Evaluation of Various Non Culture Methods for the Diagnosis of Spontaneous Bacterial Peritonitis

Introduction: Spontaneous Bacterial Peritonitis (SBP) iscommon and serious complication of patients with livercirrhosis and ascites, without an apparent surgically treatableintra abdominal source of infection. Its prevalence rangesfrom 10% to 30%. Mortality rate was earlier reported morethan 90%, but it has now reduced to 30% -50% as a resultof rapid diagnosis and prompt initiation of antibiotics. Thepresent study was done to evaluate the various non culturemethods for the diagnosis of SBP.Material and Methods: Ascitic fluid sample were collectedaseptically from 100 cirrhotic patients with ascites. PMN(polymorphonuclear leukocyte) count was determined byNeubauer’s manual counting chamber and Leishman’s stainfor differential PMN cell counts. Granulocyte esterase activitywas detected using LER (Leukocyte esterase reagent) dipstickstrips.Results: Out of 100 samples processed, PMN cell count >250 cells/mm3 was found in 91% samples by conventionallight microscopy. Scale of > 2+ by LER strip was found in61 samples. Reading of PMN cell count of > 250 cells/mm3matched in 60 samples and < 250 cells/mm3 matched in 8 cellsby both microscopy and LER strip test. Sensitivity, specificity,positive predictive value and negative predictive value ofLER strip test was 65.9%, 88.89%, 98.36% and 20.51%respectively.Conclusion: LER strips as a screening tool for SBP haveadvantage of speed, low cost, availability at odd hours, requiresno technical expertise and can be performed everywhere.Its high specificity and PPV may help in early institution ofempirical antibiotic therapy in patients.

Venous Thrombosis Complicating Acute Pancreatitis.

Most cases of pancreatitis are mild and self limited. On the other hand, approximately one quarter of patients with pancreatitis may develop vascular complications. Pancreatitis in combination with vascular complications is dangerous and potentially lethal. The survival of patients with pancreatitis and vascular complications depends on the early diagnosis of these complications. We report a case of an elderly male patient who had recurrent pancreatitis. On radiological imaging, patient was found have portal vein, splenic vein and superior mesenteric vein thrombosis. Patient recovered after emergent and timely management. The article focuses on the aspects of etiology, pathogenesis, diagnosis and management of acute pancreatitis with venous thrombosis.

Spectrum of renal disorders in a tertiary care hospital in Haryana.

INTRODUCTION: There is a paucity of data pertaining to spectrum of renal diseases in various parts of India. Available literature has emphasized more on specific clinical syndromes of renal diseases rather than over all spectrum. The present study highlights specimen of symptomatic renal disorders at a tertiary care hospital in Haryana and will find place for better resource management and planning. MATERIALS AND METHODS: It included 1806 patients either presenting for the first time to nephrology outpatient department of admitted between Jan 1996 - Dec 2001 to the institute. The study was retrospective for five years (1996-2000) and prospective for one year. Records of all these patients were analyzed and patients were grouped in different renal syndromes. RESULTS: Mean age of patients was (38.79 +/- 15.15 years) with male preponderance in all renal syndromes. Chronic renal failure (CRF) was the commonest presentation (56.02%). Nephrotic syndrome accounted for 22.36% whereas acute renal failure (ARF) was seen in 12.84%. Other presentations were acute nephritic syndrome (6.75%) and asymptomatic urinary abnormality (AUA) (0.99%). Chronic glomerulonephritis (CGN) (39.32%) and diabetic nephropathy (DN) (19.16%) were leading causes of CRF. Medical ARF accounted for 2/3rd of the cases of ARF and surgical etiology was seen in 1/5th of causes whereas obstetric cause was responsible for 1/7th of the cases. Minimal change disease (MCD) (33.33%) was the commonest cause of primary nephrotic syndrome followed by membranoproliferative glomeruolonephritis (MPGN). Secondary glomerular diseases were found in 21.28%. Post-streptococcal glomerulonephritis (PSGN) was the commonest cause of nephritic syndrome (37.70%). CONCLUSION: It is the first large study of its kind from a tertiary health care centre of Haryana. Male patients in their peak of life (3rd and 4th decade) were the major candidates requiring renal care with CRF as the commonest presentation and diabetic nephropathy as the second commonest cause of CRF after CGN. We need more Indian studies on spectrum of renal diseases for better available resource management.

Organophosphate induced delayed neuropathy.

A 19 year young male who consumed organophosphorous compound and required assisted mechanical ventilation for two weeks, later on developed delayed neuropathy is described.

Comparison of oral versus intravenous iron therapy in predialysis patients of chronic renal failure receiving recombinant human erythropoietin.

OBJECTIVES: To compare oral versus intravenous iron in pre-dialysis patients of chronic renal failure (CRF) receiving recombinant human erythropoietin (rHuEPO). METHODS: The study was undertaken in 40 adult patients of chronic renal failure. The patients were randomly divided into two groups A and B of 20 patients each. Group A patients were given oral iron and group B patients were given intravenous iron. All patients in both groups were given recombinant human erythropoietin 2000 IU twice weekly subcutaneously. The study was carried for up to three months. Patients were monitored every month for renal parameters and haematological parameters which included haemoglobin, reticulocyte count and packed cell volume. Ferrokinetic studies were done at baseline and at three months. RESULTS: It was observed that haematological parameters showed significant statistical improvement in the intravenous iron group as compared to group A (oral iron group). The ferrokinetic studies revealed that serum iron, serum ferritin and transferrin saturation, decreased significantly in oral iron group, whereas significant increase was seen in group B (intravenous iron group). None of the patients developed any adverse effects because of erythropoietin or iron therapy. CONCLUSIONS: Concomitant use of intravenous iron is better than oral iron in CRF patients treated with rHuEPO. The intravenous route of iron administration may be a preferred route along with rHuEPO therapy, more so in the Indian context where prevalence of iron deficiency anaemia is fairly high.

Evaluation of role of acute intermittent peritoneal dialysis in resistant congestive heart failure.

AIMS AND OBJECTIVES: To evaluate the role of acute intermittent peritoneal dialysis (PD) in resistant congestive heart failure (CHF). MATERIAL AND METHODS: The study was conducted on 20 adult patients of resistant CHF. These patients were subjected to 12 cycles of acute intermittent hypertonic peritoneal dialysis. Improvement was monitored by clinical symptomatology, echocardiography, measurement of ultrafiltration and quantity of sodium transferred. RESULTS: There was improvement in clinical symptomatology. There was significance improvement in left ventricular (LV) function as evidenced by improvement in ejection fraction from a predialysis value of 43.35 +/- 16.73% to a post dialysis value of 53.55 +/- 14.53%. The ultrafiltration and quantity of sodium transferred was also significant. CONCLUSIONS: Acute intermittent hypertonic peritoneal dialysis is an effective and safe treatment modality in patients of resistant CEF. The patients subsequently respond well to medical therapy.

A profile of renal/renovascular abnormalities in patients of hypertension.

After a thorough dinical examination and laboratory investigations, ultrasonography (USG) followed by minute sequence urography (MSU) and aortography and/or selective renal angiography were done in 108 patients, clinically suspected of having renal hypertension of which 32 patients (29.6%) were found to be positive for renal/renovascular disease. Out of 82 patients, who were only young hypertensives, a definite diagnosis of renal/renovascular disease could be made in only 15 cases (18.3%), whereas the pick up rate increased to 65.4% in the rest of the 26 patients who had some other clinical criteria besides hypertension and it further increased up to 92.3% (out of these 26 patients) who had 2 or more than 2 clinical criteria of selection of patients besides hypertension. USG was useful in diagnosing renal parenchymal disease/ suggesting renal abnormalities in 30 cases and MSU was able to detect renal changes in 31 patients. Aortography and/or selective renal angiography could make a definite diagnosis of renovascular disease in 17 cases and renal agenesis in one case.

Effect of protein and phosphate restricted and calcium and alphacalcidol supplemented diet on renal and parathyroid functions and protein status in chronic renal failure patients.

OBJECTIVE: To assess the effect of low protein (0.6 g/kg/day), low phosphate (5-10 mg/kg/day) diet with calcium (600 mg/day) and alpha-D3 (0.5 microgram/day) supplementation on renal and parathyroid functions in patients with chronic renal failure (CRF). METHODS: The study included 20 adult patients of CRF, maintained on diet therapy alone. The patients were followed up for renal and parathyroid functions and protein status for 6 months at monthly interval. RESULTS: There was symptomatic improvement in 88% patients. Blood urea and serum creatinine decreased significantly (p < 0.001 and < 0.01, respectively) and the slope of inverse serum creatinine against time changed to static or an upslope. Glomerular filtration rate (GFR) improved from a basal value of 29.35 +/- 18.2 ml/min to 39.25 +/- 27 ml/min after 6 months. Serum parathyroid hormone (PTH) level of 197.65 +/- 133.7 pg/ml and post treatment level of 254.55 +/- 217.19 after 6 months were not different (p > 0.05). Serum calcium remained stationary with a slight increase in serum phosphorus. Phosphorus had a negative correlation with calcium and GFR, whereas calcium had a negative correlation with PTH and phosphorus. PTH had a positive correlation with phosphorus and negative with GFR and calcium. CONCLUSION: There was an improvement in renal functions without any deleterious effect on the protein status of the patients of CRF. Also, there was halting of parathyroid dysfunction especially in those patients where there was no evidence of pre-existing hyperparathyroidism. Hence, dietry management should be strictly enforced in CRF patients early in the course of disease.

Lipid peroxidation and vitamin E in ischemic heart disease.

The study was carried on 90 adult cases which were divided into 3 groups of 30 cases each. Group A consisted of 30 normal healthy controls whereas Group B and C comprised of 30 patients each of chronic stable ischaemic heart disease and of acute myocardial infarction (AMI), respectively. Patients in all the 3 groups were age and sex matched. Group C consisted of 17 cases of anterior wall myocardial infarction, 10 of inferior wall, 2 of anterolateral and 1 of antero-inferior MI and they had an average 6.96 +/- 3.39 hours of chest pain before hospitalization. Serum vitamin E in group A, B and C on day 1 was 7.90 +/- 3.23, 5.345 +/- 2.37 and 1.302 +/- 1.090 micrograms/ml, respectively and malondialdehyde (MDA) levels in these groups were 0.759 +/- 0.27, 0.780 +/- 0.334 and 3.092 +/- 1.124 nmol/ml, respectively. Vitamin E and MDA levels in group C on day 3 were 3.382 +/- 1.088 micrograms/ml and 1.492 +/- 0.849 nmol/ml, respectively. In Group C, vitamin E levels were significantly decreased (p < 0.001) as compared to controls and remained low after 2 days. MDA levels were raised more than 3 times in AMI group (p < 0.01) and decreased slightly after 2 days but were elevated compared to controls. Findings suggest that vitamin E deficiency is inversely related to lipid peroxidation and is elevated during AMI. Therefore supplementation of vitamin E in AMI would be beneficial.

Evaluation of left ventricular functions in chronic renal failure before and after acute hemodialysis.

Left ventricular functions were evaluated in 25 adult patients of chronic renal failure by 2-D echocardiography before and after four hours of standard hemodialysis session. Eighteen patients showed clinical evidence of fluid overload. Predialysis left ventricular end-diastolic diameter, left ventricular end-diastolic volume, left ventricular end-systolic diameter and left ventricular end-systolic volume were comparable in patients with or without fluid overload. Similarly, predialysis stroke volume and left ventricular ejection fraction were not significantly different in the two subsets. However, following hemodialysis there was a significant decrease in the left ventricular systolic and diastolic volumes and diameters in patients with fluid overload. The improvement in the left ventricular ejection fraction was of the same magnitude in the two subsets. The significant improvement in the left ventricular functions both in patients with and without fluid overload indicates that fluid overload may not be the only determinant of left ventricular functions in patients of chronic renal failure, but other factors, such as various uraemia toxins and metabolic changes might also be inhibiting the myocardial functions.

Comparison of sodium nitroprusside added peritoneal dialysis and standard haemodialysis.

Thirty patients of acute or acute on chronic renal failure (ACRF) were randomly divided into two group of 15 cases each. Group A patients received 36 cycles of intermittent peritoneal dialysis (PD) with an exchange volume of one litre and duration of one hour per cycle. The 36 cycles of PD were divided into 12 clearance periods of 3 cycles each. Sodium Nitroprusside (SNP) was added in a dose of 4 mg/litre of dialysate in alternate clearance periods. Group B patients were given 4 hours of haemodialysis (HD) to compare the efficacy of two modes of dialysis. Symptomatic relief was observed in various uraemic signs and symptoms like vomiting, level of consciousness, fluid overload, hiccough and asterexis in most of the patients in both the groups. The percentage fall in blood urea and serum creatinine was 57.02 Vs 58.04 mg% and 46.9 Vs 47.8 mg% in group A and B respectively (P 70.5 each). Total dialysate urea removal following PD and HD was 118.8 +/- 57.3 gm and 98.5 +/- 37.0 gm respectively and also there was no significant difference in total creatinine removal. No untoward effects were observed with PD. However, following HD, 5 patients developed hypotension, supraventricular tachycardia was observed in one and disequilibrium syndrome in 8 of them. Therefore, it can be concluded that SNP added PD is comparable to 4 hours of haemodialysis both clinically as well as biochemically and in situations where facilities for HD do not exist or it is contraindicated, PD may be preferred mode of therapy.

The effect of hematocrit on the efficiency of hemodialysis in cases of chronic renal failure.

Twenty patients of chronic renal failure were evaluated to study the effect of increase in hematocrit (Hct) on the efficiency of hemodialysis. All the patients were subjected to two hemodialysis of identical duration with an interdialytic interval of 48 hours. All were anemic with a mean hemoglobin of 6.73 gm% and a hematocrit of 22.2%. Hematocrit was raised to a mean of 32.02% following transfusion of 2 units (600-700 ml) of whole blood (p < 0.001) in the interdialytic interval. Blood clearances (Kb). Dialysate clearance (Kd), fractional decrement and Kt/V ratio of solutes (urea, creatinine and phosphates) were calculated during both the dialysis and compared with each other. Kt/V of urea decreased from 1.0589 +/- 0.24 to 0.89 +/- 0.15 (p < 0.001), and that of creatinine 1.003 +/- 0.19 to 0.832 +/- 0.009 (p < 0.001) and phosphates 0.992 +/- 0.16 to 0.826 +/- 0.006 (p < 0.001) and it showed a negative correlation with rise in hematocrit. It was significant for creatinine and phosphates and insignificant for urea, suggesting thereby that the efficiency of dialysis decreased with increase in hematocrit. This is important in view of under dialysis in patients of normal or near normal hematocrit and suggests the need for modification of dialysis prescription in such situations.

Effect of intraperitoneal administration of sodium nitroprusside on the efficacy of peritoneal dialysis.

A prospective randomised trial of intraperitoneal sodium nitroprusside (SNP) administration on the efficacy of acute intermittent peritoneal dialysis was carried out in 40 adult patients of acute or acute on chronic renal failure. A total of 36 cycles of peritoneal dialysis (PD) with an exchange volume of 1 litre and duration of 1 hour per cycle were given to each patient. The 36 cycles of PD were divided into 12 clearance periods (I-XII) of 3 cycles each. SNP was added in a dosage of 4 mg/l of dialysate in clearance period II, IV, VI and VIII. Of 40 patients, 20 were subjected to standard PD (Gp A) while the other 20 received SNP added PD (Gp B). The peritoneal clearance of urea, creatinine, percentage fall of blood urea, serum creatinine and protein loss during the various clearance periods were compared in the two groups. It was observed that group B patients had significantly higher peritoneal clearance and the percentage reduction in the blood levels of urea and creatinine. Protein loss per clearance period was also significantly higher in group B patients. Twenty two cycles of SNP added PD were as effective as 36 cycles of standard PD. No systematic untoward effects of SNP were observed. It is therefore, concluded that intraperitoneal SNP administration is a safe and effective way of increasing the efficacy of PD thus reducing the duration of treatment.

Efficacy of magnesium sulphate in aluminium phosphide poisoning--comparison of two different dose schedules.

The results of an open randomised study on the efficacy of magnesium sulphate therapy in aluminium phosphide poisoning are presented. One hundred and fifty five patients divided in three groups and matched for age, sex, dose, duration and severity of poisoning constituted the subject matter. Significant hypomagnesemia was observed in patients who did not receive magnesium sulphate (group 1). Two dose schedules of MgSO4 therapy were tried. The dose schedule No.1 given to patients of group 2 did not raise the magnesium levels significantly as compared to controls (group 4). The difference in the mortality between groups 1 & 2 was also not significant. On the other hand, the dose schedule No.2 given to patients of group 3 raised the magnesium levels significantly and these remained above normal limits throughout the observed period. This dose schedule brought down the mortality significantly than dose schedule No.1 (p < 0.001). It was also found that dose schedule No.2 has been effective in reducing the mortality irrespective of dose of pesticide consumed and its efficacy was due to rapid rise in magnesium levels. It is suggested that hypomagnesemia might be responsible for high mortality of patients of aluminium phosphide poisoning and its correction has beneficial effect on the management and ultimate favourable outcome of the illness.