Influence of Fluid Balance on Morbidity and Mortality in Critically Ill Patients With Acute Kidney Injury.

INTRODUCTION: Fluid management in critically ill patients with acute kidney injury (AKI) is controversial. Our study is aimed to evaluate the association between fluid balance and patient outcome in AKI patients admitted to intensive care unit (ICU). MATERIALS AND METHODS: This prospective study was carried out at Lilavati Hospital and Research Centre on 130 critically ill patients with AKI admitted to ICU. Mean daily fluid balance (MDFB) was measured and its correlation with clinical characteristics and outcomes was assessed. RESULTS: During ICU stay, 48.2% patients had a positive and 52.8% had a negative MDFB. In the patients with positive MDFB, mean ICU stay was longer and ventilation requirement, duration of ventilation, inotrope requirement, and duration of inotrope were greater as compared to the group with negative MDFB. A significantly higher mortality rate were observed in the patients with positive MDFB as compared to negative MDFB (43.5% versus 7.4%). CONCLUSIONS: Negative fluid balance was independently associated with a significant reduction in mortality, ICU stay, ventilator requirement, and the need for renal replacement among critically ill patients with AKI.

Influence of prebiotic and probiotic supplementation on the progression of chronic kidney disease.

BACKGROUND: One of the main goals in chronic kidney disease (CKD) patients is to diminish the accumulation of uremic toxins and to slow the progression of renal failure. We investigated whether prebiotic and probiotic supplementation along with low protein diet retards the progression of CKD. METHODS: This is a 12-month prospective observation study with a randomized control and open-label design. A total of 24 stable CKD stage III to V patients, who are not on renal replacement therapy, were enrolled in this study. Patients were randomly assigned to 2 groups: low protein diet + prebiotic + probiotic supplementation (N.=12), receiving 3 tablets of prebiotic + probiotic supplementation daily for 6 months, and the control group receiving low protein diet only (N.=12). We examined the effects of prebiotic and probiotic supplementation on estimated glomerular filtration rate (eGFR) in CKD. RESULTS: The declining GFR during prebiotic and probiotic supplementation were significantly lower (-11.6±8.6 vs. -3.4±4.6 mL/min per 1.73 m2 per year, 95% CI -6.45 - -9.86, P<0.001) than those with low protein diet alone. CONCLUSIONS: Prebiotic and probiotic supplementation along with low protein diet delayed the progression of CKD.

Vascular access profile in maintenance hemodialysis patients.

INTRODUCTION: The aims of this study was to evaluate maintenance hemodialysis population in a tertiary care hospital based dialysis unit for vascular access (VA) types, to compare native arteriovenous fistula (AVF) and arteriovenous graft (AVG) survival, and to assess risk factors for access failure. MATERIALS AND METHODS: A total of 182 patients on maintenance hemodialysis were evaluated and followed up in terms of VA type and VA outcomes. RESULTS: Among 103 prevalent patients, 15.5% initiated dialysis with AVF. At the time of the study, 67.9% of the prevalent patients had an AVF and 29.1% had AVG. Of 79 incident patients, 64% were followed up for more than 3 months by nephrologists before initiation of dialysis. Among these patients, 13.6% were initiated with AVF. There were 25 primary failures and 50 secondary failure episodes. Of the 50 secondary failures, 15 were AVF failures and 31 AVG failures. Vascular access survival was significantly superior with AVF as compared with AVG (P = .03). With longer dialysis periods, failure rates were higher. Follow-up with nephrologists prior to initiation of dialysis had a major influence on VA. CONCLUSIONS: Arteriovenous fistula is the best VA for maintenance hemodialysis. However, when the vasculature is not ideal for AVF, AVG should be constructed. A small percentage of our patients had fistula at initiation of dialysis. This is mainly due to late nephrology referrals and also due to reluctance of patients to undergo surgical access placement when they are relatively asymptomatic.

Incidence of acute cardiorenal syndrome type 3 in India.

INTRODUCTION: The aim of this study was to determine the incidence of acute renocardiac syndrome (cardiorenal syndrome type 3) and its outcome in a suburban population in India. MATERIALS AND METHODS: In an observational study, 100 patients admitted with acute kidney injury were evaluated. RESULTS: Acute renocardiac syndrome was documented in 29%. Acute gastroenteritis (46%) was the leading cause of acute kidney injury. Cardiogenic pulmonary edema (56%) was the most common cause of acute cardiac dysfunction. Only 42% of the patients with acute renocardiac syndrome had complete recovery of kidney function. Requirement of renal replacement therapy was found to be significantly high in patients with acute renocardiac syndrome (43% versus 9% in those with AKI and no cardiorenal syndrome) and was associated with high rate of mortality (17%). CONCLUSIONS: This study shows that the incidence of acute renocardiac syndrome is high and is associated with increased morbidity and mortality. Hence, there is a need for primordial prevention and early intervention on large scale.

Acute kidney injury following Paraquat poisoning in India.

Paraquat is highly toxic to human and is widely used in agriculture as a contact herbicide. Paraquat poisoning is associated with high mortality varying from 35% to 50%. Six cases of paraquat poisoning were treated in our center. Acute kidney injury developed in all the cases and mortality was 66%. Respiratory and multiorgan failure are the main causes for mortality.

Early recurrence of diabetic nodular sclerosis in a kidney transplant recipient.

Almost all kidney transplant recipients with diabetes mellitus will eventually develop recurrence of diabetic nephropathy in their allograft. Despite this high incidence, there are very few reported cases of diabetic nephropathy of diffuse type, and the nodular sclerosis form is uncommon. Recurrence of diabetic nephropathy of nodular glomerulosclerosis type usually occurs during the second decade of transplantation. We report a rare case of diabetic nodular glomerulosclerosis developing 5 years after transplantation, leading to progressive kidney dysfunction and graft loss.

Polyomavirus associated nephropathy presenting five years after kidney transplantation.

INTRODUCTION: Polyomavirus associated nephropathy (PVAN) is being recognised as an important cause of renal transplant dysfunction. It is a difficult diagnosis to make and requires a high index of suspicion. Here we describe an unusually late presentation of PVAN that responded favourably to reduction of immunosuppression. CASE REPORT: A 52 year-old male presented with an elevated serum creatinine of 3.8 mg/dl five years after kidney transplantation. He was maintained on tacrolimus, mycophenolate mofetil (MMF), and prednisolone. He had loose motions that subsided when MMF was withdrawn. His tacrolimus trough level was very high and its dose was reduced, with no improvement in creatinine level. Doppler of the transplanted kidney revealed normal perfusion. The patient's urine was negative for decoy cells and his plasma PCR for polyoma BK virus DNA was also negative. Kidney biopsy revealed histological features suggestive of PVAN and this diagnosis was confirmed by immunohistochemistry which was positive for simian virus 40 (SV40) antigen. Tacrolimus was discontinued and the patient maintained on azathioprine and prednisolone. His serum creatinine stabilized at 1.2 mg/dl. CONCLUSION: This case highlights the propensity of PVAN to present very late after transplantation. Renal biopsy is very valuable in establishing the diagnosis and timely management can prevent graft loss.

Unusual presentation of renal tuberculosis.

Urogenital tuberculosis (TB) is a common late manifestation of an earlier symptomatic or asymptomatic pulmonary TB infection. A latency period ranging from 5 to 40 years between the time of the initial infection and the expression of urogenital TB frequently occurs. As one of the most common sites of involvement of extrapulmonary TB, urogenital TB accounts for 15% to 20% of the infections. We present a patient who had culture-negative active tubercular kidney disease due to silent tuberculous infection. Our case demonstrates the limitations of noninvasive testing in establishing the diagnosis of renal tuberculosis.

Management of scleroderma-related end-stage renal disease with automated peritoneal dialysis.

Kidney failure is the principal cause of death in scleroderma and accounts for at least 50% of deaths in this disease. Management of scleroderma-related end-stage renal disease requires some form of renal replacement therapy. Survival up to 18 months has been reported in one patient on continuous ambulatory peritoneal dialysis. Surviving for more than 1 year on automated peritoneal dialysis has not been reported. We report a patient with scleroderma-related end-stage renal disease treated with automated peritoneal dialysis with steady state control of uremia and hypertension at 18 months of follow-up.