Fever, thrombocytopenia, and AKI-A profile of malaria, dengue, and leptospirosis with renal failure in a South Indian tertiary-care hospital.

INTRODUCTION: In the tropics, the triad of fever, thrombocytopenia, and AKI portends a grim prognosis with high mortality and a severe strain on already-stretched resources. Malaria, dengue, and leptospirosis account for most cases. We undertook a review of cases to determine factors accounting for adverse prognosis. METHODS: All patients presenting to the emergency room (ER) with a history of fever, thrombocytopenia, and renal failure were included in the study. Patients were followed until discharge or death, and end points looked at were 1-week and 30-day mortality, and renal function upon discharge. Parameters like liver function test (LFT), renal function, and platelet count upon discharge were also documented. RESULTS: A total of 43 patients was included in the study. Mean age was 42.5 years with 86% males. Mean APACHE and SOFA scores on admission were 23.89 and 15.42, respectively. Mean admission platelet counts were 41,000. Mean serum creatinine was 4.1, and bilirubin was 9.94. A platelet count of < 34,000, serum creatinine of > 4, albumin of > 2.3, SOFA score of > 20, and APACHE score of > 32.2 were significantly predictive of 1 week mortality. Need for mechanical ventilation, oliguria on admission, and need for dialysis all were highly predictive of 30-day mortality. In addition, a serum bicarbonate of < 12, INR of > 1.5, hemoglobin of < 9.5 were highly predictive of higher 30 day mortality. Overall, 1-week mortality was 16.3%, of which 48% was accounted for by patients with leptospirosis. CONCLUSIONS: Factors like low platelet count, oliguria, need for dialysis, high APACHE and SOFA scores on admission, need for mechanical ventilation, and low serum albumin portend a grave prognosis. There is need for randomized control trials (RCT) to further determine adverse prognostic factors in this subsect of patients.

[The hepatorenal syndrome - a review]. / La sindrome epato-renale: una revisione della letteratura.

The Hepato Renal Syndrome (HRS) remains a diagnostic and therapeutic conundrum. Controversies persist in the definition, understanding of pathophysiological mechanisms, diagnosis, and therapy of renal dysfunction complicating End Stage Liver Disease (ESLD).While ESLD is complicated by dysfunction in multiple organs, renal disease holds particular bearing on long term outcomes. Liver transplantation is the therapy of choice for ESLD-and co existing renal dysfunction makes it more difficult and challenging. Given that a bare minimum of patients with ESLD will ultimately receive a liver transplant, especially in the developing world, renal dysfunction may ultimately portend untimely death in a many of these patients. It is also critical to recognize the fact that HRS is not the sole cause of renal failure in ESLD. Hence, early recognition and therapy may prolong life even in those who will not receive a transplant for multitude of reasons. Renal Replacement Therapy (RRT) is also a challenge in this patient population, leading to issues with hemodynamics, vascular access and anticoagulation. We take a look at recent literature and advances in the understanding of the pathophysiology of this particularly difficult condition, and its diagnosis and management.

Maximizing the erythropoietin response: iron strategies.

Anemia is a significant cause of morbidity and lowers the quality of life of patients suffering from chronic kidney disease (CKD). Iron deficiency is the most important cause of erythropoietin (EPO) hyporesponsiveness in CKD. EPO administration significantly increases the costs of CKD management. It follows that paramount importance must be given to enhancing responsiveness to EPO thereby ensuring that the patient derives maximum benefit. Intravenous iron (IVI) administration has been used for decades to replenish body iron stores. Multiple preparations of Iron are available in the market. However, IVI administration is fraught with dangers like adverse drug reactions, susceptibility to infection, and, as recently postulated, direct cellular toxicity. Traditional approaches to IVI administration have focused on multiple administrations of lower doses for fear of adverse reactions. However, recent studies have demonstrated that higher doses can be safely administered in a single infusion, thereby reducing hospitalization costs and patient inconvenience. Newer preparations of IVI are relatively safer, easier to administer and efficacious. Preparations like Iron sucrose, ferumoxytol, ferric carboxymaltose and iron isomaltoside do not require test doses and allow higher doses to be administered at a time with cost and effect benefits.

Prophylaxis against fungal peritonitis in CAPD--a single center experience with low-dose fluconazole.

BACKGROUND/AIMS: Fungal peritonitis (FP) significantly alters the outcome of patients on peritoneal dialysis (PD). Exposure to antibiotics is a risk factor for subsequent FP. Antifungal prophylaxis has been tried, with varying success, to prevent the occurrence of antibiotic-related fungal peritonitis (AR-FP). We aimed to evaluate the effect of prophylaxis with a low dose of fluconazole, in preventing AR-FP. METHODS: In this retrospective review, we examined the incidence of FP in a cohort of 115 patients, who had received antibiotics for bacterial peritonitis and received a co-prescription of fluconazole, 50 mg/day for the duration of antibiotic therapy. The incidence of bacterial peritonitis and FP for up to 3 months after antibiotic therapy was noted. RESULTS: One hundred and fifteen patients were followed up over a 6-year period, for 2549 patient-months. We observed 82 episodes of bacterial peritonitis and a total of 137 antibiotic prescriptions. The peritonitis rate was 1 episode per 31.08 patient-months (1 per 2.58 patient-year, 0.38 episodes every patient-year). We had six episodes of FP. There were no episodes of AR-FP. CONCLUSION: We observed very low rates of both bacterial peritonitis and FP, and prophylaxis with low-dose fluconazole seemed to confer protection against AR-FP. We did not encounter any adverse effects with its use.

Outcome of patients with end stage renal disease admitted to an intensive care unit in India.

AIMS: We sought to determine outcome and evaluate performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores upon admission in predicting 30-day mortality of end-stage renal disease (ESRD) patients admitted in ICU. METHODS: This prospective observational cohort study examined 73 consecutive ESRD patients admitted in an ICU of a tertiary care institute over 15 months. Primary outcome measure was 30-day mortality. Data on patient characteristics, reason for ICU admission, cause of ESRD, mode of renal replacement, and use of mechanical ventilation (MV) or inotropes were recorded. The APACHE 2 and SOFA scores were calculated based on admission characteristics. RESULTS: First-day median APACHE II, SOFA, and APACHE II-predicted hospital mortality rates were 26 (14-49), 7 (4-17), and 56.9% (18.6-97.4%), respectively. Observed ICU and 30-day mortality rates were 27.4%, and 41.1%, respectively. During the ICU course, MV and inotropic support was required in 27 (37%) and 23 (35.1%) patients, respectively. Need for MV (p < 0.001) and inotropic support (p < 0.001) were predictors of 30-day mortality in univariate analysis. Area under receiver operating characteristic curve for APACHE II in predicting 30-day mortality was 0.86 (95% CI, 0.76-0.93) compared with 0.92 (95% CI, 0.83-0.97) for SOFA score (p = 0.16). CONCLUSIONS: Outcome of ESRD patients admitted to ICU is poor, especially if they require other organ support. APACHE II and SOFA scores perform well as predictors of 30-day mortality.

Ultrasound-guided femoral dialysis access placement: a single-center randomized trial.

BACKGROUND AND OBJECTIVES: Insertion of dialysis catheters (DCs) is a prerequisite for successful initiation of hemodialysis. We attempted to determine if ultrasonography-guided (USG) insertion was superior and safer than the anatomical landmark-guided technique (ALT) for the femoral vein (FV). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This was a randomized prospective study on 110 patients requiring FV DCs in a tertiary care hospital. Patients were randomized into two groups: USG and ALT. Data were collected on demography, operator experience, and side of insertion. The USG group had their catheters inserted under USG guidance, whereas the ALT group had their DC inserted by ALT. Outcome measures included successful insertion of DC, number of attempts, and complications. RESULTS: Both groups were comparable regarding age and gender of patients, operator experience, and the side of catheterization. The overall success rate was 89.1%, with 80% using ALT and 98.2% under USG guidance (P = 0.002). First attempt success rate was 54.5% in the ALT group as compared with 85.5% in the USG group (P = 0.000). The complication rate was 18.2% in the ALT group and 5.5% in the USG group (P = 0.039). The odds ratio (OR) for complications with two or more attempts was 10.73 with a relative risk (RR) of 3.2. The OR for successful insertion using USG was 13.5 (95% CI: 1.7 to 108.7). CONCLUSIONS: USG significantly improves success rate, reduces number of attempts, and decreases the incidence of complications related to FV DC insertion.