Senescent chronic kidney disease: The challenges faced and the strategies to overcome.

The management of chronic kidney disease (CKD) in elderly patients continues to pose constant challenges to clinical nephrologists. Right from the perplexing issue of calculating the glomerular filtration rate (GFR) to the confusion between the choice of disease-oriented approach and individual-centered approach, the challenges faced are mammoth. This article seeks to bring a consensus in sorting out these practical problems so that a systematic way of approach could be arrived at in managing such fragile patients. The last decade has seen an evolution and ongoing refinement of a disease-oriented approach to CKD. Since the average GFR tends to decrease with age, CKD becomes increasingly prevalent with advancing age, and thus, disproportionately elderly patients meet the criteria for CKD.

Evaluation of Protein-Energy Wasting and Inflammation on Patients Undergoing Continuous Ambulatory Peritoneal Dialysis and its Correlations.

BACKGROUND: Protein-energy wasting (PEW) and heightened inflammation are prevalent in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and is a strong risk factor for morbidity and mortality in these patients. Evaluation of PEW, prevalence of inflammation as well as interrelationship between various nutritional indices and inflammation has not been studied in much detail in patients undergoing CAPD. OBJECTIVES: This study was conducted to evaluate the interrelationship between PEW and inflammation in patients undergoing CAPD. PATIENTS AND METHODS: Sixty-three patients undergoing CAPD (M = 28, F = 35) were assessed with regard to their nutritional status and inflammation after a minimum of 3 months CAPD initiation. Nutritional status was assessed by dietary diary, anthropometry, subjective global assessment, and multifrequency bioelectrical impedance analysis (BIA). In addition, their serum albumin, prealbumin, transferrin, and cholesterol level were measured. Also, inflammation in these patients was assessed by High-Sensitivity C-Reactive Protein (hs-CRP > 3 mg/L) and Interleukin-6 (IL-6 > 2 µg/mL). Later on, diagnosis of malnutrition was made based on different methods. Correlation between inflammation and various nutritional assessment indices were analyzed statistically. RESULTS: Mean (SD) age of the patients was 57.6 (11.6) years. The average (SD) calorie and protein intake per day were 25.5 (4.6) kcal and 0.81 (0.2) mg, respectively. The mean and standard deviation of anthropometry variables of body mass index (BMI), mid-arm circumference (MAC), tricipital skin-fold thickness (TST), mid-arm muscle circumference (MAMC), and corrected mid-arm muscle area (cMAMA) were 23.7 ± 5 kg/m(2), 26.3 ± 4.5 cm, 1.624 ± 0.4 cm, 25.6 ± 4.5 cm, and 45.7 ± 19.7 cm(2), respectively. The mean values of serum protein, albumin, prealbumin, transferrin, cholesterol, triglyceride, hs-CRP, and IL-6 were 5.9 g/dL, 3.0 g/dL, 21.11 mg/dL, 130.6 mg/dL, 155.9 mg/dL, 136.1 mg/dL, 8.8 ± 7.6 mg/L, and 8.4 ± 12.2 µg/dL, respectively. Based on subjective global assessment (SGA); 11.63 (17.4%), 34.63 (54%), and 18.65 (28.6%) patients undergoing CAPD had normal, moderate, and severe malnutrition status, respectively. According to serum albumin level; 13.63 (21%), 39.63 (62%), and 11.63 (17%) patients undergoing CAPD had normal, moderate, and severe malnutrition status, respectively. Finally, based on BMI; 33.63 (52%), 23.63 (37%), and 7.63 (11%) patients undergoing CAPD had normal, moderate, and severe malnutrition status, respectively. About 76.1% and 9.5% of patients undergoing CAPD were malnourished based on lean tissue index (LTI) and fat tissue index (FTI), respectively. Based on hs-CRP and IL-6 findings, 70% (44/63) and 71.8% (45/63) of patients undergoing CAPD had high inflammation, respectively. High sensitive C-reactive protein correlated negatively (significantly) with serum albumin, prealbumin, and transferrin. Interleukin -6 correlated negatively (significantly) with MAC; MAMA; serum albumin, cholesterol, and transferrin. There was significant positive correlation between hs-CRP and IL-6. There is statistically significant difference in total protein intake (g/d), protein intake (g/kg/d), serum protein (g/dL), albumin (g/dL), transferrin (mg/dL), and cholesterol (mg/dL) between patients with and without inflammation. CONCLUSIONS: Protein-energy wasting (80% - 85%) by various methods and inflammation (70%) was very prevalent among patients undergoing CAPD. Inflammatory markers show significant negative correlation with anthropometry and serological markers. Inflammatory markers are suggested to be included in the regular assessment of patients undergoing CAPD, for the better management of protein-energy wasting.

Estimation of renal function in the intensive care unit: the covert concepts brought to light.

Frantic efforts have been made up to this date to derive consensus for estimating renal function in critically ill patients, only to open the Pandora's box. This article tries to explore the various methods available to date, the newer concepts, and the uncared issues that may still prove to be useful in estimating renal function in intensive care unit patients. The concept of augmented renal clearance, which is frequently encountered in critically ill patients, should always be taken into account, as correct therapeutic dosage of drugs sounds vital which in turn depends on correctly calculated glomerular filtration rate. Serum creatinine and creatinine-based formulae have their own demerits that are well known and established. While Cockcroft-Gault and 4-variable modification of diet in renal diseases formulae are highly inadequate in the intensive care setup for estimating glomerular filtration rate, employing isotopic methods is impractical and cumbersome. The 6-variable modification of diet in renal diseases formula fairs better as it takes into account the serum albumin and blood urea nitrogen, too. Jelliffe's and modified Jelliffe's equations take into account the rate of creatinine production and volume of distribution which in turn fluctuates heavily in a critically ill patient. Twenty-four-hour and timed creatinine clearances offer values close to reality although not accurate and cannot provide immediate results. Cystatin C is a novel agent that offers a sure promise as it is least influenced by factors that affect serum creatinine to a major extent. Aminoglycoside clearance, although still in the dark area, may prove a simple yet precise way of estimating glomerular filtration rate in those patients in whom these drugs are therapeutically employed. Optic ratiometric method has emerged as the most sophisticated one in glomerular filtration rate estimation in critically ill patients.

Analysis of case series of milky urine: A single center and departmental clinical experience with emphasis on management perspectives: A prospective observational study.

BACKGROUND: Milky urine can be due to chyluria or lipiduria due to nephrotic syndrome. Filarial chyluria usually responds to medical management while non-filarial cases may require surgical intervention. AIM: To perform a prospective observational study in patients presenting with milky urine in our centre over a period of one year from July 2011 to June 2012, a complete biochemical work up and imaging to find out the site of leakage of lymph if it is a case of chyluria, its response to medical management and the requirement of surgical intervention. MATERIALS AND METHODS: Routine blood and urine investigations, 24 hour urine protein excretion, USG abdomen, serum lipid profile and rapid filarial antigen test were done in all. MRI abdomen was done in affordable patients. Renal biopsy was done in some chyluria patients for academic purpose and in milky urine with negative urine ether test. Sclerotherapy was done with 50% dextrose and 0.2% povidone iodine. Patients were followed up with 24 hour urine protein and triglyceride estimation. RESULTS: 18 cases of milky urine were encountered. 8 were filarial chyluria, 9 non- filarial and 1 MCD. Mean urine TG level and median 24 hour urinary protein excretion were 37.2 ± 24.6 mg% and 4.96 g respectively. The mean age for filariasis (22.9 ± 4.5 years) was significantly different from that of non-filarial etiology (31.5 ± 4.8 years) (P = 0.005). The mean 24 hour urinary protein for normal MRI cases (4.64 ± 0.70 g) was significantly different from those with dilated lymphatics (8.15 ± 2.55 g) (P = 0.02). All the non- filarial and 4 filarial cases required sclerotherapy. One patient required a second sitting. CONCLUSION: Milky urine is most commonly due to chyluria and occasionally due to nephrotic syndrome. Nephrotic syndrome is managed in its own way while chyluria not amenable to pharmacological intervention is managed with sclerotherapy.

Post cardiac surgery acute kidney injury: a woebegone status rejuvenated by the novel biomarkers.

BACKGROUND: Acute kidney injury (AKI) is common after cardiac surgery, the incidence varying between 7.7% and 28.1%. It significantly increases morbidity and mortality. Creatinine considerably delays the diagnosis with its own attended demerits. Novel urinary biomarkers are emerging which help in rapid diagnosis thus reducing the morbidity and mortality. Biomarkers of our study were neutrophil gelatinase-associated lipocalin (NGAL) and Interleukin-18 (IL-18). OBJECTIVES: To find out the incidence of AKI in post-cardiac surgery patients in our hospital, the ability of the two biomarkers in early diagnosis in predicting the severity of AKI based on RIFLE's criteria and their ability to discriminate pre-renal from intrinsic AKI. PATIENTS AND METHODS: One-hundred patients who underwent cardiac surgery were selected. Midstream urine samples were collected at 3 time intervals (baseline before surgery, 24 hours and 7 days after surgery). Biomarkers were measured by ELISA using BIORAD processors. Fractional excretion of sodium and urea were used to discriminate pre-renal from intrinsic AKI. RESULTS: Out of 100 patients, 31 had AKI, 11 being pre-renal and 20 intrinsic AKI. Four patients required renal replacement therapy (12.9% among AKI cases and 4% in the overall study cohort). Four among 31 expired in intensive care unit. Identifiable risk factors for AKI included insulin requiring diabetes mellitus, chronic obstructive pulmonary disease, increased cardio-pulmonary bypass time, combined valvular surgery and coronary artery bypass grafting, employment of intra-aortic balloon counter pulsation, left main coronary artery occlusion and an ejection fraction of < 40%. NGAL was extremely sensitive (area under curve-0.96) in detecting intrinsic AKI at 24 hours followed by IL-18 ratio with an area under curve of 0.89. Creatinine at 24 hours was able to detect only 31.6% of intrinsic AKI. None of the pre-renal cases showed rise in the urinary biomarker levels. Patients with higher stages of AKI had higher levels of both biomarkers than those at lower stages. CONCLUSIONS: NGAL and IL-18 obviated the disadvantages of creatinine. They were efficient in early detection of AKI, in differentiating pre-renal from intrinsic AKI and in predicting the severity of AKI reliably in post-cardiac surgery patients.

Nontraditional cardiovascular biomarkers and estimation of cardiovascular risk in predialysis chronic kidney disease patients and their correlations with carotid intima media thickness.

BACKGROUND: Cardiovascular biomarkers such as N-terminal pro-B-type natriuretic peptide (NT-proBNP), cardiac troponin T (cTnT), hs-CRP (high sensitivity C-reactive protein), and albuminuria predict underlying heart disease in the general population as well as CKD patients. OBJECTIVES: We aimed to study the association of NT-proBNP, cTnT, hs-CRP, and spot urine albumin creatinine ratio with carotid intima media thickness (CIMT) for cardiovascular risk estimation in predialysis CKD (chronic kidney disease) patients. PATIENTS AND METHODS: This cross-sectional study included a total of 120 adult predialysis CKD patients. Forty patients were allocated in each predialysis CKD group of stages 3, 4, and 5. Serum cTnT and hs-CRP, plasma NT-proBNP, and single spot urine albumin creatinine ratio (ACR) were measured. Ultrasonographic examination of carotid artery was done with 7.5 MHz linear probe in B mode ultrasonography and carotid intima media thickness was measured. RESULTS: Mean values ± standard deviation of plasma NT-proBNP (pg/mL), serum hs-CRP (mg/L), spot urine ACR (mg/g of creatinine), and CIMT (mm) were 585.68 ± 514.84, 5.96 ± 2.52, 719.37 ± 411.36, and 0.78 ± 0.15, respectively in predialysis CKD patients (n = 120). Serum cTnT level was high in 40% of predialysis CKD patients. Among cardiovascular biomarkers, plasma NT-proBNP had maximum strength of correlation (Spearman Rho correlation coefficient; r = 0.575 and P < 0.0001) with the carotid intima media thickness followed by serum cTnT (Spearman Rho correlation coefficient; r = 0.419 and P < 0.0001), spot urine albumin creatinine ratio (Spearman Rho correlation coefficient; r = 0.322 and P < 0.0001), and serum hs-CRP (Spearman Rho correlation coefficient; r = 0.246 and P = 0.007). CONCLUSIONS: Nontraditional cardiovascular biomarkers such as plasma NT-proBNP, serum cTnT, serum hs-CRP, and spot urine ACR significantly correlate with CIMT. These biomarkers can estimate the cardiovascular risk in a predialysis CKD population with expected high cardiac morbidity and mortality.