiography. Descriptive study. The Aga Khan University Hospital, Karachi, from January 2005 to December 2007. Case records of patients who underwent coronary angiography with a serum creatinine of >/= 1.5 mg/dl at the time of procedure were evaluated. Clinically significant contrast induced nephropathy [CSCIN] was defined as either doubling of serum creatinine from baseline value within a week following the procedure or need for emergency hemodialysis after the procedure. One hundred and sixteen patients met the inclusion criteria. Mean age was 64.0 +/- 11.5 years, 72% were males. Overall prevalence of CIN was 17% [rise of serum creatinine by >/= 0.5 mg/dl] while that of clinically significant CIN [CSCIN] was 9.5% [11 patients]. Patients with CSCIN had significantly lower left ventricular ejection fraction [p = 0.03, OR: 0.24; 95% CI = 0.06 - 0.91] and higher prevalence of cerebrovascular disease [p < 0.001, OR: 14.66; 95% CI = 3.30 - 65.08]. Mean baseline serum creatinine was significantly higher, 3.0 +/- 1.5 vs. 2.0 +/- 1.1 mg/dl [p = 0.03, OR: 1.47; 95% CI = 1.03 - 2.11] whereas mean GFR estimated by Cockcroft-Gault formula was significantly lower at 25 +/- 7.4 vs. 41.0 +/- 14.6 ml/minute [p = 0.001, OR = 0.89, 95% CI = 0.84 - 0.95] at the time of procedure in patients with CSCIN. Mean length of hospital stay was significantly higher in this group compared to those without CIN, 9.0 +/- 5.1 vs. 3.0 +/- 3.2 days [p = 0.001, OR = 1.31, 95% CI = 1.12 - 1.54]. Multivariate analysis revealed low GFR [p = 0.001, OR = 0.88; 95% CI = 0.82 - 0.95] and low ejection fraction [p = 0.03, OR = 0.20; 95% CI = 0.04 - 0.91] to be independent factors associated with CSCIN. No significant differences were noted between the two groups in patients with hypertension, diabetes and heart failure. CSCIN is a significant concern in high risk groups despite prophylaxis. Patients with lower EF, cerebrovascular disease and low GFR at the time of procedure are more likely to have CIN.

APACHE II scores as predictors of cardio pulmonary resuscitation outcome: evidence from a tertiary care institute in a low-income country

The aim of this study was to demonstrate that APACHE II scores can be used as a predictor of the cardio-pulmonary resuscitation [CPR] outcome in hospitalized patients. A retrospective chart review of patients admitted, from 2002 to 2007, at the Aga Khan University Hospital, Karachi, was done for this study. Information was collected on 738 patients, constituting all adults admitted in general ward, ICU, CICU and SCU during this time, and who had under-went cardiac arrest and received cardiopulmonary resuscitation during their stay at the hospital. Patient characteristics, intra-arrest variables such as event-witnessed, initial cardiac rhythm, pre arrest need for intubation and vasoactive drugs, duration of CPR and survival details were extracted from patient records. The APACHE II score was calculated for each patient and a descriptive analysis was done for demographic and clinical features. The primary outcome of successful CPR was categorized as survival >24 h after CPR versus survival <24 h after CPR. Multivariable logistic regression was used to assess the association between the explanatory variables and successful CPR. Patients with APACHE II scores less than 20 had 4.6 times higher odds of survival compared to patients with a score of >35 [AOR: 4.6, 95% CI: 2.4-9.0]. Also, shorter duration of CPR [AOR: 2.9, 95% CI: 1.9-4.4], evening shift [AOR: 2.1, 95% CI: 1.3-3.5] and Male patients [AOR: 0.6, 95% CI: [0.4-0.9] compared to females were other significant predictors of CPR outcome. APACHE II score, along with other patient characteristics, should be considered in clinical decisions related to CPR administration