Bioimpedance Spectroscopy-Guided Ultrafiltration Normalizes Hydration and Reduces Intradialytic Adverse Events in Hemodialysis Patients.

Chronic fluid overload as well as excessive fluid removal are associated with increased morbidity and mortality in hemodialysis (HD) patients. The clinical method to probe the dry weight is often inaccurate and the bioimpedance spectroscopy (BIS) is shown to improve the accuracy. We compared the impact of BIS and clinical methods to guide ultrafiltration (UF) in a randomized controlled study on the intradialytic complications and blood pressure control in prevalent HD patients. Fifty patients on maintenance HD were randomized to BIS method (BIS-group) and clinical method (CL-group) to guide UF. The body composition monitor (BCM) was done post-HD in all patients at baseline and 2-weeks interval during the study period of 6 months to determine the hydration status, but the result was revealed only to the nephrologist managing the patients in BIS-group to probe the dry weight. The endpoints of the study were blood pressure control, intradialytic complications and anti-hypertensive drug burden. The mean age was 56.0 ± 12.0 years and 70% were male. There was significant increase in patients with normal hydration in BIS-group (20% vs. 88%, p = 0.0001), but remained similar to baseline in CL-group (40% vs. 48%, p = 0.3) at 6 months. The incidence of intradialytic hypotension was significantly reduced in BIS-group (4.84 ± 3.0 vs. 2.8 ± 3.13 events/patient/6 months, p = 0.003). There was 35% reduction in hypertensive pill burden in BIS-group with similar blood pressure, compared to CL-group. Post-dialysis underhydration was more common than over or normal hydration at baseline in our population, indicating that clinical method to probe dry weight often resulted in hypovolemia. BIS method to determine dry weight resulted in normalization in volume status and consequently resulted in significant reduction in intradialytic hypotension and anti-hypertensive pill burden over 6-month period.

Clinical utility of urine neutrophil gelatinase-associated lipocalin measured at admission to predict outcomes in heterogeneous population of critically ill patients.

Urine neutrophil gelatinase-associated lipocalin (uNGAL) is a reliable early biomarker of acute kidney injury (AKI) in a homogeneous patient population. However, its utility in a heterogeneous population of critically ill, in whom the time of onset of renal insult is often unclear, is not clearly established. We evaluated the ability of a single measurement of uNGAL in a heterogeneous adult population, on admission to intensive care unit (ICU), to predict the occurrence of AKI and hospital mortality. One hundred and two consecutive adult patients had uNGAL measured within 8 h of admission to ICU. The demographic and laboratory data were collected at admission. The diagnosis of AKI was based on AKI Network (AKIN) criteria. The primary outcome was the development of AKI, and the secondary outcome was hospital mortality. The mean age was 54 ± 16.4 years and 65% were males. Urine NGAL (ng/ml) was 69 ± 42 in patients with AKI (n = 42) and 30.4 ± 41.7 in those without AKI (P < 0.001). The area under the receiver operating characteristic (ROC) curve for prediction of AKI was 0.79 and for serum creatinine (SCr) was 0.88. The sensitivity and specificity for a cut-off value of uNGAL of 75 ng/ml to predict AKI were 0.5 and 0.85 respectively. uNGAL > 75 ng/ml was a strong (odd ratio = 5.17, 95% confidence interval: 1.39-19.3) and independent predictor of hospital mortality. A single measurement of uNGAL at admission to ICU exhibited good predictive ability for AKI though the sensitivity was low. The predictive ability of uNGAL was inferior to simultaneously measured SCr at admission, hence limited its clinical utility to predict AKI. However, admission uNGAL was a strong, independent predictor of hospital mortality.

Cytomegalovirus infection inducing flare of Behcet's disease with possible recurrence of glomerulonephritis after renal transplantation.

We present a case of young male with end-stage renal disease due to type III membranoproliferative glomerulonephritis (GN) and clinical features consistent with Behcet's disease (BD). He developed flare of BD 3 months after deceased donor renal transplantation following cytomegalovirus infection, in the form of oral and genital ulcers. He also had GN characterized by mild mesangial proliferation, neutrophilic infiltration and subepithelial, mesangial and intramembranous electron dense deposits, which could possibly be attributed to recurrence of renal disease due to BD. The clinical flare of BD was treated with colchicine with good response.

Rituximab: A viable treatment option for epoetin-induced pure red cell aplasia.

Pure red cell aplasia (PRCA) due to neutralizing antibodies can rarely develop following treatment with epoetin. The treatment of this condition is generally unsatisfactory and immunosuppression is often recommended, which improves chances of hematological recovery. We describe a case of PRCA due to neutralizing anti-epoetin antibodies following therapy with epoetin-α in a 68-year-old man on hemodialysis. He presented with severe transfusion-dependent anemia and was initially treated with prednisolone and oral cyclophosphamide. However, within 2 weeks the immunosuppressive drugs had to be stopped due to complications, following which he remained transfusion dependent. Subsequently, he was given two doses 700 mg each of rituximab following which there were hematological recovery and resolution of anti-epoetin antibodies.

Immunoglobulin G4 related tubulointerstitial nephritis.

Tubulointerstitial nephritis is an uncommon manifestation of IgG4 related disease. A case of tubulointerstitial nephritis with special features including isolated renal involvement in this multisystem disorder and the absence of response to steroid therapy in a young male is reported here. There was no nephromegaly, eosinophilia or other organ involvement. The importance of early detection and treatment for preservation of kidney function is highlighted.

Acute interstitial nephritis due to statin and its class effect.

Recent reports indicate that statins can cause nephrotoxicity. However, the mechanisms of nephrotoxicity remain unclear. We report a case of acute kidney injury (AKI) in a 54-year-old man following the administration of atorvastatin Renal biopsy showed acute interstitial nephritis. Atorvastatin was withdrawn and he was treated with corticosteroid following which renal function recovered. When he was rechallenged with rosuvastatin 6 months later following an episode of acute myocardial infarction, he developed AKI again indicating class effect of statin for nephrotoxicity.

Accuracy of spot urine protein creatinine ratio in measuring proteinuria in chronic kidney disease stage 3 and 4.

We studied the accuracy of spot urine protein creatinine ratio (SpUr-PCR) to assess 24 h urine protein excretion (24 h-UP) in patients with chronic kidney disease (CKD). A total of 100 proteinuric CKD patients of stages 3 and 4 were studied. 24 h urine was collected to measure 24 h-UP and creatinine. A random day time urine sample was analyzed to measure the PCR. A formula to estimate 24 h creatinine excretion was derived from linear regression analysis and a correction factor was introduced to assess whether this improves the accuracy of the SpUr PCR in predicting 24 h-UP. Accuracy of the SpUr-PCR was assessed by Pearson's correlation, regression analysis, and Bland Altman analysis. Mean age was 51.85 ± 12 years and 81% of the patients were male. SpUr-PCR predicted 24 h-UP with good accuracy (r = 0.86 on a data transformed to a logarithmic scale, P < 0.001) and there was a good agreement between these two measures of proteinuria. However, SpUr-PCR was inaccurate in the subgroup with nephrotic range proteinuria (r = 0.35, P = 0.062), but when a correction factor for 24-h urine creatinine (24 h-UCr) was introduced, the accuracy of SpUr-PCR improved significantly in this group (r = 0.45, P = 0.013). Introduction of the correction factor improved the degree of agreement between these two measures in women, but not the correlation. Overall, SpUr-PCR accurately predicted 24 h-UP. Adding a correction factor for 24 h-UCr improved correlation in the subgroup of patients with the nephrotic range proteinuria and the degree of agreement in female patients, and hence may be used in expressing proteinuria measured by SpUr-PCR to improve its accuracy in them.

Retarding the progression of chronic kidney disease with renin angiotensin system blockade.

We assessed the effect of renin angiotensin system blockade (RASB) in chronic kidney disease (CKD) of diverse etiology. Two hundred and sixty-five consecutive CKD patients attending our renal clinic, with estimated glomerular filtration rate (eGFR) of 20-70 ml/min/1.73m(2) at baseline and a minimal follow-up of 1 year, were studied retrospectively. We devised a scoring system to quantify RASB, wherein the maximum dose of an agent recommended for control of hypertension was scored as 1. The renal endpoints studied were the rate of change in eGFR (ΔeGFR) and decline of eGFR>50%. The mean age was 48 ± 11.2 years and 69% were male. The mean duration of follow-up was 4 ± 2.7 years. The rate of ΔeGFR was -1.5 ± 5.0 ml/min/1.73 m(2) per year in patients who received RASB (N=168) and -6.0 ± 5.4 in those who did not (N=97) (P<0.001). The incidence of decline of eGFR >50% was 11.3% with RASB and 24.7% without (P=0.003). In a subgroup of patients who received RASB, the incidence of decline of eGFR >50% was 17.8% in the low-dose RASB group (N=84, RASB score 0.63 ± 0.38) and 4.8% in the high-dose group (N=84, RASB score 2.5 ± 0.7) (P=0.001). RASB was associated with significantly better renoprotection in CKD of diverse etiology, even in nonproteinuric diseases. This effect appeared to be dose-dependent, with higher supramaximal doses exhibiting better renoprotection than the lower conventional doses. Our results make a strong case for use of aggressive RASB in all CKD patients to postpone end-stage renal disease.

Medical therapy is best for atherosclerotic renal artery stenosis: Arguments for.

Atherosclerotic renal artery stenosis (ARAS) is a common condition that causes hypertension and reduction in the glomerular filtration rate and is an independent risk factor for death. Despite high technical success, the clinical benefit of renal artery (RA) angioplasty with stenting in ARAS remains doubtful. The published randomized clinical trials provide no support for the notion that renal angioplasty with stenting significantly improves blood pressure, preserves renal function, or reduces episodes of congestive heart failure in patients with ARAS. RA stenting is associated with procedure-related morbidity and mortality. Agents to block the renin-angiotensin-aldosterone system improve outcome and should be a part of a multifaceted medical regimen in ARAS. Medical therapy effectively controls atherosclerotic renovascular disease at all levels of vasculature and hence is the best therapy for ARAS.

Hypophosphatemic rickets due to Dent's disease: A case report and review of literature.

We report a case of rickets due to Dent's disease in a two-year-old boy. He was treated with sodium phosphate, calcitriol and potassium citrate supplements, following which there was a remarkable improvement in mobility, growth and bony deformities. The hypercalciuria associated with Dent's disease was effectively corrected using hydrochlorothiazide.

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) and neurological crisis due to acute intermittent porphyria, successfully treated with haemodialysis.

We report an eighteen year old female, a case of acute intermittent porphyria with syndrome of inappropriate antidiuretic hormone secretion, as presenting feature for its rarity. The neurological crisis was successfully treated with haemodialysis.

Refractory hyperkalaemia due to trimethoprim, successfully treated with fludrocortisone.

We report a case of intractable hyperkalaemia in an elderly patient with myeloma, who received conventional dose of trimethoprim-sulfamethoxazole and hyperkalaemia resolved following therapy with fludrocortisone. We recommend monitoring of serum potassium in high-risk patients receiving conventional doses of trimethoprim-sulfamethoxazole for 5 or more days.

'O' set connector system in CAPD.

51 CAPD patients (age 55.5 +/- 14.5 yrs, 35 male, 16 female) on CAPD using 'O' set were studied retrospectively during the period January 1993 to April 1995. Etiology of ESRD was Diabetic nephropathy-25(49%) and the other causes-26(51%). The total duration of observation on 'O' set was 553 patient months, the mean duration was 10.8 +/- 6.1 months. 24 patients (47%) developed total of 30 episodes of peritonitis. The incidence of peritonitis was 18.4 patient months per episode of peritonitis. The organisms responsible for peritonitis were Gram positive-6(20%), Gram negative-3(10%), Fungal-1(3.3%), Mycobacterial-1(3.3%), Eosinophilic-1(3.3%), Sterile-12(40%) and unknown-6(20%) 2 patients of bacterial peritonitis and a patient with tuberculous peritonitis died while rest of the patients responded favourably to antibiotics. 13(52%) diabetic patients and 11(42%) non-diabetic patients had peritonitis (p-NS) and the peritonitis rates in diabetics and non diabetics were 18.3 and 18.6 patient months per episode respectively (p-NS). Exit site infection was seen in 5 patients (10%) (Staph aureus-4, Enterococci-1) and all responded to antibiotic therapy. 7 patients had total of 10 episodes of symptomatic accidental intraperitoneal sodium hypochlorite instillation, none had any long term adverse effects. The 'O' set procedure was done by self in 10(20%) and by others in 41(80%) cases. The peritonitis rates when performed by self and others were 18.5 and 18.4 patient months per episode respectively (p-NS). The cost of being on CAPD using 'O' set, Y-bag and twin bag were Rs. 1,50,000, 2,10,000 and 3,72,000 per annum respectively and cost of maintenance haemodialysis was 1,36,800 per annum. The cost of CAPD using 'O' set was comparable to that of maintenance haemodialysis. The 'O' set connector system in CAPD is found to be safe, cost effective and efficient.